Exploring drug sourcing among regular prescription opioid users in Canada: data from Toronto and Victoria.

• Author: Fischer, Benedikt

Introduction

Recent North American data document substantial increases in non-medical prescription opioid (PO) use (e.g., morphine, hydromorphone, oxycodone) in both general (e.g., adult, student, youth) and street-drug-use populations (Compton and Volkow 2006; Fischer and Rehm 2007; Fischer, Rehm, Patra, and Firestone Cruz 2006; McCabe, Teter, Boyd, Knight, and Wechsler 2005; Rosenblum, Parrino, Schnoll, Fong, Maxwell, Cleland, Magura, and Haddox 2007). For Canada specifically, data from a multisite cohort of illicit opioid-and other drug users recruited from street-drug-use populations in cities across Canada (OPICAN study) showed that PO use had become more prevalent than heroin use in most study sites since 2001 (Fischer and Rehm et al. 2006). In the United States, PO misuse has been associated with substantive increases in morbidity and mortality outcomes (e.g., emergency room mentions and overdose deaths [ODI) (Gilson, Ryan, Joranson, and Dahl 2004; Hurwitz 2005; Martin, Woodall, and McLellan 2007; Paulozzi, Budnitz, and Xi 2006). Notably, in the United States, PO-related ODs have recently come to outnumber those involving heroin and cocaine (Paulozzi et al. 2006). Unfortunately, comparable systematic morbidity or mortality data specifying involvement of PO substances are not available for Canada (Fischer, Rehm, Goldman, and Popova, forthcoming).

While the increasing prevalence of non-medical use of POs, with its attendant risks and outcomes, is receiving growing research attention, relatively little is known about the distinct features or dynamics of PO supply for such use, specifically for street-drug-user populations. These supply features are presumed to be different in several crucial aspects than those for conventional illicit drugs (e.g., heroin or crack), which are essentially products or raw materials generated abroad, illegally imported, and exclusively distributed to end-users on the street, mainly in the context of street-drug markets, through vertical distribution chains involving multiple levels, usually with the final transaction occurring between a small-scale dealer and the end-user (Poret 2000). The fundamental premises for PO distribution to non-medical users are different in that POs are not illegal products per se but are prescription medications legitimately produced and disseminated domestically for therapeutic purposes (e.g., pain treatment) by the medical system (Hurwitz 2005; Fischer, Gittins, and Rehm, forthcoming). |n this context, it is important to note that the United States and Canada are the world's first and third ranked countries, respectively, in terms of quantities of POs consumed per capita and hence provide for an extremely PO-rich environments (International Narcotics Control Board 2006; Fischer and Rehm 2007). Within these parameters, the supply of POs for illicit use among street-drug users in North America can be assumed to occur largely through different forms of diversion from medical sources (Joranson and Gilson 2006). The mechanics of this diversion have been shown to be rather heterogeneous in a few (largely non-Canadian) studies, yet the specific role of traditional street-drug markets (vis-a-vis other possible sourcing routes) for the purposes of PO distribution to street-drug users is not clear to date (Haydon, Rehm, Fischer, Monga, and Adlaf 2005; Inciardi, Surratt, Kurtz, and Cicero 2007).

For example, recent studies from the United States have demonstrated that PO supply routes may involve a number of different sources, including double doctoring or over-scripting (e.g., drug users feigning symptoms and/or presenting to multiple doctors in order to obtain drug prescriptions, which will then be illicitly used or exchanged for other drugs), prescription forgeries, or thefts or robberies (Forgione, Neuenschwander, and Vermeer 2001; Inciardi et al. 2007; Joranson and Gilson 2006; Zacny, Bigelow, Compton, Foley, Iguchi, and Sannerud 2003) The phenomenon of double-doctoring among illicit PO users has been documented for other jurisdictions, including Australia (Martyres, Clodes, and Burns 2004). Fountain and colleagues (2000) demonstrated that, among street-drug users in London, England, the diversion of POs and other prescription drugs on the basis of multi-doctoring/scripting was highly prevalent, and a great proportion of the drugs obtained in this way were subsequently either sold or exchanged for other (e.g., more desirable) drugs. This further underscores the finding from other studies that most street-drug users are also involved in some form of supply activity in the form of small-scale dealing (e.g., drug selling or exchanging; see Bretteville- Jensen and Sutton 1996; Fischer, Medved, Kirst, Rehm, and Gliksman 2001). A recent study on PO misuse in New York City confirmed the utilization of a variety of sources by street-drug users, including doctors or pharmacies as well as street dealers (Davis and Johnson 2008). Interestingly, the use of a given source was correlated with the main reported purpose of PO use in this sample; that is, whether the drug was used principally for pain relief or for euphoria. In both baseline and follow-up assessments of the Canadian OPICAN study cohort, illicit PO users also reported utilizing a variety of sources (including doctors, friends, dealers) to obtain POs (Haydon et al. 2005; Fischer, Firestone Cruz, and Rehm 2006). Already a decade ago, Sajan et al. found that POs had become highly available commodities in street-drug markets in Vancouver (Sajan, Corneil, and Grzybowski 1998). However, no detailed information is currently available on PO sourcing activities among street-drug users, especially in the wider contexts of street-drug markets in Canada.

The objective of this study was to explore characteristics of PO sourcing among regular PO and other street-drug users in the two Canadian cities of Toronto and Victoria.

Methods

The study sample consisted of non-medical users of POs and other drugs, recruited in Toronto, Ontario (N=43), and Victoria, British Columbia (N=39), between June and August 2007. These study sites were chosen because there was evidence of a substantial prevalence of PO use among street-drug users and there was an appropriate infrastructure for conducting research with the target population. Participants were eligible for the study if they were regular users of POs (i.e., reported use of POs on 15 or more use days in the past month) and were at least 18 years of age. Recruitment took place at local community health agencies in both sites, with agency staff handing out a study-information card to study participant candidates. Prospective participants called a study phone line, underwent a brief eligibility screening, and, if eligible, were invited for a study interview, which was conducted, in a private setting, by one designated research assistant per site. The interview consisted of a uniform interviewer-administered questionnaire including mainly closed- and some open-ended items on socio-demographics, drug-use-related income and expenditures, past and current drug use, details on opioid-and non-opioid-drug sources, and drug selling/trading activities. Each interview took approximately 30 to 50 minutes to complete, and overall closely followed the uniform protocol structure of questions; probes, illustrations, or recall aids were given as appropriate. For example, when asking about the use of regular versus irregular sources, respondents were offered possible characteristics describing either type of source. No personal information was collected. Participants provided informed consent prior...