Psychoactive substance use prior to the development of iatrogenic opioid abuse: A descriptive analysis of treatment-seeking opioid abusers

Physicians are frequently thought to be a major source of opioids diverted for non-therapeutic purposes, largely because it is so difficult for them to discern which patients might abuse them. In this study we sought to determine whether those who were first exposed to an opioid through a physician's prescription, and subsequently developed a substance use disorder, had a history of using psychoactive drugs prior to abusing opioids. Patients entering one of 125 drug treatment programs across the country for opioid abuse were asked to provide detailed histories of psychoactive drug use prior to their initial opioid exposure. Nearly half (47.1%, N=4493) indicated they were first exposed to opioids through a prescription from their physician to treat pain. Of these, 94.6% indicated experience with at least one other psychoactive substance (mean=4.55±0.05) prior to, or coincident with, their first exposure to an opioid from a physician. Alcohol (92.9%), nicotine and/or tobacco (89.5%), and marijuana (87.4%) were used by nearly all patients prior to, or coincident with, their first opioid prescription. If one excludes these drugs, 70.1% (N=2913) still reported some psychoactive drug use of licit or illicit stimulants (77.8%), benzodiazepines (59.8%) or hallucinogens (55.2%). Our results indicate that pain patients who developed a substance use disorder were rarely drug naïve prior to receiving their first opioid prescription. Rather, most have an extensive history of psychoactive drug use. As such, physicians should routinely ascertain complete licit and illicit drug histories in patients for whom they prescribe opioids.