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Published in final edited form as: J Subst Use Addict Treat. 2024 Jun 8;164:209436. doi: 10.1016/j.josat.2024.209436

Generational and Gender Patterns of Prescription Opioid Misuse Among Black Adults

Brittany D Miller-Roenigk 1, Paris B Wheeler 2, Jasmine K Jester 1, Candice N Hargons 1, Danelle J Stevens-Watkins 1
PMCID: PMC11300149  NIHMSID: NIHMS2001022  PMID: 38852823

Abstract

Introduction.

Opioid-related overdose mortality disproportionally affects Black adults in Kentucky, particularly overdoses associated with prescription opioid misuse (POM). Black adults also face other consequences of POM, such as disparate health and legal outcomes. While several factors effect POM, such as generational factors and gender, these risk factors are understudied among Black adults with a history of POM. Current literature primarily focuses on White individuals who use opioids.

Method.

The present study qualitatively examined reasons for POM, prescription opioids misused, how prescription opioids are obtained, and initiation of POM among Black adults using thematic analysis. Participants included a sample (n = 39) of Black adults from a southern state, stratified by gender and age across four cohorts: born (1) 1995 – 2001, (2) 1980 – 1994, (3) 1970 – 1979, and (4) 1955 – 1969.

Results.

Results revealed similarities and differences in these themes across age cohorts and gender.

Conclusions.

Implications for findings were discussed, including the importance of culturally responsive interventions that utilize dual diagnosis treatment and idiographic approaches due to heterogeneous experiences with POM among Black adults.

Keywords: Prescription Opioid Misuse, Black Adults, Gender Differences, Generational Patterns

Introduction

Opioid overdoses in Kentucky increased over 54% from 2020 – 2021 (Ahmad et al., 2023), ranking fourth in overdose deaths in recent years during the COVID-19 pandemic (Center for Disease Control and Prevention [CDC], 2022). In response to the opioid epidemic, efforts towards policy change have intensified, including increased research on pain and addiction, as well as progressions towards accessible treatment services. Though, most of these efforts have targeted White, suburban, middle-class, and rural individuals that use opioids—a population politically and socially represented as being uniquely affected by the opioid epidemic (James & Jordan, 2018). However, in 2020, opioid-related overdose deaths among Black individuals surpassed White individuals for the first time in U.S. history (Gibbons et al., 2023), highlighting a heightened risk among this population. Moreover, overdose deaths involving synthetic opioids, such as fentanyl, are increasing at a faster rate among Black individuals than any other racial group (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020).

Some Black populations are at a greater risk for opioid-related overdoses. For example, Black adults in Kentucky are disproportionately affected by prescription opioid overdoses compared to Kentucky’s overall overdose rates (Larochelle et. al, 2021). Specifically, overdose rates significantly increased by an estimated 38% among Black adults in Kentucky from 2018 to 2019 relative to White adults, with no change among other racial and ethnic groups (Larochelle et al., 2021). Further, overdoses increased by 57% in 2020 among Black non-Hispanic residents compared to 45% among White non-Hispanic residents (Slavova et. al, 2021). Although data related to opioid overdoses outline a clear disparity in mortality rates among Black Kentuckians, limited research exists among this population, and much of the current literature examining the opioid epidemic among Black populations has focused on drug laws and policy implications (James & Jordan, 2018). It is essential to also examine the various aspects of opioid use, such as specific patterns of misuse among Black individuals, who have been largely underrepresented in national opioid research.

Researching potential differences in patterns of prescription opioid misuse (POM) among Black individuals, for example, may lead to a deeper understanding of addiction, resulting in effective culturally tailored POM treatment, overdose, and prevention interventions (Avalos & Mulia, 2012). There are various types of prescription opioids (CDC, 2021a), such as semi-synthetic opioids (e.g., Hydrocodone [common form: tablet; other compound names: Lortab, Vicodin], Percocet [common form: tablet; other compound names: Oxycodone, OxyContin]), synthetic opioids (e.g., Methadone [common forms: syrup, tablet]), and natural opiates (e.g., Codeine [common form: tablet, syrup; other compound names: Promethazine, “Syrup,” “Lean”] and Morphine [common form: tablet, liquid, capsule]). Natural opiates, synthetic opioids (man-made), and semi-synthetic opioids all target opioid receptors in the brain to reduce pain and are known to have high addiction potential (CDC, 2021a).

