Rates of prescription opioid nonmedical use continue to rise, and little is known about how to best screen and treat individuals with prescription opioid use problems. A better understanding of characteristics and correlates associated with prescription opioid use problems is needed in order to enhance the design of interventions and provision of care. Research on other substances of abuse, such as alcohol and cocaine, demonstrate clinically-relevant, gender-specific differences in a number of areas, including rates of use and treatment seeking, reasons for use, methods of initiation, physiological consequences, and treatment outcome (Brady et al., 2009
). The current study expands the limited data available on gender-specific differences with regard to prescription opioids, as such information is needed to help address this growing public health problem.
Several important gender differences in prescription opioid use patterns and motives of use were observed. Men were more likely than women to consume prescription opioids by alternative routes, particularly crushing and snorting the pills. In fact, the large majority of men in the sample (75%) endorsed crushing and snorting pills and 42% of men endorsed injecting prescription opioids. The more rapid routes of delivery most often chosen by men may speak to differences in the reasons for using prescription opioids. Both pharmacological and nonpharmacological motives are involved in the acquisition and maintenance of drug dependence. Treatments that seek to be effective need to adequately address both sets of motives, and be able to tailor treatment to the primary motive when appropriate. In the current study, examination of motives for using prescription opioids also revealed differences between men and women. Women were more often motivated by negative reinforcement processes and nonpharmacologic reasons, such as coping with interpersonal stress (73%) and negative affect (55%). This finding is in agreement with previous research investigating gender-specific motives to use other substances, including cocaine, alcohol and nicotine. Several studies have shown that women are more likely to use alcohol to help quell emotional pain or negative affect, whereas men are more likely to use alcohol to enhance pleasurable emotions or conform in social groups (Annis & Graham, 1995
; Schall, Weede, & Maltzman, 1991
). In addition, research shows that men may use substances more often than women for the direct pharmacologic effect. For example, men’s smoking behavior may be more influenced by nicotine than women’s smoking behavior (Perkins 1996
; Perkins 2008
; Perkins, Dunny, & Caggiula, 1999
). These gender-specific motives provide information that may be used for tailoring screening and intervention efforts. In addition, psychotherapeutic and pharmacologic interventions should be tailored to address concurrent mood or anxiety disorders among women, in particular, as these may substantially increase risk of use or relapse (Greenfield & Pirard, 2009
A particularly unique aspect of this study is the data collected regarding the time of day that prescription opioids are most commonly consumed. Notably, the large majority of both men and women in the sample related using prescription opioids first thing in the morning in order to increase their energy levels and “get things done.” Consuming prescription opioids was likened to consuming coffee in the morning. Women, however, were significantly more likely than men to use prescription opioids first thing in the morning. Some women even noted that they consumed prescription opioids each morning before getting out of the bed. Men, on the other hand, were significantly more likely than women to use in the early evening, typically when they were getting home from work and making plans to go out later in the evening. This information is useful clinically because it provides critical information about high-risk times and settings for men and women. For example, clinicians may need to help female patients modify their sleeping environment or early morning routine to decrease likelihood of use first thing in the morning, schedule female patients for early morning appointments, and help women develop healthier ways to increase energy levels.
The average age of onset of prescription opioids was 22.2 years, which is similar to recent NSDUH data that showed the average age of onset to be 21.2 among 2.9 million prescription opioid users (SAMHSA, 2010
). Although no statistically significant gender differences in age of onset or age of regular use was observed, it is notable that women were on average six years older than men when they first used prescription opioids, but were only three years older than men when they began to use them regularly. This finding suggests there may exist an accelerated progression of prescription opioid use among women. This phenomenon, referred to as “telescoping,” has been previously shown among men and women across a variety of substances (e.g., Johnson, Richter, Kleber, McLellan, & Carise, 2005
; Piazza, Vrbka, & Yeager, 1989
). Telescoping highlights the clinical significance of early screening and early intervention among women in order to minimize the progression of the disease and the concomitant negative consequences of the disease. Telescoping suggests that the window of opportunity for preventing progression from use to dependence is smaller for women.
When asked how men and women were first introduced to prescription opioids, the majority related that they first received them from a physician. In each instance, subjects reported receiving opioids from the physician in order to treat a physical injury (e.g., broken limb from a motorcycle accident) or because of a medical procedure they underwent (e.g., having wisdom teeth removed, abortion). However, as time passed and physical pain receded, subjects continued to take the medication for other reasons. An important task for the field will be to develop screening measures that can better assist physicians in determining which patients are at highest risk for later misuse of prescription opioids (Butler, Budman, Fernandez, & Jamison, 2004
). Alternative compounds with less abuse liability and more effective psychotherapeutic means of treating pain will also assist. In the current sample, 71% endorsed suffering from chronic pain. However, it is unclear what role the chronic use of prescription opioids and potential hyperanalgesia may play, as well as issues related to pain sensitivity and perception of pain. While subjects endorsed having chronic pain, many related that pain was not the reason why they were using prescription opioids. Similar to previous research (McCabe & Boyd, 2005
; McCabe, Cranford, Boyd, & Teter, 2007
), another common source of prescription opioids included family and friends. As such, patients receiving prescription opioid medications need to be educated about the dangers of sharing their medications with others, and about proper storage and disposal techniques.
Rates of other substance use were high among men and women in the study, highlighting the need for a thorough assessment at the time of treatment entry. In addition, patients need to be warned against the consequences, possibly fatal, of combining prescription opioids with other substances. Of note, few individuals reported concomitant use of heroin. The data suggests that there may be distinct subgroups of opiate users, with little overlap between heroin and prescription opioid dependent individuals. However, further research with larger samples sizes is needed to further investigate this issue.
In summary, a number of gender differences were observed which may have implications for the design of gender-sensitive screening, prevention and clinical interventions. Namely, motives for using prescription opioids, high-risk times of consumption, and routes of administration varied significantly by gender. The findings should be tempered by the fact that the sample size was small and generalizability is limited. In addition, the current findings may be limited because some research suggests that individuals are hesitant to report stigmatized behaviors in less-private settings, such as focus groups. This assumption is not always the case, however (Kitzinger, 1999), and the majority of the interviews in the current study consisted of only one individual. Future research with a larger, more representative sample and more anonymous reporting of behaviors is needed to confirm the findings. Despite these limitations, the findings add to the limited data available regarding prescription opioid dependence and gender, and may help alert clinicians to issues that should be targeted in the assessment and treatment planning for men and women with prescription opioid dependence.
- Almost half (46%) of subjects endorsed crushing and snorting prescription opioids.
- Men were more likely than women to crush and snort prescription opioids.
- Women were more likely than men to use opioids to cope with interpersonal stress.
- Women were more likely than men to use opioids to cope with negative affect.
- More women than men used prescription opioids first thing in the morning.