We thank Ruan and colleagues for their letter and appreciate their comments regarding our recent study, which demonstrated an independent association between non-medical use of prescription opioids (NMUPO) and heroin initiation among US veterans

Banerjee, Geetanjoli

Barry, Declan T.

Becker, William C.

Cerdá, Magdalena

Crystal, Stephen

Edelman, E. Jennifer

Fiellin, David A.

Gaither, Julie R.

Gordon, Adam J.

Gordon, Kirsha S.

Kerns, Robert D.

Marshall, Brandon D. L.

Martins, Silvia S.

English

Columbia University Academic Commons

3. Meyer R., Patel A. M., Rattana S. K., Quock T. P., Mody S. H.Prescription opioid abuse: a literature review of the clinicaland economic burden in the United States. Popul Health Manag2014; 17: 372–87.4. Ruan X.,WycheM. Q. III, Kaye A. D. Analyzing the relationshipbetween nonmedical prescription-opioid use and heroin use. JOpioid Manag 2016; 12: 11–14.5. Centers for Disease Control and Prevention. National VitalStatistics System, Mortality file. Number and age-adjustedrates of drug-poisoning deaths involving opioid analgesicsand heroin: United States, 1999–2014. Available at: http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf (accessed 27October 2016) (Archieved at http://www.webcitation.org/6lZ0N8gPN).6. Compton W. M., Jones C. M., Baldwin G. T. Relationshipbetween nonmedical prescription-opioid use and heroin use.N Engl J Med 2016; 374: 154–63.7. Muhuri P. K., Gfroerer J. C., Davies M. C. Subtance Abuse andMental Health Services Administration (SAMHSA). Associa-tions of nonmedical pain reliever use and initiation of heroinuse in the United States. Available at: http://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm (accessed 13 November 2016)(Archived at http://www.webcitation.org/6m0MYw9lf).8. Centers for disease Control and Prevention. Notes from thefield: risk factors for hepatitis C virus infections among youngadults—Massachusetts, 2010. Morb Mortal Wkly Rep 2011;60: 1457.9. Klevens R. M., Hu D. J., Jiles R., Holmberg S. D. Evolving epide-miology of hepatitis C virus in the United States. Clin Infect Dis2012; 55: S3–9.REPLY TO RUAN ET AL. (2017): NON-MEDICALUSE OF PRESCRIPTION OPIOIDS ISASSOCIATEDWITH HEROIN INITIATIONAMONG US VETERANSWe thank Ruan and colleagues for their letter andappreciate their comments regarding our recentstudy [1], which demonstrated an independent associa-tion between non-medical use of prescription opioids(NMUPO) and heroin initiation among US veterans [2].Our results indicate that participants who reported prioror concurrent NMUPO had 5.43 times the adjusted haz-ard of heroin initiation, compared to participants whoreported no NMUPO [95% confidence interval(CI) = 4.01–7.35]. While we acknowledge in our paperthat these results are not necessarily generalizable to allUS veterans, given the inclusion of participants who areHIV-infected and/or hepatitis C virus (HCV)-infected, theobserved effect of NMUPO on risk for heroin initiationwas robust to sensitivity analyses. For example, as de-scribed in our published study, excluding the 701 HCV-positive participants did not affect the result [adjustedhazard ratio (AHR) = 6.21, 95% confidence interval(CI) = 4.54–8.51)] meaningfully. In light of the concernsraised by Ruan and colleagues, we repeated the analysisexcluding HIV-infected individuals, and in fact foundthat the relationship between NMUPO and heroin initia-tion was stronger (AHR = 7.01, 95% CI = 5.40–9.09).Thus, although the observed absolute rate of heroininitiation may be greater than in the general US veteranpopulation due to the specific inclusion of higher-risk pa-tients, it does not appear that the relationship betweenNMUPO and heroin initiation is affected by HCV orHIV prevalence.Ruan and colleagues also highlighted the increase inheroin-related deaths from 2013 to 2014, with the con-current decrease in people reporting non-medical