Limited research examines patterns associated with how POM patterns differ across generations of adults who use opioids nonmedically (Hu et. al, 2017; Miech et al., 2013), even though broad generational patterns have emerged in existing national data. For example, National Survey on Drug Use and Health (NSDUH) data indicates higher rates of POM among adults born between 1980 and 1994 compared to those born prior to 1980 (Miech et al., 2013). Recent research from 2019 – 2020 reveals more nuanced generational patterns among Black individuals specifically. Black individuals aged 15 – 24 were shown to have the highest relative increase in overdose deaths, while the highest overall opioid-related overdose deaths were among Black adults aged 45 – 64 (Kariisa et al., 2022). While research shows generational patterns of overdose among Black individuals, research specific to POM among Black populations is limited. Black populations are less likely to follow substance use progression patterns like other racial and ethnic groups, such that Black populations show later initiation than White populations but have a crossover effect regarding rates of use in adulthood compared to other racial and ethnic groups, including White adults (Banks & Zapolski, 2018). Black adults also report delayed treatment entry compared to other racial and ethnic groups (Lewis et. al, 2018). These differences in use patterns over time highlight the need to examine specific generational patterns of POM among Black populations.

Patterns of POM are further nuanced when considering gender. Black men are disproportionately affected by overdose deaths, with rates more than tripling from 2015 – 2020 (Gramlich, 2022). Black men have the highest rates of overdose deaths compared to the other racial and ethnic groups and gender groups, with prescription opioids playing a dangerous role in some of these deaths (Gramlich, 2022). Rates of overdose among Black women have also increased in recent years, more than doubling from 2015 – 2020 (Gramlich, 2022), and women show a slower decrease in POM than men (Marsh et. al, 2018). Further, NSDUH data indicates rates of POM are 3.4% among Black women and 4.9% among Black men (Nicholson & Vincent, 2019), with changes in rates by gender across age groups (Jordan et al., 2021). Thus, understanding generational and gender patterns of POM—with a more detailed lens beyond prevalence data—is critical. Differences across these characteristics can result in differential outcomes, especially for Black individuals who often suffer disparate consequences of substance use including medical problems and criminal justice involvement (Vilsaint et al., 2019; Wildeman & Wang, 2017).

The Current Study

Despite risks of POM and overdose deaths among Black adults, research examining gender and generational patterns of POM is vastly underrepresented in current literature, which limits the capacity to develop the most culturally appropriate and effective treatment and prevention interventions among Black adults. As such, the current study examined generational and gender patterns of POM by highlighting specific qualitative themes related to reasons for POM, common prescription opioids misused, how prescription opioids were obtained, and prescription opioid misuse initiation. The current study utilized a qualitative approach to highlight themes of POM to allow space for participants to elaborate when discussing their POM experiences. This method may be more culturally appropriate, given that storytelling is a Black cultural tradition (Banks-Wallace, 2002).

Method

Study Design

Data for this study came from the first aim of a mixed methods study examining POM among Black individuals in one southern state. The parent study was approved by a university institutional review board (IRB). The parent study qualitatively explored cultural and generational characteristics associated with POM, illicit drug use, and treatment. From 2020 – 2021, participants were recruited through social media (e.g., Facebook, Instagram, Twitter) and strategically distributed flyers in zip codes with between 40 and 95% Black residents in the state. Participants were eligible if they: (1) self-identified as Black, (2) were 18 years of age or older, (3) were English speaking, (4) reported using a prescription opioid not prescribed at least once in the last six months or differently than prescribed in the last six months, and (5) were willing to be audio-recorded.

Eligible participants provided informed consent to participate in the study. After obtaining informed consent, participants completed a brief demographic survey, a mini-mental state examination (Cockrell & Folstein, 2002), and an audio-recorded semi-structured interview lasting between 55 – 120 minutes. Interviews were conducted by race-matched study team members in private rooms and were audio-recorded using HIPAA compliant Zoom software (Zoom Video Communications, Inc., 2021). Participants answered several items related to their POM (e.g., What prescription drugs are you using in a way that is NOT prescribed? Where do you usually get prescription drugs that are NOT prescribed? Have you gotten prescription opioids from friends and family members? If so, tell me how it usually happens. Tell me about the first time you remember using prescription drugs without a prescription or in a way not prescribed?). Post-hoc analyses then examined experiences of mental health symptoms and diagnoses, such as depression and anxiety. This data was captured with a series of items, such as: Do you have personal experience with any symptoms of anxiety? Do you have personal experience with any symptoms of depression? Do you have personal experience of other current mental health concerns? and, Were you ever diagnosed or treated with mental health concerns as a child or adult? Participants could answer yes or no, and often expanded on their experience. Participants received $40 for completing the interview. Participants were also offered opioid overdose education and free Narcan®, an emergency intervention for suspected opioid overdose (Emergent Devices, Inc., 2021).

Participants

The study sample consisted of 39 participants stratified across four age cohorts: (1) born 1995 – 2001, (2) born 1980 – 1994, (3) born 1970 – 1979, and (4) born 1955 – 1969. Each cohort was recruited to have equal representation of men and women, however, one sub-cohort, Black women born 1995 – 2001, was not filled (n = 3). Also, another sub-cohort, Black women born 1980 – 1994, was oversampled (n = 6). As such, the study’s final analytic sample included n = 39 Black individuals (20 men and 19 women). The average age of the participants was 41 years old (M = 41.5; SD = 13.5). Participants self-identified as African American (n = 35, 90%), African (n = 1; 2.5%), Caribbean (n = 1; 2.5%), and biracial (n = 2; 5%). Most of the sample was single/never married (n = 25; 66%), identified as heterosexual (n = 28; 72%), and completed at least 12 years of education (n = 29; 74%). Finally, most participants reported an average annual household income of less than $20,000 (n = 29, 74%).

