Abstract
Purpose: Heightened rates of prescription opioid misuse have been observed among sexual minority (SM) compared with heterosexual populations. In addition, depression and suicidal ideation are risk factors for misuse, and they are also elevated among SM populations. The purpose of this analysis was to examine whether depression and suicidal ideation attenuate disparities in prescription opioid misuse among SM adults.
Methods: Data came from a publicly available, nationally representative data set, the National Survey on Drug Use and Health, 2015–2018. Among adults, survey-weighted logistic regression was used to assess the relationship between sexual orientation and past-year opioid misuse adjusting for demographics and either past-year major depressive episode or suicidal ideation. Probabilities of prescription opioid misuse were also assessed under counterfactual rates of depression and suicidal ideation. Analyses were stratified by sex.
Results: Among participants in the analytic sample (N = 169,759; SM = 11,268), 9254 (5.5%) reported past-year prescription opioid misuse. The overall rate of opioid misuse decreased from 6.2% in 2015 to 4.6% in 2018. The association between sexual orientation and opioid misuse was attenuated downward for gay men, lesbian women, and bisexual individuals (men and women) after adjusting for either major depressive episode or suicidal ideation, but opioid misuse remained higher among most SM groups. In addition, rates of opioid misuse were found to be lower in counterfactual analyses with a nearly 2.5- and 4-fold decrease in depression and suicidal ideation among gay men and bisexual women, respectively.
Conclusion: Efforts to reduce disparities in depression and suicidal ideation affecting SM individuals may reduce disparities in prescription opioid misuse affecting this population.
Keywords: depression, opioids, sexual minority populations, suicidal ideation
Introduction
National trends in overall opioid prescriptions peaked by 2012 and then decreased to their current low point in 2017 at a rate of 58.7 prescriptions per 100 people.1–3 Even in light of this downward trend, the rate of long-term opioid prescriptions between 2006 and 2017 (those lasting longer than 30 days) experienced a persistent 3% annual increase1 and, in 2018, two million people reported having an opioid use disorder.4 In addition to these stark statistics, opioidsa account for more than two thirds of drug overdose deaths, which have risen steadily each year through 2017.5 Furthermore, rates of opioid use, prescription opioid misuse, and overdose deaths vary by demographic characteristics, particularly sexual orientation and sex.6–8
Sexual minority (SM) men and women, compared with their heterosexual counterparts, have higher rates of opioid use.6 For example, they initiate prescription opioid misuse at younger ages7 and exhibit 40%–140% higher rates of misuse.8 Among generalized samples, men have long been demonstrated to be more likely to use opioids9–11; however, recent work has demonstrated that this trend is reversed among SM individuals, with SM women more likely to use opioids than SM men.6 This same study noted that only SM men aged 50 years and older, compared with similar aged SM women, exhibited greater rates of past 12-month opioid use.6 In addition, past work has noted a faster increase in the rate of opioid-related overdose deaths among women since 1999 (400% among women vs. 265% among men),12 although distinctions based on sexual orientation were not made. Of note, while recent studies have continued to document sexual orientation disparities in opioid use, we are not aware of any studies that have sought to explore potential mechanisms driving this disparity.
In addition to substance use,13–19 SM individuals are also affected disproportionately by negative mental health outcomes, such as depression and suicidal ideation.20,21 For example, compared with their heterosexual counterparts, SM populations are more likely to meet criteria for major depressive disorder and persistent depressive disorder,22 and to report suicidal behaviors.23 These findings are particularly striking for bisexual individuals, who experience disparities relative to both heterosexual individuals, gay men, and lesbian women. Importantly, depression and suicidal ideation are associated with increased rates of prescription opioid misuse,3,24 suggesting that they may attenuate the disparity in opioid misuse affecting SM individuals.