use ofprescription opioids. This inverse relationship may, infact, be attributable to the fact that large numbers ofpeople who developed opioid use disorder (as a result ofnon-medical use of prescription opioids) have transitionedsubsequently to heroin use [3,4]. The trend betweenincreased rates of death associated with heroin use anddecreased rates of death associated with use of pres-cription opioids thus speaks to the potential role oftransitioning from the misuse of prescription opioids tothe use of heroin in many parts of the country [5,6].This phenomenon is consistent with the findings of ourpaper, given that NMUPO may be one step in a complex,multi-step cascade that increases risk of transition toheroin use in the population [7,8].Additionally, while Compton and colleagues notedthat: ‘only a small percentage of non-medical users ofprescription opioids initiate heroin use’, they also go onto say that: ‘given the large number of nonmedicalusers, even a small percentage who initiate heroin usetranslates into several hundred thousand new heroinusers’ [9]. Ruan et al. cite a statistic that 3.6% of thepeople reporting NMUPO initiated heroin use within5 years of beginning NMUPO. Indeed, even this smallpercentage, if correct, would result in approximately370800 individuals initiating heroin use by 2019. Priorand subsequent years would contribute similarproportions of individuals initiating heroin due toNMUPO [10].In conclusion, we appreciate that the rates of heroininitiation in our study are potentially higher compared torates of heroin initiation among studies that do not includeHIV- and HCV-infected veterans. However, this limitationdoes not obscure the primary findings of our study, whichspeaks to the observed increased relative risk of heroininitiation among participants who report prior/concurrentNMUPO compared to participants who report no prior/concurrent NMUPO.Declaration of interestsNone.728 Letters to the Editor© 2017 Society for the Study of Addiction Addiction, 112, 727–732Keywords Epidemiology, heroin, longitudinal study,NMUPO, non-medical use of prescription opioids,veterans.GEETANJOLI BANERJEE1, E. JENNIFER EDELMAN2,3,DECLAN T. BARRY4,5, WILLIAM C. BECKER6,MAGDALENA CERDÁ7, STEPHEN CRYSTAL8,JULIE R. GAITHER3,9, ADAM J. GORDON10,KIRSHA S. GORDON11, ROBERT D. KERNS6,12,SILVIA S. MARTINS13, DAVIDA. FIELLIN2,3 &BRANDON D. L. MARSHALL1Department of Epidemiology, Brown School of Public Health,Providence, RI, USA,1 Department of Internal Medicine, Yale Schoolof Medicine, Yale University, New Haven, CT, USA,2 Yale Center forInterdisciplinary Research on AIDS, Yale School of Public Health, YaleUniversity, New Haven, CT, USA,3 Yale University, New Haven, CT,USA,4 APT Foundation Pain Treatment Services, New Haven, CT,USA,5 Pain Research, Informatics, Multi-morbidities and Education(PRIME) Center, VA, Connecticut Healthcare System, West Haven,CT, USA,6 Department of Emergency Medicine, University ofCalifornia, Davis, Sacramento, CA, USA,7 Institute for Health, HealthCare Policy, and Aging Research, Rutgers University, NewBrunswick, NJ, USA,8 Yale Center for Medical Informatics, YaleSchool of Medicine, New Haven, CT, USA,9 Center for Health EquityResearch and Promotion (CHERP) and Mental Illness ResearchEducation and Clinical Center (MIRECC), VA Pittsburgh HealthcareSystem and University of Pittsburgh, Pittsburgh, PA, USA,10 VAConnecticut Healthcare System, West Haven, CT, USA,11Departments of Psychiatry, Neurology and Psychology, YaleUniversity, New Haven, CT, USA12 and Department of Epidemiology,Mailman School of Public Health, Columbia University, New York,NY, USA13E-mail: brandon_marshall@brown.eduReferences1. Ruan X., Luo J. J., Kaye A. M., Kaye A. D. Non-medical useof prescription opioids is associated with heroin initiationamong US veterans. Addiction 2017; 112: 727–8.2. Banerjee G., Edelman E. J., Barry D. T., Becker