Data Analysis

Interviews were de-identified and transcribed using a professional transcription service, followed by upload to Dedoose, a qualitative and mixed methods research analysis tool (Sociocultural Research Consultants, LLC, 2021). Through a constructivist paradigm, the first and second author completed a six phase, inductive thematic analysis (Braun & Clarke, 2006; Braun et al., 2018). Analysis began with the authors familiarizing themselves with the transcripts and field notes and recording their own memos throughout the process. Following data familiarization, authors identified segments of each transcript using a search tool in Dedoose where participants discussed initiation of POM, reasons for using, sources of prescription opioid obtainment, and common prescription opioids that were used nonmedically. Then, the authors read the full transcripts to ensure the search tool did not miss information in the theme domains. Segments were highlighted using a highlighting tool in Dedoose and were analyzed for latent and semantic components during initial coding, then grouped into larger themes. Authors achieved consistency and agreement of the themes by meeting weekly to discuss codes and identified themes to help ensure data trustworthiness (Nowell et al., 2017). Finally, the qualitative sample size was deemed appropriate for interpretation given guidelines on informational power (see Malterud et al., 2016).

Results

Themes for Generational and Gender Patterns of POM

There were various patterns that emerged related to generational and gender cohort patterns for POM across four general theme domains: (1) reasons for POM, (2) common prescription opioids misused, (3) how the prescription opioids were obtained, and (4) when the POM was initiated (aggregated in Figure 1). Participants were given pseudonyms and data for the specific themes and sub-themes for each participant are detailed in Table 1.

Figure 1.

Figure 1.

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Aggregate of Generational and Gender Patterns of Nonmedical Prescription Opioid Misuse Among Black Adults: Themes and Sub-themes

Table 1.

Pseudonyms and specific theme-related data.

Pseudonym Gender Age Cohort Reason(s) for POM Common Opioid(s) Obtainment Initiation
Aaron Male 1970–1979 Pain Percocet Friends Young adult/college
Breonna Female 1980–1994 Pain, relaxing, depression Percocet Family, Friends Did not say
Corinne Female 1980–1994 Relaxing/numbing, pain Lortab, Percocet Friends, unknown person 17
Darrin Male 1980–1994 Pain Lortab, Percocet Acquaintances, partner 15
Elle Female 1980–1994 Depression, Pain, peers using at a party Hydrocodone, Percocet Family, prescription, friends 17
Fantasia Female 1980–1994 To get high, pain Percocet, Methadone Friends, prescription, family of friends 15
Gary Male 1955–1969 Physical and mental pain Lortab, Percocet Streets, friends, prescription Did not say
Henry Male 1955–1969 Available Percocet Friends, family 30
Isaac Male 1970–1979 Sex, curiosity, pain Percocet Streets Young adult/college
Junior Male 1980–1994 To get high Did not say Streets 15
Keosha Female 1980–1994 Peers doing it, calming, to fit in Percocet Friends 14
Lanisha Female 1980–1994 To feel accepted Percocet Prescription, family, friends 22
Madison Female 1970–1979 Pain, numbing, curiosity, sleep Percocet Unknown person, prescription Did not say
Nate Male 1970–1979 Numbing emotions Percocet Friends, streets 17
Otis Male 1980–1994 Depression/anxiety, experimenting Lortab, Percocet Friends, family 22
Percy Male 1970–1979 Pain Percocet, Lean Friends, prescription 21
Quincy Male 1970–1979 Cope with stress and trauma Percocet Unknown person, family, acquaintances, friends 20
Randy Male 1980–1994 Pain Lortab Friends, family, prescription, family of friends Did not say
Steven Male 1955–1969 Relaxes/calms, cope Percocet Streets, family 14
Tyrone Male 1955–1969 Pain Lortab Family, friends 20
Ulysses Male 1955–1969 Pain Lortab Friends, prescription 45
Veronica Female 1970–1979 To get high Percocet Friends 18
Walter Male 1980–1994 Pain Lortab Family, streets 28
Xavier Male 1995–2001 To get high Lortab Family, streets 15
Yolanda Female 1995–2001 Numbing, anxiety relief, relaxation Did not say Friends of family, family, peers in treatment 23
Zendaya Female 1995–2001 Pain, mellow, numb emotions, trauma Percocet Social media 12
Ada Female 1955–1969 Depression, pain Lortab, Percocet Prescription Did not say
Bertha Female 1955–1969 Pain Lortab, Percocet Prescription 53
Calvin Male 1995–2001 Sex, relax, to get high Percocet Prescription, streets 16
Denise Female 1970–1979 Pain Percocet, Hydrocodone Friends, family, prescription, streets 14
Emerald Female 1970–1979 Pain Lortab, Percocet Prescription 15
Felicia Female 1955–1969 Pain, Anxiety Lortab Family, friends 25
Grace Female 1970–1979 Pain Percocet Unknown people, prescription 48
Henrietta Female 1955–1969 Pain, sleep Lortab Prescription, streets 58
Idell Female 1955–1969 Pain Percocet Friends, family of friends, streets 20s
Justin Male 1995–2001 Sex, sleep Lortab, Percocet Streets 17
Kyle Male 1995–2001 Peers offering Lean, Hydrocodone Family Young adult/college
Langston Male 1995–2001 Pain, to get high, curiosity, parties Lortab, Percocet Family 19
Maya Female 1995–2001 Pain, numbing Hydrocodone Partner 22
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Reasons for POM