There are several potential explanations for why this population is at increased risk for prescription opioid misuse as well as depression and suicidal ideation relative to heterosexual individuals. Minority stress theory suggests that SM individuals experience unique stressors related to their stigmatized identity (e.g., discrimination, the internalization of negative societal attitudes) and that these unique stressors contribute to disparities in both substance use and mental health problems.25 Furthermore, based on the psychological mediation framework, stigma-related stressors can contribute to maladaptive coping mechanisms (e.g., using substances to regulate negative emotions), which in turn can contribute to substance use problems.26 This suggests that SM populations may use substances to cope with depression and suicidal ideation, and previous research has found that this extends to the misuse of prescription drugs including opioids.27 Despite evidence of sexual orientation disparities in opioid misuse, depression, and suicidal ideation,13–23 as well as evidence that depression and suicidal ideation are associated with opioid misuse,3,24 we are not aware of any previous studies that have examined whether either of these mental health factors attenuate the disparity in prescription opioid misuse affecting SM individuals.
To address this gap in the literature, we aimed to assess potential mechanisms underlying disparities in past-year prescription opioid misuse affecting SM adults in the National Survey on Drug Use and Health (NSDUH) from 2015 to 2018. First, we aimed to estimate potential differences in prevalence of prescription opioid misuse under the counterfactual scenario that rates of depression and suicidal ideation among SM participants were similar to those among heterosexual participants. Second, we examined whether depression or suicidal ideation attenuate the disparity in prescription opioid misuse affecting this population while also adjusting for demographic and other risk factors. Finally, we explored whether any of these associations differ by sex.
Methods
Study population
Data for these analyses came from the publicly available NSDUH data sets.28 The NSDUH is an ongoing nationally representative cross-sectional survey of private noninstitutionalized U.S. citizens across all 50 states and the District of Columbia. The study provides current information on tobacco, alcohol, and drug use, mental health, and other health conditions. Survey sample weights are provided by the NSDUH as part of the publicly available data and are used to obtain nonbiased estimates for survey outcomes. The analyses conducted as part of this study were exempt from institutional review board review as all data are publicly available and provided as a de-identified data set.
The analytic data set utilized here was limited to the NSDUH data from 2015 to 2018. These years were chosen as 2015 was the first year that the NSDUH assessed sexual identity among participants and 2018 was the final year available at the time of data analysis. The analytic sample was limited to adults, as minors did not receive questions related to sexual identity, and to those individuals who responded to the mental health questions. Nor did we include data for those who selected “Not Sure” when asked about their sexual identity. For the purposes of analysis, data were aggregated across all study years (N = 169,759) and models were adjusted for year of data collection.
Measures
Survey participants self-reported demographic information, including age, race and ethnicity, sex, and sexual identity. Age was provided as a recoded categorical variable in the NSDUH data set and included the following categories: 18–25, 26–34, and 35 years or older. Race was similarly recoded, with the categories: non-Hispanic White, non-Hispanic Black, non-Hispanic Native American/Alaska Native, non-Hispanic Native Hawaiian/Pacific Islander, non-Hispanic Asian, and non-Hispanic Multiracial. Participants reporting a Hispanic ethnicity were coded as such, regardless of their racial identity. Sexual identity was assessed with the question, “Which of the following do you consider yourself to be?” and coded as heterosexual individuals, lesbian women, gay men, or bisexual individuals.
Prescription opioid misuse
Misuse of prescription opioids was defined as use in any manner which was not directed by a medical doctor, including: use without one's own prescription; use in greater amounts, more often, or longer than told to take the drug; or use in any other manner not directed by the medical provider. Analyses were limited to past-year prescription opioid misuse to align with the similar timing of the depression and suicidal ideation variables.
Depression
Participants were classified as having had a major depressive episode in the past year if they met diagnostic criteria for a major depressive episode from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV).29 Items assessing depressive symptoms were adapted from the National Comorbidity Survey. Please see the following for details regarding the specific diagnostic criteria.28
Suicidal ideation
Participants indicated whether or not they had “seriously thought about killing oneself in the past year” (yes or no).