W. C.,Cerda M., Crystal S. et al. Non-medical use of prescriptionopioids is associated with heroin initiation among US vet-erans: a prospective cohort study. Addiction 2016; 111:2021–31.3. Mars S. G., Bourgois P., Karandinos G., Montero F.,Ciccarone D. ‘Every “never” I ever said came true’: transi-tions from opioid pills to heroin injecting. Int J Drug Policy2014; 25: 257–66.4. Cicero T. J., Ellis M. S., Surratt H. L., Kurtz S. P. The chang-ing face of heroin use in the United States: a restrospectiveanalysis of the past 50 years. JAMA Psychiatry 2014; 71:821–6.5. Dart R. C., Surratt H. L., Cicero T. J., Parrino M. W., SevertsonS. G., Bucher-Bartelson B. et al. Trends in opioid analgesicabuse and mortality in the United States. N Engl J Med2015; 372: 241–8.6. Bohnert A., Ilgen M., Trafton J. A., Kerns R. D., EisenbergA., Ganoczy D. et al. Trends and regional variation in opioidoverdose mortality among Veterans Health Adminstrationpatients, fiscal year 2001 to 2009. Clin J Pain 2014; 30:605–12.7. Cicero T. J., Ellis M. S., Harney J. Shifting patterns of prescrip-tion opioid and heroin abuse in the United States.NEngl JMed2015; 373: 1789–90.8. Jones C. M. Heroin use and heroin use risk behaviors amongnonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010. Drug AlcoholDepend 2013; 132: 95–100.9. Compton W. M., Jones C. M., Baldwin G. T. Relationshipbetween nonmedical prescription-opioid use and heroin use.N Engl J Med 2016; 374: 154–63.10. Muhuri P. K., Gfroerer J. C., Davies M. C., Substance Abuseand Mental Health Services Administration (SAMHSA).Associations of Nonmedical Pain Reliever Use and Initiation ofHeroin Use in the United States. CBHSQ Data Review. Availableat: http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf (accessed 20December 2016) (Archived at http://www.webcitation.org/6ncLPhIZD on 18 January 2017).DRUG TESTING IN FORENSIC MENTALHEALTH SETTINGSThe use of illicit substances is extremely common amongforensic psychiatry populations and is recognized widelyas one of the most potent risk factors for interpersonalviolence. Detection and management of substance misusein patients prone to behave violently is critical formaintaining the safety of patients, staff members and thepublic at large. The most commonly used specimen typein UK mental health settings is urine [1]. This was, untilrecently, the case at the State Hospital, the high-securitypsychiatric hospital for Scotland and Northern Ireland.In 2013 we reported on the results of a pilot study inwhich patients in high security were offered the choice ofeither urine or oral fluid testing (OFT) [2]. The pilot wassuccessful, with oral fluid testing being generally preferredby both patients and staff members. The additionalfinancial cost at that time was considered to be outweighedby the significant benefits arising from offering patientschoice, preservation of patient dignity and staff timesavings. As a result of the successful pilot, since 2010 allpatients at the State Hospital have been offered the choiceof either urine or OFT for routine testing for illicitsubstances, a move which was viewed positively by theMental Welfare Commission.We provide an update on our experience since 2010 as,to our knowledge, we are the only secure psychiatricsetting which routinely offers patients the choice ofdrug-testing method. Prior to the pilot study, urine testingrepresented more than 99% of testing. In 2010 testing byLetters to the Editor 729© 2017 Society for the Study of Addiction Addiction, 112, 727–732

Reply to Ruan et al. (2017): Non-medical use of prescription opioids is associated with heroin initiation among US veterans.

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Reply to Ruan et al. (2017): Non-medical use of prescription opioids is associated with heroin initiation among US veterans.

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