There were various sub-themes regarding reasons participants reported POM. These reasons centered around pain, getting high, relaxation, and social reasons. Less common reasons were for sleep (n = 3; 8%), curiosity (n = 4; 10%), and racism in the military (n = 1; 3%). Unsurprisingly, the most common reason and sub-theme for POM expressed across every gender and age cohort was pain, with over half of the sample (n = 24; 62%) stating that pain was a contributor to their POM, at least in part. For example, Percy (1970 – 1979, M) reported that he started taking Percocet because, “[he] knew that take[s] pain away.” Another participant recounted, “It would be just for pain, mostly. If my knee hurt, back hurt, bad headache, or something, you take a pill and it take the pain away. You forget all about whatever the hell was hurting when you take it,” (Darrin; 1980 – 1994, M). These participants provide a glimpse into the main purpose of prescription opioids; it reduces or eliminates experienced pain, whether general feelings of discomfort, or pain because of a previous injury. However, there were other reasons participants reported POM, some of which were unique to gender and/or age cohorts.

Participants across all the cohorts, except the oldest cohort (1955 – 1969) of men and women, described that another primary reason and sub-theme for misusing prescription opioids is to get high (n = 7; 18%). For example, participants expressed, “trying to get high,” (Junior; 1980 – 1994, M), and “[using] to get high,” (Xavier; 1995 – 2001, M), as at least one of the goals for misusing prescription opioids. Notably, many additional participants (n = 13; 33%) described feelings that could be associated with getting high, but they didn’t explicitly express “getting high” as a motivation. Instead, participants described feelings such as “numb,” “calm,” and “relaxed” as the target sensations for misusing prescription opioids. It remains unclear if these participants were, in fact, describing what a “high” feels like for them, and identifying those specific sensations as their reason for POM. Nonetheless, these participants described these sensations as pleasurable because they either relieve mental health symptoms or provide a comforting feeling.

More specifically, many of the 13 participants (n = 10; 77%) identified that those calming and numbing feelings were a motivator because it helped relieve undesirable mental health symptoms such as anxiety, depression, or symptoms related to trauma. As such, relieving mental health symptoms was the next identified sub-theme. For example, Felicia (1955 – 1969, W) said, “it takes the anxiety away, and I don’t feel so bad.” The remaining 3 participants (23%) did not specify mental health symptoms as a reason for wanting to feel “relaxed” or “calm,” they just described those feelings in the context of feeling “comfortable.” Importantly, the youngest male cohort (1995 – 2001) was the only cohort to not mention mental health symptoms as a key reason for POM, and these men were more likely to describe relaxation as a means for comfort, highlighting a more general sub-theme of relaxation and comfort. For example, one participant described his thought process before using pills: “…I am going to have to relax everything. Like, anytime I’m in an uncomfortable situation,” (Yolanda; 1995 – 2001, W).

A final common reason reported for POM was social reasons, and these reasons also had specific gender and age patterns. First, men and women in the youngest cohorts (1980 – 1994 and 1995 – 2001) were the primary cohorts to describe the sub-theme of partying and/or gatherings as a reason for POM (n = 6; 15%). Elle (1980 – 1994, W) recounted, “At a party, my friends and I. They were crushing up the pills, and I was looking at it. I was looking like, ‘You’re going to put that up your nose?’ I just felt kind of strange about it, but because everyone else did it, I did.” This participant not only described the partying/gathering as the reason for POM, but also the peer pressure involved in those environments. Another social reason, expressed by only men (n= 4; 10%), was POM as an enhancer for sexual encounters, which was the final identified sub-theme. Specifically, the younger and middle-aged men (i.e., 1995 – 2001 and 1970 – 1979 cohorts) provided this as a reason. For example, Justin (1995 – 2001, M) said, “If you want to get extra groovy, last two, two and half, three hours, you feel me? You pop a perc,” when talking about Percocet and having sex.

