Are adolescent sexual minorities at increased risk for opioid misuse?
During the past two decades, opioid-involved overdose deaths have substantially increased among adolescents and young adults. Identifying factors associated with increased risk for opioid use and opioid use disorder can help to reverse this trend. Sexual identity is one factor that is shown to influence the risk of opioid use among adults, with sexual minorities (e.g., lesbian, gay, bisexual, etc.) having higher rates of opioid use than their heterosexual-identified counterparts. The current study extends these earlier findings on adults to U.S. national high-school aged youth. Findings suggest that, like their adult counterparts, adolescents with non-heterosexual identities and experiences may be at increased risk of heroin and prescription opioid misuse.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Opioid-related overdose deaths increased dramatically among adolescents and young adults between 1999 and 2016; among individuals aged 15 to 19 years, deaths involving synthetic opioids, heroin, and prescription opioids increased 30-fold, 5-fold, and doubled, respectively. Thus, additional evaluation of adolescent populations is needed to better understand opioid use among youth and to identify cohorts with increased risk.
Adolescents who identify as sexual minorities (e.g., LGBTQ) are generally shown to have higher rates of substance use, including alcohol, tobacco, and marijuana. However, little research has examined how sexual minority status relates specifically to opioid use. National surveys show higher rates of general prescription drug (e.g., stimulants, opioids, tranquilizers) misuse among adolescent sexual minorities, but survey questions did not previously allow for investigation of prescription opioid misuse specifically. Studies conducted among older cohorts also reveal disproportionately higher rates of opioid use among sexual minorities, including higher rates of heroin and prescription opioid misuse among young adults ages 18 to 25 as well as higher rates of prescription opioid misuse among adults 18 and older, relative to their heterosexual counterparts. At present, it is unclear if sexual minorities who are under the age of 18 are also at increased risk for heroin and prescription opioid misuse.
Given the recent rise in opioid-related deaths among adolescents and young adults, it is important to identify the adolescent populations at risk of using these high-risk and often life-threatening substances. In this study, the researchers examined the role of sexual identity and sexual behavior in the prevalence and likelihood of heroin and prescription opioid misuse among adolescents.
HOW WAS THIS STUDY CONDUCTED?
This study was a secondary data analysis of the 2017 Youth Risk Behavior Survey, a nationally representative survey of health-related behaviors (sexual behaviors, substance use, physical activity, etc.) among 14,108 high school students (grades 9 to 12), assessing the prevalence and odds of prescription opioid misuse and heroin use among adolescents in the US, by sexual identity and sexual behavior. In contrast to prior Youth Risk Behavior surveys, the one conducted in 2017 allowed for the specific investigation of prescription opioid misuse, in addition to heroin use.
Outcomes of interest to the current study included: (1) lifetime use of heroin (yes/no), (2) lifetime misuse of prescription opioids (yes/no), (3) sexual identity (heterosexual, gay/lesbian, bisexual, or unsure), and (4) sexual behavior (i.e., whether the individual had a history of sexual contact with the opposite sex, same sex, both sexes, or no one). The investigators initially assessed the prevalence of lifetime opioid use among different sexual identity and sexual behavior groups. Thereafter, the association between sexual identity / behavior and opioid misuse was compared with heterosexual youth, controlling for age, sex, and race.
Consistent with the general population of US adolescents, the majority of participants were white (43%) non-Hispanic (75%). Participants had an average age of 16 years; about half were female. Two percent of all participants had a lifetime history of heroin use, and 14% had a lifetime history of prescription opioid misuse;85% of individuals identified as heterosexual;15% identified as a sexual minority (i.e., 3% gay/lesbian, 8% bisexual, 4% unsure). Regarding sexual behaviors, 51% had no history of sexual contact, 42% reported prior sexual contact with the opposite sex, and 7% reported sexual contact with the same sex (2%) or both sexes (5%).
WHAT DID THIS STUDY FIND?