Statistical analyses
Separate multivariable survey-weighted logistic regression models, adjusting for demographic characteristics and year of data collection, were then utilized to examine whether depression or suicidal ideation was associated with sexual orientation. Next, similar models were analyzed to assess the association between past-year prescription opioid misuse and sexual orientation adjusting for: (1) demographic characteristics and year of data collection; (2) past-year major depressive episode and variables in (1); and (3) past-year suicidal ideation and variables in (1). Given differing rates of depression and suicidal ideation among women and men, all analyses were stratified by sex. All statistical and known confounders were included in all multivariable regression models, and statistical significance was established at alpha <0.05.
Secondary analyses were conducted to determine what rates of prescription opioid misuse would be expected for heterosexual and SM groups if SM individuals experienced similar rates of depression and suicidal ideation as heterosexual individuals, referred to as a counterfactual scenario. For these calculations, we used methods previously described in detail by Ahern et al.30 Briefly, we used the models mentioned in the previous paragraph to estimate the associations between prescription opioid misuse and SM status, adjusting for demographic characteristics and other variables. Next, we used the regression equations from these models to impute the log odds of: (1) prescription opioid misuse when rates of depression and suicidal ideation were fixed to the average rate for the heterosexual group for all individuals (counterfactual predicted rates) and (2) prescription opioid misuse given an individual's own depression or suicidal ideation (actual predicted rates). Log odds were subsequently converted to probabilities. Finally, computed probabilities were averaged within each sexual orientation group, stratified by sex, to determine the average predicted probability of prescription opioid misuse under counterfactual and actual circumstances. All analyses were performed in Stata 14.0 (StataCorp LP, College Station, TX).
Results
Among 169,759 participants between 2015 and 2018, 9254 (5.5%) reported prescription opioid misuse in the past year (Table 1). This overall rate of misuse decreased across the analysis period from 6.2% (n = 2678) in 2015 to 4.6% (n = 1954) in 2018. This rate varied widely, however, by sexual orientation with misuse among heterosexual individuals decreasing from 5.8% to 4.3%, misuse among lesbian women and gay men from 10.6% to 7.9%, and misuse among bisexual individuals from 14.2% to 9.8%. Further disparities in prescription opioid misuse were observed between men and women with men experiencing a decline from 6.3% to 4.4% and a decline among women from 5.2% to 4.1%. Meanwhile, 15,063 (8.9%) met criteria for a major depressive episode in the past year and 9990 (5.9%) reported suicidal ideation in the past year. Regarding demographic characteristics, the majority of participants were aged 35 years or older (n = 79,825, 47.0%), female (n = 90,883, 53.5%), identified as heterosexual (n = 156,026, 91.9%), and non-Hispanic White (n = 102,754, 60.5%).
Table 1.
Demographic Characteristics of Participants in the Analytic Sample, the National Survey on Drug Use and Health, 2015–2018 (N = 169,759)
| Variable | Total |
No past-year prescription opioid misuse |
Past-year prescription opioid misuse |
p | |||
|---|---|---|---|---|---|---|---|
| N | % | n | % | n | % | ||
| Past-year depression | <0.001 | ||||||
| No | 154,696 | 91.1 | 147,384 | 95.3 | 7312 | 4.7 | |
| Yes | 15,063 | 8.9 | 13,121 | 87.1 | 1942 | 12.9 | |
| Past-year suicidal ideation | <0.001 | ||||||
| No | 159,490 | 94.0 | 151,903 | 95.2 | 7587 | 4.8 | |