Prescription Opioids Misused

The prescription opioids misused were fairly consistent among the sample. All gender and age cohorts reported misusing Percocet (n = 23; 59%), making it the most common opioid used among the sample. The next most common opioid was Lortab (n = 16; 41%). Interestingly, Percocet and Lortab were not only the prescription opioids of choice among the participants, but they were also often used together, though not necessarily at the same time. For example, of the 23 participants identifying Percocet and 16 identifying Lortab as common prescription opioids used, 10 of these participants reported using both Percocet and Lortab. Walter (1980 – 1994, M) said when describing what he uses, “Lortabs, Percocets. Honestly, whatever I can find in that category.” This participant’s statement suggests that while Lortab and Percocet may be common, he would be open to any prescription opioid.

The most notable gender and generational patterns were found in the use of Hydrocodone (the same compound as Lortab) and Lean (i.e., Promethazine; Codeine). Regarding Hydrocodone, mostly women (n = 4; 10%) reported using this opioid, with exception of the youngest cohort (1995 – 2001), where one of the men (3%) also reported using Hydrocodone. Regarding Lean, only men (n = 2; 5%) reported using this opioid: one in the 1995 – 2001 cohort and one in the 1970 – 1979 cohort. Comparably, Hydrocodone and Lean were mentioned less often than Percocet and Lortab. Only one participant (3%) in the 1980 – 1994 women’s cohort reported having used Methadone. A final notable finding is that the younger (1995 – 2001) men reported regular misuse of the most varied prescription opioids, reporting misuse of four different substances.

Prescription Opioid Obtainment

Sub-themes for how prescription opioids were obtained revealed that prescriptions from doctors, the streets, friends, family, and social media were the most common sources of obtaining prescription opioids. Notably, women across the cohorts more commonly discussed getting a prescription from a doctor and misusing the prescription (n = 10; 26%) compared to men (n = 5; 13%). Percy (1970 – 1979, M) described misusing his prescription pills and connecting it to a level of privacy he desired: “…Because I can sit back quietly and be high and observe or whatever, be numbed. And it’s really nobody’s business because it’s prescribed to me.” His description suggests a level of expected indifference about misusing one’s own prescription since it is prescribed to him. Another participant, when asked if she used her prescriptions as prescribed, noted, “Sometimes,” (Grace; 1970 – 1979, W), again showing access to prescription pills through a prescription potentially leading to misuse.

Another source for obtaining prescription opioids were “the streets,” and similarly, from friends/peers. Men across all of the age cohorts (n = 9; 23%) more commonly reported obtaining pills from the streets compared to women (n = 3; 8%). Of the women reporting that they obtained prescriptions opioids from the streets, they were from the older cohorts of women (1970 – 1979 and 1955 – 1969). When describing where he gets his prescription opioids from, Justin (1995 – 2001, M) stated, “For the most part, it’s just people on the streets.” Similarly, Walter (1980 – 1994, M) described, “…When I couldn’t get them myself, I was just buying them on the streets. And one thing leads to another, taking them because you need them, to abuse, to both, because I do need them. I can say I need them. I do. I hurt, but I want to get high too.” Walter described the progression of his use once he started getting them off the streets. Notably, when obtaining prescription opioids from others, only 4 participants (10%) described that the person they obtained them from was a random person, suggesting participants typically know the person they are getting prescription opioids from.

Often, the people on the streets that participants obtain prescription opioids from were friends. Other times, participants get them from friends (not in a street transaction). Overall, participants getting opioids from friends was nearly equal across gender and age cohorts (nwomen = 8; 21% and nmen = 7; 18%), with exception of the youngest cohort (1995 – 2001), who did not report obtaining from direct friends. Aaron (1970 – 1979, M) said, “Sometimes they prescribe me stuff, but sometimes I got stuff too, from other players and my friends.” This participant shows that the way prescription opioids are obtained may change across the course of the substance use journey. Interestingly, the youngest cohort, which was a cohort likely to use in a partying/gathering context, did not report obtaining from friends. They reported getting them from friends of friends, social media, or relatives. For example, Yolanda (1995 – 2001, W) stated she got prescription pills from her “brother’s friends.”

Family (n = 15; 38%) was another common source for obtaining prescription opioids for all the cohorts except men and women in the 1970 – 1979 cohort. Some participants expressed being given prescription opioids by a family member. For example, Tyrone (1955 – 1969, M) recalled, “I got one from my sister. She pulled something in her back. She just gave me one,” when talking about how he obtained Lortab. Contrarily, other participants shared that they stole the prescription opioids from a family member that had a prescription. For example, Xavier (1995 – 2001, M) described that he knew where his grandma stored her medications and how he would take them, “My granny, old people, they keep theirs in they little pill bottles. They got the Monday, Tuesday, Wednesday, Thursday pills. I just bye-bye, bye, bye.”