Lifetime heroin and prescription opioid misuse were more prevalent among sexual minority than heterosexual youth.
Lifetime heroin use and prescription opioid misuse significantly differed between groups and were most prevalent among youth who identified as gay/lesbian (9% lifetime heroin use, 29% prescription opioid misuse), and lowest among adolescents identifying as heterosexual (1% heroin use, 13% prescription misuse).
Figure 1. Figure depicts the percentage of adolescents in each sexual identity group who reported lifetime misuse of prescription opioids or heroin. Individuals who identified as gay/lesbian and bisexual had significantly higher rates of prescription opioid misuse, relative to those who identified as heterosexual and unsure. Individuals who identified as gay/lesbian or unsure had significantly higher rates of heroin use than those who identified as heterosexual or bisexual.
The odds of lifetime heroin and prescription opioid misuse were higher among all sexual minority groups, when compared to heterosexual youth.
Controlling for demographic factors (age, biological sex, race) and compared to heterosexual youth, the odds of reporting lifetime heroin use were 4.8, 4.3, and 8.2 times higher among adolescents identifying as gay/lesbian, bisexual, and ‘unsure’, respectively. Similarly, the odds of prescription opioid misuse were 96% higher among gay/lesbian youth, 127% higher among bisexual youth, and 44% higher among adolescents who were unsure about their sexual identity, relative to heterosexual youth.
Concerning sexual behaviors, lifetime heroin and prescription opioid misuse were more prevalent among adolescents who had engaged in non-heterosexual behaviors.
Lifetime heroin and prescription opioid misuse was most prevalent among youth who reported sexual contact with the same sex (6% & 24%, respectively) or both sexes (5% & 38%, respectively). Adolescents who had not yet engaged in sexual behaviors (i.e., no prior sexual contact) reported the lowest rates of heroin (1%) and prescription opioid (8%) misuse.
Figure 2. Figure depicts the prevalence of lifetime heroin and prescription opioid misuse among adolescents who endorsed various sexual behaviors (i.e., sexual contact with the opposite sex, same sex, both sexes, or no one). Individuals who had sexual contact with the same sex only or both sexes had significantly higher rates of prescription opioid misuse and heroin use, relative to those who had sexual contact with the opposite sex only or no history of sexual contact.
When opioid use was assessed among those with a history of sexual behavior (i.e., ‘contact’), sexual minorities remained disproportionately affected.
Controlling for demographic factors and compared to individuals who had only engaged in heterosexual contact, the odds of reporting lifetime heroin use were 3.8 and 7.2 times higher among those who had sexual contact with the same sex or both sexes, respectively. Adolescents who reported sexual contact with both sexes also had higher odds (2.6 times higher) of lifetime prescription opioid misuse compared to those who only engaged in heterosexual contact. On the other hand, odds of heroin and prescription opioid misuse were 0.76 and 0.73 times higher, respectively, among individuals who engaged in heterosexual behaviors compared to those who had not engaged in any sexual behavior.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
Studies like this help us better understand the factors that put our nation’s youth at risk for opioid use. Given the recent rise in opioid-related deaths among adolescents and young adults, characterizing the factors that influence opioid use and identifying sub-populations with disproportionately high rates of use can reveal novel avenues for targeted prevention and intervention strategies that can help to curb opioid misuse, related health problems, and premature death among adolescents.
Consistent with research conducted among adults, this study found that high-school aged adolescents who identify as sexual minorities, as well as those who have engaged in sexual behavior with the same sex or both sexes, were more likely to engage in opioid use. With regard to sexual identity, all sexual minority groups (i.e., lesbian/gay, bisexual, and unsure) had increased odds of heroin use and prescription opioid misuse compared to youth who identified as heterosexual, revealing an important opioid-related disparity. Some of the reason for this may relate to a desire to self-medicate using opioids to help reduce the heightened levels of psychological distress that are commonly experienced by sexual minority individuals. According to the minority stress theory, homophobic attitudes can lead to discrimination, stigma, violence, and victimization of sexual minorities, resulting in disproportionate stress and exacerbated mental health problems. Indeed, sexual minority adolescents, including those who are unsure about their sexual identity, have significantly higher rates of depression, anxiety, self-harm, and suicidality than heterosexual adolescents, as well as lower academic achievement.