| Yes | 9990 | 5.9 | 8345 | 83.5 | 1645 | 16.5 | |
| Age, years | <0.001 | ||||||
| 18–25 | 54,907 | 32.3 | 50,941 | 92.8 | 3966 | 7.2 | |
| 26–34 | 35,027 | 20.6 | 32,673 | 93.3 | 2354 | 6.7 | |
| 35 or older | 79,825 | 47.0 | 76,891 | 96.3 | 2934 | 3.7 | |
| Sex | <0.001 | ||||||
| Female | 90,883 | 53.5 | 86,449 | 95.1 | 4434 | 4.9 | |
| Male | 78,876 | 46.5 | 74,056 | 93.9 | 4820 | 6.1 | |
| Sexual orientation | <0.001 | ||||||
| Heterosexual | 156,026 | 91.9 | 148,106 | 94.9 | 7920 | 5.1 | |
| Lesbian/gay | 3636 | 2.1 | 3303 | 90.8 | 333 | 9.2 | |
| Bisexual | 7632 | 4.5 | 6713 | 88.0 | 919 | 12.0 | |
| Race | <0.001 | ||||||
| NH White | 102,754 | 60.5 | 96,844 | 94.2 | 5910 | 5.8 | |
| NH Black | 21,261 | 12.5 | 20,260 | 95.3 | 1001 | 4.7 | |
| NH Native American/Alaska Native | 2482 | 1.5 | 2293 | 92.4 | 189 | 7.6 | |
| NH Native Hawaiian/Other Pacific Islander | 846 | 0.5 | 790 | 93.4 | 56 | 6.6 | |
| NH Asian | 7999 | 4.7 | 7825 | 97.8 | 174 | 2.2 | |
| NH Multiracial | 5499 | 3.2 | 5051 | 91.9 | 448 | 8.1 | |
| Hispanic | 28,918 | 17.0 | 27,442 | 94.9 | 1476 | 5.1 | |
| Year of survey | <0.001 | ||||||
| 2015 | 43,082 | 25.4 | 40,404 | 93.8 | 2678 | 6.2 | |
| 2016 | 42,134 | 24.8 | 39,801 | 94.5 | 2333 | 5.5 | |
| 2017 | 42,066 | 24.8 | 39,777 | 94.6 | 2289 | 5.4 | |
| 2018 | 42,477 | 25.0 | 40,523 | 95.4 | 1954 | 4.6 | |
The analytic sample includes all individuals who answered survey questions related to depression.
NH, non-Hispanic.
Weighted logistic regression models were used to examine the relationship between sexual orientation and each of these variables, adjusting for demographic characteristics (data not shown). Compared with heterosexual individuals, both lesbian women and gay men (adjusted odds ratio [aOR] = 2.18; 95% confidence interval [CI]: 1.80–2.49) and bisexual individuals (aOR = 3.41; 95% CI: 3.15–3.71) had greater odds of major depressive episode in the past year. In stratified analyses, these results were similar for both lesbian (aOR = 1.95; 95% CI: 1.62–2.35) and bisexual (aOR = 3.28; 95% CI: 3.00–3.59) women as well as gay (aOR = 2.48; 95% CI: 2.03–3.04) and bisexual (aOR = 4.06; 95% CI: 3.39–4.86) men.
Similar results were observed for suicidal ideation. Compared with heterosexual individuals, lesbian women and gay men (aOR = 2.74; 95% CI: 2.38–3.16) and bisexual individuals (aOR = 4.00; 95% CI: 3.66–4.37) had greater odds of suicidal ideation in the past year. These results remained consistent when stratifying by sex. Compared with heterosexual men and women, both lesbian (aOR = 2.41; 95% CI: 2.01–2.88) and bisexual (aOR = 3.85; 95% CI: 3.49–4.25) women and gay (aOR = 3.03; 95% CI: 2.47–3.73) and bisexual (aOR = 4.36; 95% CI: 3.63–5.24) men had greater odds of suicidal ideation in the past year.
The results of the multivariable weighted logistic regression analyses are presented in Tables 2 and 3 (for women and men, respectively). The models among women revealed positive associations between past-year major depressive episode and prescription opioid misuse (aOR = 2.88; 95% CI: 2.58–3.21) as well as between past-year suicidal ideation and opioid misuse (aOR = 3.86; 95% CI: 3.41–4.38). In the model that adjusted for past-year major depressive episode, the association between sexual orientation and past-year prescription opioid misuse was attenuated for both lesbian (aOR = 1.72; 95% CI: 1.36–2.18) and bisexual (aOR = 2.37; 95% CI: 2.08–2.70) women. Similarly, in the model that adjusted for past-year suicidal ideation, the association between sexual orientation and past-year prescription opioid misuse was attenuated for both lesbian (aOR = 1.66; 95% CI: 1.31–2.12) and bisexual (aOR = 2.33; 95% CI: 2.04–2.67) women. Similar patterns of associations between demographic characteristics, survey year, and prescription opioid misuse as reported above were observed in these models.