A less common source for obtaining prescription opioids that was unique to the youngest cohort (1995 – 2001) of men and women was social media (n = 2; 5%). Zendaya (1995 – 2001, W) described how she and her friends would get pills from Facebook, a social media platform, “Facebook, Facebook. There’s something about people, we don’t post it. It’s just like codewords and what not. ‘I’ve got doo, doo, doo,’ ‘oh do you?’ ‘Well, I need about four or five of those.” Other less common sources were from partners (n = 2; 5%), work (n = 1; 3%), and peers in treatment facilities (n = 1; 3%).

POM Initiation

Prescription opioids were initiated at similar times across many of the age and gender cohorts. The sub-themes for initiation were adolescence, emerging adulthood and adulthood, and mid-to-late adulthood. For all cohorts except the oldest cohort (1955 – 1969) of men and women, POM was initiated from adolescence (i.e., teenage years) through their early 20s. Some participants discussed being high-school aged, like participant Elle (1980 – 1994, W) when she talked about nearing her high-school graduation, “At the end was when my friends and I started to get into pills.” Others were in college/college-aged, like participant Isaac (1970 – 1979, M), who stated simply, “My progression didn’t start until my second year of college,” or Kyle (1995 – 2001, M), “I think I was in college. I think it was my first summer after college. I think, or before college. Either my first summer coming back from college or just before I went to college.”

A very different age of initiation was observed among the men and women in the 1955 – 1969 cohort. These participants tended to start misusing prescription opioids much later, mostly in adulthood, from mid- to late-20s into as late as their 50s. For example, Henry (1955 – 1969, M) recalled how he started POM in his 30s, “Yeah [when I was 30 something] I had crossed that line.” Another participant in this age group stated, “I have only been getting the prescription pain pills for probably about six years or something like that,” (Bertha; 1955 – 1969, W).

Discussion

The current study highlighted generational and gender patterns of POM across four theme domains: reasons for POM, prescription opioids misused, prescription opioid obtainment, and POM initiation. Findings indicated some similarities and differences across these domains among generational and gender cohorts, which can be used to inform culturally appropriate POM prevention and treatment interventions among Black adults.

Reasons for POM

Findings highlighted that Black adults in the current sample reported POM to manage pain, to get high, for relaxation, and during social encounters and clear age and gender patterns emerged. Aligned with previous literature, pain was the most common reason for misusing prescription opioids, which may be distinct from affect-related motivations (McHugh et al., 2022). Notably, pain was consistently expressed as a reason across all the gender and age cohorts. Disparities in treatment of pain and cultural norms around pain in the Black community may influence the likelihood of POM among Black populations. For example, not only are Black populations less likely to receive prescriptions in a formal setting (e.g., doctor’s offices, Emergency Departments) or be referred to pain management for experienced pain (Jordan et al., 2021; Tamayo-Sarver et al., 2003), but cultural norms may place Black individuals, particularly Black men (Samulowitz et al., 2018), at greater risk for self-medicating through misuse of opioids rather than discussing chronic pain with physicians or peers. Black populations have been shown to suppress feelings of pain to maintain a cultural and societal expectation of resilience and strength (Cousin et al., 2022). Suppression of pain may motivate POM among this population. Paired with physicians’ underestimation of Black patients’ pain (Staton et al., 2007), Black individuals experiencing pain may be less likely to be prescribed effective doses of prescription opioids. To help mitigate POM, and in turn, overdose among the Black population, ensuring equitable and thorough assessments of pain and medical monitoring of pain treatment among Black populations may help to improve rates of misuse.

A more nuanced finding was that participants expressed relaxation as a motivator for POM, though, “relaxation” varied in its appeal and meaning. Some participants (18%) explicitly described a desire to get high when talking about relaxation as a motivator, but more participants (26%) described less explicit sensations that could be associated with getting high that tended to center around numbing and relaxing distressing emotions. Notably, the oldest cohort (1955 – 1969) did not express getting high as a key reason for POM but did mention mental health symptoms. This finding suggests that interventions among older Black populations should seek to examine these other underlying motivators for POM, such as mental health complaints and pain. Findings related to mental health symptoms aligned with previous literature. For example, the disproportionate effect of the opioid epidemic on Black individuals may be partially attributed to pre-existing mental health disparities found in the Black community. Black populations are shown to have more persistent/severe depressive and anxiety disorders than other racial and ethnic minorities (Vilsaint et al., 2019). Among the current sample, post-hoc analyses revealed that 74% of participants reported experiencing a diagnosis or symptoms of anxiety, while 69% experienced a diagnosis or symptoms of depression. These rates are considerably higher than the rate of anxiety and depression symptoms in the general population (41.5%; CDC, 2021b). Given that anxiety and depression, as well as trauma, were reasons participants reported misusing opioids, dual diagnosis treatment for mental health and opioid misuse is indicated as a need among this population across all age and gender groups.