Given this study’s finding of increased opioid use risk among sexual minority adolescents, it may be that psychological distress related to sexual identity contributes to the initiation of opioid use, which may serve as a mechanism to cope with stress. Other studies suggest that sexual minorities are more likely than heterosexual individuals to report higher perceived drug availability and more tolerant social norms (including substance use), which might contribute to the enhanced risk of substance use and related disorders among this population. Although additional research is needed to characterize the reasons underlying increased risk, the observed disparity in opioid use among sexual minorities is certainly alarming and demands greater attention.
Importantly, research shows that higher rates of victimization among sexual minorities are seen at very young ages, even before adolescents acknowledge or become aware of their sexual identity. Furthermore, sexual identity, sexual behavior, and sexual attraction often conflict during adolescence. Therefore, it is important to acknowledge that an individual can, for example, engage in non-heterosexual behaviors but identify as heterosexual or unsure, and to assess how these various sexual minority identities intersect with sexual behaviors to influence substance use.
In the context of the current study, evaluation of sexual behaviors as opposed to sexual identity revealed similar opioid-related disparities among sexual minorities. More specifically, all non-heterosexual behavior groups (i.e., sexual contact with same sex or both sexes) had increased odds of heroin or prescription opioid misuse compared to youth who reported heterosexual-only behaviors. Although the specific pattern of results differed slightly between sexual identity and behavior analyses (i.e., increased risk of prescription misuse for same sex behaviors was not significant when the researchers controlled for demographics), the overall story remains the same: sexual minority youth, are at increased risk for using opioids and additional effort may be needed to prevent opioid use, disorder development, and related mortality among adolescents.
Other studies have suggested that this minority-related risk also extends to treatment and related factors, with sexual minorities reporting greater clinical severity and more barriers to help seeking for substance use disorders. To help address this increased risk, it is important to recognize adolescents who identify as sexual minorities, as well as those who engage in non-heterosexual behaviors regardless of identity, and how identity and behavior intersects, to help address any psychological or environmental factors that might contribute to the initiation or ongoing use of opioids and other substances. Recovery high schools that have LGBTQ (lesbian, gay, bisexual, transgender, queer) friendly policies in place may be a potential avenue for helping sexual minority youth with opioid use disorder, given their adolescent-geared recovery support.
In sum, there appear to be important opioid-related disparities among sexual minority youth. Although this study focused on lifetime opioid use and therefore included youth who had only used opioids once, any amount of opioid use can increase risk for a variety of harms and hazards. The earlier an individual is exposed to opioids, the greater their risk for developing opioid use disorder in the future, and risk of overdose increases with repeated exposure to opioids at escalating doses. Thus, identifying adolescent cohorts at risk of using opioids and employing prevention and intervention strategies that reduce risk of use and transition to disorder development have the potential to substantially limit the impact of the opioid epidemic on future generations. Sexual minorities appear to be one sub-population of youth for which prevention and intervention strategies are needed to help address opioid-related risk disparities.
- Survey questions did not define ‘sexual contact’ with other individuals and was interpreted by the survey respondent. Moreover, opioid use was evaluated dichotomously (i.e., yes vs. no) and individuals who had used opioids only one time were designated as having a “history of lifetime use” and placed in the same category as those with much more frequent use. Additional research is needed to determine if findings hold when examined with respect to individuals who have engaged in repeated use, and with a more detailed examination of opioid use behaviors (e.g., routes of opioid administration, types of prescription opioids misused and their source, etc.).
- The study was underpowered to examine the interaction of biological sex (male/female) and sexual identity/behavior, warranting additional research with larger sample sizes to determine if certain subgroups (e.g., biologically male & bisexual vs. biologically female & bisexual) adolescents exhibit different patterns of opioid misuse risk.