Table 2.
Results of the Multivariable Weighted Logistic Regressions Examining the Association Between Sexual Orientation and Past-Year Prescription Opioid Misuse Among Women in the National Survey on Drug Use and Health, 2015–2018
| Variable | Adjusting for demographics only |
Adjusting for past-year depression |
Adjusting for past-year suicidal ideation |
||||||
|---|---|---|---|---|---|---|---|---|---|
| n = 89,930 |
n = 89,238 |
n = 89,646 |
|||||||
| aOR | 95% CI |
aOR | 95% CI |
aOR | 95% CI |
||||
| Lower | Upper | Lower | Upper | Lower | Upper | ||||
| Past-year depression | |||||||||
| No | — | — | — | Ref. | — | — | — | — | — |
| Yes | — | — | — | 2.88*** | 2.58 | 3.21 | — | — | — |
| Past-year suicidal ideation | |||||||||
| No | — | — | — | — | — | — | Ref. | — | — |
| Yes | — | — | — | — | — | — | 3.86*** | 3.41 | 4.38 |
| Age, years | |||||||||
| 18–25 | Ref. | — | — | Ref. | — | — | Ref. | — | — |
| 26–34 | 0.95 | 0.86 | 1.05 | 1.00 | 0.91 | 1.11 | 1.06 | 0.96 | 1.18 |
| 35 or older | 0.46*** | 0.42 | 0.51 | 0.51*** | 0.46 | 0.56 | 0.54*** | 0.49 | 0.60 |
| Sexual orientation | |||||||||
| Heterosexual | Ref. | — | — | Ref. | — | — | Ref. | — | — |
| Lesbian | 1.89*** | 1.50 | 2.38 | 1.72*** | 1.36 | 2.18 | 1.66*** | 1.31 | 2.12 |
| Bisexual | 2.93*** | 2.59 | 3.31 | 2.37*** | 2.08 | 2.70 | 2.33*** | 2.04 | 2.67 |
| Race | |||||||||
| NH White | Ref. | — | — | Ref. | — | — | Ref. | — | — |
| NH Black | 0.70*** | 0.61 | 0.81 | 0.75*** | 0.65 | 0.87 | 0.72*** | 0.62 | 0.84 |
| NH Native American/Alaska Native | 1.25 | 0.89 | 1.74 | 1.21 | 0.87 | 1.70 | 1.24 | 0.89 | 1.72 |
| NH Native Hawaiian/Other Pacific Islander | 1.57 | 0.84 | 2.93 | 1.53 | 0.79 | 2.95 | 1.62 | 0.86 | 3.05 |
| NH Asian | 0.36*** | 0.24 | 0.54 | 0.38*** | 0.25 | 0.57 | 0.38*** | 0.25 | 0.56 |
| NH Multiracial | 1.22 | 0.94 | 1.60 | 1.20 | 0.92 | 1.58 | 1.17 | 0.90 | 1.54 |
| Hispanic | 0.79*** | 0.70 | 0.90 | 0.83** | 0.73 | 0.95 | 0.82** | 0.72 | 0.93 |
| Year of survey | 0.94** | 0.90 | 0.98 | 0.94** | 0.90 | 0.98 | 0.93** | 0.90 | 0.97 |
p < 0.01; ***p < 0.001.
aOR, adjusted odds ratio; CI, confidence interval.
Table 3.