A final finding under the reasons for POM theme was social reasons. The youngest cohort (1995 – 2001) were the primary participants to describe partying as a reason for POM. Years of research indicates that peer substance use predicts young adult substance use (e.g., Andrews et al., 2002), and current findings indicate this relationship may extend to opioid misuse as well. Notably, many participants described these encounters as circumstantial and happenstance, rather than seeking prescription opioids in these settings. Given the high addiction potential of opioids (Mayo Clinic, 2023), this casual use of opioids may carry a risk of continual use to avoid withdrawal symptoms. The findings of the current study regarding situational POM suggests that prevention interventions for POM among young Black men and women should seek to help identify social triggers for use and provide alternative means for enjoying social activities, as well as skills to resist peer pressure. Skills training and identification/avoidance of triggers are components of Cognitive Behavioral Therapy for substance use disorders (McHugh et al., 2010), which is an empirically supported intervention shown to be effective for treating substance use disorders (Magill et al., 2019). The effectiveness of these strategies for prevention interventions should be examined. Similarly, and related to social encounters, men in the sample (particularly men from the 1995 – 2001 and 1970 – 1979 cohorts) reported POM to enhance sexual experiences. Findings are consistent with previous literature among men who have sex with men (MSM) and the “chemsex” movement, whereby individuals who mix sex and drugs do so with the expectation that their sexual encounters will be positively affected (Maxwell et al., 2019). This relationship is more common among MSM than heterosexual men in the literature, and often involves alcohol, cannabis, and/or MDMA (Lawn et al., 2019). However, the expectation to improve sexual encounters appears to extend to our sample of primarily heterosexual men who misuse prescription opioids. This finding highlights a need for interventions on safe sex practices among Black men who use opioids, since mixing drugs and sex has been shown to lead to riskier sexual encounters (Calsyn et al., 2010).

Prescription Opioids Misused

The most common prescription opioids used among the sample were consistent across all age cohorts of men and women. Percocet was the most common prescription opioid misused among the sample, and Lortab was the second most common. Percocet and Hydrocodone-containing substances are the leading prescription opioids of abuse (Mayo Clinic, 2022), which is aligned with the results of the current study. Semisynthetic opioid analgesics, such as Percocet and Hydrocodone, are designed to mimic natural opiates, but are more potent (Das et al., 2022), giving them a high addiction potential. Thus, it is imperative to closely monitor individuals prescribed these medications during health service encounters since our sample showed that access to a prescription from a doctor was often a catalyst for later misuse. Mental health professionals can also work with these individuals by targeting the underlying reasons the misuse typically starts, as highlighted in this study (e.g., pain and mental health symptoms). Interventions like Cognitive Behavior Therapy for Chronic Pain (CBT-CP; Murphy et al., 2012), and management of mental health symptoms, may be critical intervention areas of focus among Black adults who misuse opioids given the current study findings.

Further, Codeine misuse, specifically referred to as lean (i.e., mixture of promethazine and codeine) among the sample, was identified among the young and middle-aged men. Results are aligned with previous literature showing that lean, or syrup, is a commonly endorsed prescription opioid of misuse among Black men (Wheeler et al., 2018), which may be related to exposure to trauma (Dogan-Dixon et al., 2023). While the present study did not examine trauma history, exploring traumatic experiences may be beneficial for reducing codeine misuse among this population. Further, previous literature describes a trend in POM towards younger populations, with drug-related messaging in popular music playing a key role in glamorizing prescription drug misuse, such as misuse of codeine (Peteet et al., 2021). The glamorizing of drugs in popular music, such as rap music, began in the 1980s and 1990s, when drug mentions in rap music increased six-fold (Herd, 2008). These trends suggest a subcultural evolution (Golub et al., 2005) of POM. While it can be difficult to change the development of subcultural trends and the significance of drug use and drug popularity, it is important to be aware of these trends to better understand the impact of drugs and drug use within a culture. Results of the current study suggest a potential consequence of this trend is music leading to an apparent acceptance of POM, with young and middle-aged Black men in the current sample reporting using opioids, such as codeine, in social contexts.

Prescription Opioid Obtainment

Black adults in the current study reported obtaining prescription opioids from doctor’s prescriptions, “the streets,” friends, family, and social media. Sources of prescription opioids varied across gender and age cohorts. Specifically, women across all age cohorts more commonly reported obtaining prescription opioids from a doctor’s prescription compared to men, whereas men more commonly reported obtaining prescription opioids from “the streets.” This finding is consistent with research that shows that women are more likely to talk about experiences of pain and be more sensitive to pain—with pain being a common reason the current sample reported misusing opioids—while men are more likely to find expression of pain to be a threat to their masculinity (Samulowitz et al., 2018). These gendered norms in the expression and presentation of pain may lend women to seek treatment and receive prescriptions for pain more readily than men. Thus, women may be more likely to obtain pain medications from prescriptions, while men utilize other means of obtaining relief. Further, research suggests women’s pain may be undertreated, even though they may seek treatment more readily. For example, women are more likely to experience bias in treatment whereby their pain is often not believed (Samulowitz et al., 2018). As such, women may receive ineffective doses of pain medication (Samulowitz et al., 2018), potentially effecting misuse patterns to be able to properly manage symptoms. Providers should seek to encourage men to express experiences of pain, while simultaneously being aware of biases against women’s reports of pain.

