Illicit Methadone Use Among Rural Appalachian Substance Users

Background: Despite a long and successful history of methadone maintenance for the treatment of opioid dependence, recent use of the drug for pain management has been associated with an increase in methadone-related overdose deaths. Methadone and other prescription drugs result in more fatal drug overdoses in the U.S. than illegal drugs. Community-based studies on illicit methadone use are rare, particularly in rural areas. The aims of this study were to describe the prevalence and correlates of illicit methadone use and to distinguish low- and high frequency use in a cohort of rural Appalachian substance users. Methods: Rural substance users were recruited by respondent driven sampling for a study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, substance use, psychiatric disorders, and HIV risk behaviors. The 400 participants averaged 32.3 (SD = 8.4) years of age, and were predominantly White (4% African-American, 93.8% White, and 2.2% other) and male (58.8%). Results: Overall, 379 participants (94.8%) reported having illegally used methadone to get high at some point in their lifetime. Of those who had illegally used methadone, nearly half reported either weekly or daily use. Friends (49.6%) were the most common source of illicit methadone, followed by a dealer (24.8%), family member (12.4%), spouse/partner (9.2%), doctor/dentist (2.9%), stolen (0.8%), and multiple sources (0.3%). Compared to low-frequency users (n = 198) of illicit methadone, high-frequency users (n = 181) were significantly younger, had fewer medical problems, and were less likely to receive pension for disability. Frequency groups did not differ with regard to lifetime use of other psychoactive substances, but high-frequency illicit-methadone users reported more frequent barbiturate and tranquilizer use in the last six months and were more likely to have used multiple substances in a day. However, in the past 30 days, low-frequency illicit methadone users reported significantly more days of OxyContin use compared with high-frequency misusers. Low-frequency illicit methadone users were also more likely to have injected drugs and engaged in risky injection practices, such as using injection paraphernalia another person had used. Risky sexual behaviors differed between frequency groups in that high-frequency illicit methadone users were significantly more likely to have used methadone immediately before or during sex. Psychiatric symptoms did not differ among high- and low-frequency illicit methadone misusers. Nor did groups differ with regard to the number of lifetime alcohol or drug treatment admissions, though low-frequency illicit methadone users reported significantly more weeks of abstinence in outpatient drug treatment over the past year. In logistic regression models predicting frequency of illicit methadone use, a higher rate of sedative use and more frequent and distressing substance-related problems were characteristic of high-frequency illicit methadone users. Conclusions: Rates of illicit methadone use among this rural sample of substance users were considerably higher than those previously reported in the literature. Illicit methadone use, regardless of frequency, is related to other high-risk substance use and sexual behaviors. Health practitioners in rural areas should routinely screen for and treat illicit methadone use and associated risks.