Results of the Multivariable Weighted Logistic Regressions Examining the Association Between Sexual Orientation and Past-Year Prescription Opioid Misuse Among Men in the National Survey on Drug Use and Health, 2015–2018
| Variable | Adjusting for demographics only |
Adjusting for depression |
Adjusting for suicidal ideation |
||||||
|---|---|---|---|---|---|---|---|---|---|
| n = 78,630 |
n = 78,056 |
n = 78,317 |
|||||||
| aOR | 95% CI |
aOR | 95% CI |
aOR | 95% CI |
||||
| Lower | Upper | Lower | Upper | Lower | Upper | ||||
| Past-year depression | |||||||||
| No | — | — | — | Ref. | — | — | — | — | — |
| Yes | — | — | — | 3.09*** | 2.69 | 3.55 | — | — | — |
| Past-year suicidal ideation | |||||||||
| No | — | — | — | — | — | — | Ref. | — | — |
| Yes | — | — | — | — | — | — | 3.67*** | 3.20 | 4.20 |
| Age, years | |||||||||
| 18–25 | Ref. | — | — | Ref. | — | — | Ref. | — | — |
| 26–34 | 1.02 | 0.93 | 1.12 | 1.07 | 0.97 | 1.18 | 1.08 | 0.98 | 1.19 |
| 35 or older | 0.45*** | 0.41 | 0.49 | 0.48*** | 0.44 | 0.53 | 0.49*** | 0.45 | 0.54 |
| Sexual orientation | |||||||||
| Heterosexual | Ref. | — | — | Ref. | — | — | Ref. | — | — |
| Gay | 1.62*** | 1.28 | 2.05 | 1.47** | 1.16 | 1.86 | 1.41** | 1.11 | 1.79 |
| Bisexual | 1.62*** | 1.26 | 2.09 | 1.33* | 1.02 | 1.74 | 1.28 | 0.98 | 1.67 |
| Race | |||||||||
| NH White | Ref. | — | — | Ref. | — | — | Ref. | — | — |
| NH Black | 0.86* | 0.76 | 0.99 | 0.90 | 0.78 | 1.03 | 0.88 | 0.77 | 1.01 |
| NH Native American/Alaska Native | 1.31 | 0.95 | 1.81 | 1.34 | 0.96 | 1.87 | 1.31 | 0.94 | 1.83 |
| NH Native Hawaiian/Other Pacific Islander | 0.91 | 0.55 | 1.49 | 0.96 | 0.58 | 1.58 | 0.94 | 0.57 | 1.56 |
| NH Asian | 0.30*** | 0.22 | 0.40 | 0.30*** | 0.22 | 0.41 | 0.30*** | 0.22 | 0.40 |
| NH Multiracial | 1.25 | 0.99 | 1.59 | 1.22 | 0.96 | 1.55 | 1.18 | 0.93 | 1.50 |
| Hispanic | 0.82** | 0.72 | 0.93 | 0.84** | 0.74 | 0.95 | 0.84** | 0.74 | 0.96 |
| Year of survey | 0.91*** | 0.87 | 0.94 | 0.89*** | 0.86 | 0.93 | 0.90*** | 0.87 | 0.94 |
p < 0.05; **p < 0.01; ***p < 0.001.
Overall, the results for men were similar to the results for women. These models revealed positive associations between past-year major depressive episode and prescription opioid misuse (aOR = 3.09; 95% CI: 2.69–3.55) as well as between past-year suicidal ideation and opioid misuse (aOR = 3.67; 95% CI: 3.20–4.20). In the model that adjusted for past-year major depressive episode, the association between sexual orientation and past-year prescription opioid misuse was attenuated for both gay (aOR = 1.47; 95% CI: 1.16–1.86) and bisexual (aOR = 1.33; 95% CI: 1.02–1.74) men. In the model that adjusted for past-year suicidal ideation, the association between sexual orientation and past-year prescription opioid misuse was attenuated and remained significant only for gay men (aOR = 1.41; 95% CI: 1.11–1.79). Of note, the effect became nonsignificant for bisexual men. Again, similar patterns of associations between demographic characteristics, survey year, and prescription opioid misuse as reported above were observed in these models. The one exception was that non-Hispanic Black men no longer had significantly lower odds of prescription opioid misuse compared with non-Hispanic White men in the models that adjusted for either major depressive episode or suicidal ideation.