Participants also obtained prescription opioids from friends and family, which was consistent across gender and age cohorts. However, the youngest cohort (1995 – 2001), did not report friends as a source for obtaining prescription opioids, instead reporting social media as a unique source. Longstanding research details peer substance use as a risk factor for use among adolescents (Trucco, 2020), and the current study further suggests this relationship among adults. Thus, assessing peer use among Black adults may be an effective way to assess risk of opioid misuse. Findings related to social media are also aligned with previous research that shows higher social media usage among young adults (Auxier & Anderson, 2021). Given the results of the current study, social media appears to be becoming a tool for obtaining opioids and future research should examine the effectiveness of intervening with social media prevention campaigns to mitigate misuse among young Black populations. Previous research suggests social media prevention campaigns may be effective for peer-to-peer use (Evans et al., 2017), and this strategy may extend to Black young adults who misuse opioids.

POM Initiation

A final theme examined was POM initiation. For all gender and age cohorts except the oldest cohort of men and women (1955 – 1969), participants initiated from teenage/high school aged into their early 20s. The oldest cohort, on the other hand, reported initiation of POM later, from mid- to late-20s to as late as their 50s. Previous research highlights POM initiation typically follows marijuana and alcohol use and begins around 14 years of age (Lankenau et al., 2012). However, these initiation patterns are typical among majority White samples. Current findings suggest, though, initiation of opioids among Black adults occurs at a similar, or even slightly later ages, which is consistent with research examining initiation patterns of other substances among Black individuals when compared to White individuals (Clemans-Cope et al., 2021). Older Black adults, though, initiate POM considerably later. Overall, findings have important implications for prevention interventions among Black populations, with idiographic approaches—that is, with particular focus on the individual—being indicated as potentially most effective among this population, given stratified initiation patterns.

Strengths, Limitations, and Future Research

The present study examined gender and generational patterns for POM among an underrepresented, yet disproportionally affected, population of Black adults. A strength of the study is that it highlights factors of POM among a sample of Black adults in a state with increasing rates of overdose, which can inform culturally relevant treatment and prevention interventions during at critical time of need. However, this study is not without limitations. This study utilized cross-sectional qualitative data, which limits the ability to make causal inferences. While the current study highlights key generational and gender differences of POM qualitatively, future research should extend the current work by examining within group differences quantitatively. This will allow providers and researchers determine which differences may be more relevant regarding treatment and prevention. Similarly, future research should conduct longitudinal research using proposed strategies and considerations for intervention among Black adults who misuse prescription opioids to determine the overall effectiveness of these strategies in health, substance use, and treatment outcomes. Finally, the current sample consisted of Black adults from a single southern state. Although the current sample was chosen due to a represented increased risk for opioid use and overdose, the findings in the current study may not be transferable to other Black samples. Future research should examine these patterns among a more representative sample of Black adults to see if findings replicate.

Conclusions

The current study highlighted generational and gender patterns of POM related to reasons for POM, common prescription opioids misused, prescription opioid obtainment, and POM initiation. Findings suggest that pain and mental health factors are key contributors in POM across groups, emphasizing the need for dual diagnosis treatment. However, several unique contributors to POM were also identified and can inform targeted prevention and treatment interventions for specific gender and age cohorts. For example, findings highlight a need to help young Black men and women recognize social norms and triggers of POM and skills to navigate situations whereby they may encounter prescription opioids, such as social settings and social media. Education around the dangers of casual use of these highly addictive substances is imperative among this group. Another key finding was the risk of drug diversion among the sample, particularly among women. Women in the current sample were most likely to misuse and share prescribed opioids directly from a doctor. These heterogeneous experiences with POM across gender and age groups highlight the need idiographic approaches. Finally, prevention efforts among at-risk youth would likely be most beneficial before adolescence and young adulthood, which was a common initiation period among the current sample. Overall, strategies to prevent and intervene with POM require intentional focus on not only internal experiences, such as pain and mental health, but also external motivators, such as peer use and access.

Highlights.

  • Pain and mental health factors are key contributors of POM across age and gender.

  • Percocet and Lortab were the most common prescription opioids misused.

  • Doctors, the streets, and social media are common sources of prescription opioids.

  • POM initiation varied across age and gender cohorts.

  • Dual-diagnosis and idiographic approaches are culturally-relevant POM treatments.

Author Note/Acknowledgements

Research reported in this manuscript was supported by the National Institute on Drug Abuse (NIDA; R01-DA049333; PI: Danelle Stevens-Watkins). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health. The authors report no conflicts of interest.

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