- This study did not assess the overlap between sexual identity and sexual experience, and how discrepancies between the two contributed to opioid use. Additional research is needed to determine how sexual identity and sexual behavior individually and collectively contribute to adolescent heroin and prescription opioid misuse.
Studies like this help identify particular populations that are at higher risk for engaging in opioid use, which ultimately help guide prevention and intervention efforts aimed at curbing opioid misuse and related harms. Focusing on high-school aged youth, this study found that adolescent sexual minorities, including those who identify as non-heterosexual and those who engage in sexual behaviors with the same sex or both sexes, exhibit increased risk of heroin and prescription opioid misuse relative to heterosexual youth. Individuals who identify as sexual minorities often experience stigma and discrimination, which can lead to increased psychological distress. This, in turn, may lead to attempts to self-medicate to reduce the distress through opioid use. Therefore, prevention and intervention strategies that focus on sexual minority youth in particular may be needed to reduce opioid-related risks and limit the impact of the opioid epidemic on future generations. Additional research is needed to provide more detailed understanding of the factors underlying and influencing opioid-use risk among sexual minority youth.
- For individuals and families seeking recovery: Sexual minority youth are more likely to experience stigma and discrimination than their heterosexual peers, leading to heightened psychological distress increasing risks to potentially self-medicate to mitigate this distress through opioid use. Addressing sexual minority specific stress might ultimately help support these individuals and prevent initiation of opioid use. Educating adolescents on the serious risks associated with opioid use and incorporating discussions around sexual identity and behavior may also help to support prevention and intervention efforts that you or your family might pursue. Recovery high schools that have LGBTQ friendly policies may also be helpful for supporting sexual minority youth with opioid use disorder.
- For treatment professionals and treatment systems: Given the recent rise in opioid-related deaths among adolescents and young adults, and this study’s finding of increased risk of opioid use among sexual minority youth, it is essential to acknowledge sexually-relevant factors in clinical contexts. Adolescents often exhibit discrepancies between sexual identity, sexual behaviors, and sexual attraction, and this study suggests that opioid-related disparities might exist across these various categories. Therefore, clinicians are encouraged to ask patients about sexual attraction and behavior, in addition to sexual identity, when discussing substance use during preventative medical exams, as it may help to identify risks for opioid or other substance use that can be addressed through prevention or early intervention.
- For scientists: Additional research is needed to compare sub-populations of sexual minorities and examine the interaction between sexual identity and biological sex, as well as the factors underlying heightened risk of opioid use in adolescent sexual minorities. Given that this study focused on sexual identity and behaviors, and that youth often exhibit discrepancies between sexual identity, behavior, and attraction (etc.), further investigation is also needed to determine if heightened opioid-use risk exists across these various facets. Moreover, this study assessed lifetime opioid use dichotomously and it will be important to determine opioid-related risk in relation to different levels of opioid involvement.
- For policy makers: Adolescent sexual minorities might experience opioid-related disparities compared to heterosexual youth, including higher rates of heroin and prescription opioid misuse. Given the recent rise in opioid-related deaths among adolescents and young adults, as well as the stigma and psychological distress often experienced by sexual minority youth, prevention and intervention strategies that target this population are essential. Policies and novel initiatives to fund LGBT-supportive recovery high schools and other community-based services might ultimately help to support sexual minority youth in their path to recovery. Additional funding for research will also advance our understanding of the specific sexual minority-related risks regarding opioid use and related harms and will help facilitate the development of novel prevention and intervention efforts that might more effectively mitigate opioid initiation.
Wilson, J. D., Sumetsky, N. M., Coulter, R. W., Liebschutz, J., Miller, E., & Mair, C. F. (2020). Opioid-related disparities in sexual minority youth, 2017. Journal of Addiction Medicine, 14(6), 475-479. DOI: 10.1097/ADM.0000000000000628