Finally, results of secondary analyses considering counterfactual and actual mean probabilities of prescription opioid misuse are presented in Table 4. Here, we demonstrated that, among both SM women and men, all rates of prescription opioid misuse would be lower under the counterfactual scenario in which SM adults' rates of depression and suicidal ideation were reduced to levels experienced by heterosexual participants. Indeed, these rates would be drastically lower in this counterfactual scenario. The smallest decrease was for gay men, with a proportional decrease of 14.3% in prescription opioid misuse when rates of depression were reduced to those experienced by heterosexual individuals. The largest decrease was for bisexual women, who would be expected to experience a 26.8% proportional decrease in prescription opioid misuse if rates of suicidal ideation were reduced to those experienced by heterosexual participants.
Table 4.
Counterfactual Probability of Prescription Opioid Misuse Among Sexual Minority Adults Assuming Rates of Depression and Suicidal Ideation Among Heterosexual Adults Compared with Actual Probabilities of Use, the National Survey on Drug Use and Health, 2015–2018
| Depression |
|
Suicidal ideation |
|
|||
|---|---|---|---|---|---|---|
| Actual | Counterfactual | Proportional difference (%) | Actual | Counterfactual | Proportional difference (%) | |
| Lesbian/gay women | 0.083 | 0.070 | −15.6 | 0.086 | 0.067 | −22.1 |
| Bisexual women | 0.135 | 0.104 | −23.0 | 0.138 | 0.101 | −26.8 |
| Gay men | 0.098 | 0.084 | −14.3 | 0.096 | 0.080 | −16.7 |
| Bisexual men | 0.103 | 0.081 | −21.4 | 0.104 | 0.077 | −26.0 |
Discussion
Among a nationally representative data set, using multiple years of publicly available data, we sought to examine whether the previously observed disparities in prescription opioid misuse affecting SM adults could be accounted for by elevated rates of either major depression or suicidal ideation. We observed stronger associations between sexual orientation and past-year prescription opioid misuse among women compared with men; however, among both groups, these associations were attenuated by both major depression and suicidal ideation. Interestingly, bisexual women had the highest elevation in prescription opioid misuse compared with their same-sex heterosexual peers and also experienced the greatest attenuation in disparities in prescription opioid misuse by depression and suicidal ideation. Finally, we demonstrated that lowering the rate of both depression and suicidal ideation to levels experienced by heterosexual individuals would greatly reduce rates of prescription opioid misuse among SM adults. These results suggest that the disparity in prescription opioid misuse affecting SM populations can be partially accounted for by major depression and suicidal ideation and that efforts to improve mental health among this high-risk population may also help to reduce the observed disparity in prescription opioid misuse affecting this population.
At least part of the previously reported disparity in prescription opioid misuse between heterosexual and SM individuals can be accounted for by disparities in both major depression and suicidal ideation. Our initial models corroborate past findings,22,23 namely that strong disparities in both depression and suicidal ideation exist based on sexual orientation, with bisexual individuals having the greatest likelihood of experiencing both in the past year. In turn, each of these variables partially attenuated the previously reported associations31,32 between sexual orientation and opioid misuse. This was further corroborated by our counterfactual analyses, which demonstrated large reductions in the probability of prescription opioid misuse given reductions in depression and suicidal ideation.
Given that the disparities in past-year prescription opioid misuse affecting SM participants generally persisted even after adjusting for past-year major depression or suicidal ideation, continued investigation into additional mechanisms driving disparities in opioid misuse affecting SM populations is warranted, particularly those examining bidirectional effects using longitudinal data. For example, based on minority stress theory,25 stigma-related stress could help to explain why SM individuals are disproportionately affected by prescription opioid misuse as well as depression and suicidal ideation. In fact, previous research has found that stigma-related stress (e.g., discrimination) is associated with opioid misuse, depression, and suicidal ideation among SM populations.25,33 Unfortunately, we were unable to account for stigma-related stress in our analyses because it is not assessed in the NSDUH. As such, it will be important for future studies to examine multiple potential mechanisms underlying sexual orientation disparities in opioid misuse (e.g., depression and suicidal ideation, stigma-related stress) to identify potential intervention targets for reducing prescription opioid misuse in this population.
Beyond these main findings, differences were observed based on demographic characteristics. Most interestingly, we observed differences by sex when examining whether depression and suicidal ideation attenuated the relationship between sexual orientation and opioid misuse. Past research has noted that men have historically used opioids at a higher rate than women,9–11 but that women are experiencing a faster increase in the rate of overdose deaths.12 Our results take these past findings a step further, demonstrating that past-year opioid misuse has fallen at a faster rate among men than among women, with the two rates nearly converging in 2018. Additionally, our results correspond to past work suggesting that sexual orientation disparities are more pronounced for bisexual adults, a group of individuals at high risk for both depression and substance use disorders8,20,31,34 and who experience more barriers to substance use treatment than heterosexual individuals, lesbian women, and gay men.35 Future research should endeavor to develop a better understanding not only of disparities affecting SM compared with heterosexual individuals but also of disparities within the population of SM adults, particularly those affecting bisexual women who appear to be a uniquely high-risk group.
Limitations
Even in light of these key findings, we must view our results in the context of study limitations. The variables used here rely on self-report data and are thus subject to both recall and social desirability biases. Response options for sexual orientation were limited to heterosexual, gay/lesbian, or bisexual. As sexual identity is more nuanced than these limited categories, we were not able to more accurately assess the relationship between sexual orientation, prescription opioid misuse, and depression or suicidal ideation. In addition to this, sexual identity was not assessed among adolescents, thus any prescription opioid misuse among this age group could not be considered.
Gender minority status was not assessed or considered in the survey and should be considered in future work in this area. Next, pain level is not assessed in the NSDUH and is also a major indicator for opioid prescription receipt and use, the perception of which can be exacerbated by depression and vice versa. Future studies should include this assessment in their analyses. Finally, the survey is cross-sectional and thus does not allow for longitudinal analyses of variables. Although we demonstrated that accounting for a major depressive episode or suicidal ideation attenuated the associations between SM status and opioid misuse, longitudinal data are needed to formally test mediation. Furthermore, given that the associations between a major depressive episode/suicidal ideation and opioid misuse are likely bidirectional, longitudinal data are also needed to test temporality.
Conclusion
In summary, SM adults are at increased risk for opioid misuse, which has been previously demonstrated in past research and confirmed in this sample. However, they are also at increased risk for both depression and suicidal ideation compared with heterosexual men and women, and each of these has been associated with opioid misuse. Our results demonstrate that while associations between sexual orientation and prescription opioid misuse are attenuated after accounting for either of these mental health variables, SM adults continue to be at heightened risk for prescription opioid misuse. Future research should aim to continue assessing other risk factors, which may explain these disparities, particularly minority stressors and stigma. Based on the findings presented here, together with past research,36 targeting public health interventions toward SM individuals experiencing either a major depressive episode or suicidal ideation in the past year has the potential to reduce the disparity in prescription opioid misuse affecting this population.
These findings highlight the importance of assessing sexual orientation in health care systems and screening for substance use (including opioid misuse) as well as depression and suicidal ideation. By assessing sexual orientation, health care providers can identify patients who may be at increased risk for these negative health outcomes. Then, by screening for substance use and mental health problems, they can identify unmet health care needs and intervene as necessary. To intervene, clinicians could draw on existing evidence-based interventions to simultaneously target the mental and behavioral health problems affecting SM clients.36 Furthermore, based on our findings, specifically targeting depression or suicidal ideation could have the added benefit of contributing to reductions in opioid misuse as well. Finally, policies focused on increasing access to mental health treatment among individuals who misuse opioids may help to reduce opioid misuse itself. However, given that the sexual orientation disparity in prescription opioid misuse persisted after accounting for depression and suicidal ideation (even though it was reduced in size), it is likely that a multilevel approach (e.g., individual and structural interventions) will be necessary to eliminate this disparity.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health. The sponsor had no involvement in the conduct of the research or the preparation of the article.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This work was supported by grants from the National Institute on Drug Abuse at the National Institutes of Health (K08DA045575, principal investigator [PI]: Feinstein; K01DA046716, PI: Dyar).
The use of “opioids” alone throughout this article refers to both prescription and nonprescription use.
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