From Popping Pills to Using Heroin: NYU Study Finds Three-Quarters of High School Heroin Users Started with Prescription Opioids

Nearly 25% of seniors who misused prescription opioids more than 40 times, also used heroin


Nonmedical use of prescription opioids (a.k.a.: pain-killers, narcotics) such as Vicodin, Percocet, and Oxycontin has become increasingly problematic in recent years with increases nation-wide in overdoses, hospital treatment admissions, and deaths. Use also appears to be contributing to heroin initiation, which has increased in recent years, as the demographics of users are shifting. Those previously at low risk—women, whites, and individuals of higher income—are now using at unprecedented rates.

A recent study, published in Drug and Alcohol Dependence by Joseph J. Palamar, PhD, MPH, an affiliate of the Center for Drug Use and HIV Research (CDUHR) and an assistant professor of Population Health at NYU Langone Medical Center (NYULMC), is among the first nationally representative studies in the US to examine the linkages between nonmedical use of opioids and heroin in high school seniors. The researchers examined associations between frequency and recency of nonmedical use of opioids and heroin. Sociodemographic correlates of use of each drug were also examined.

“12.4% of students reported lifetime nonmedical opioid use and 1.2% reported lifetime heroin use,” said Dr. Palamar. “As frequency of lifetime opioid use increased, so too did the odds for reporting heroin use, with over three-quarters of heroin users reporting lifetime nonmedical opioid use. More frequent and more recent nonmedical opioid use was associated with increased odds for reporting heroin use.”

The study, “Nonmedical Opioid Use and Heroin Use in a Nationally Representative Sample of US High School Seniors,” used data from Monitoring the Future (MTF), a nationwide ongoing annual study of the behaviors, attitudes, and values of American secondary school students. The MTF survey is administered in approximately 130 public and private schools throughout 48 states in the US. Roughly 15,000 high school seniors are assessed annually. The study utilized MTF responses (N = 67,822) from 2009-2013.

Recent (last 30-day) opioid use was also a robust risk factor for heroin use. Almost a quarter (23.2%) of students who reported using opioids >40 times reported lifetime heroin use. Females and students residing with two parents were consistently at low odds for reporting use of opioids and heroin; black and Hispanic students were less likely to report opioid or heroin use than white students.

“Interestingly, said, co-author Pedro Mateu-Gelabert, PhD, a principal investigator with CDUHR, “while we found that black and Hispanic students were at low risk for both opioid and heroin use generally, black and Hispanic students were more likely to use heroin without first using opioids in a nonmedical manner. This suggests that it is primarily the white students who may be transitioning from pill use to heroin.”

The researchers note that future interventions should be aimed at decreasing nonmedical opioid use among adolescents and young adults in order to prevent initiation of heroin use.

“The importance and urgency of the need for prevention, treatment, and intervention cannot be emphasized enough,” said Dr. Mateu-Gelabert.  “Governmental officials at the local, state and federal agencies such as Health and Human Services (HHS) and now the Food and Drug Administration (FDA), are all desperately trying to stem the unprecedented rise in drug overdose deaths, which are now the leading cause of injury death in the U.S.” 

“Any nonmedical use of opioids can be risky, but special attention needs to be given to adolescents who use more frequently,” stressed Dr. Palamar.

Dr. Palamar goes on to point out that a good number of teens are not educated about prescription opioids. Teens may think they're safe because they're government approved, pharmaceutical grade, and easily found in their parents' medicine cabinet.

“A teen may take an Oxy a couple of times and remain unscathed,” he said. “But a lot of teens don't realize these pills can be physically addicting. A lot of teens don't trust warnings about the harm prescription opioids can cause because they're taught that using any drug--even marijuana—even once--will ruin their life forever.”

The researchers emphasize that nonmedical opioid use can and does place teens at serious risk--for accidental overdose and for dependence.

“Teens experimenting with pills need to look at all of these people around them becoming addicted to--and dying from heroin,” says Dr. Palamar. “Most of these people started on pills and felt they had no choice but to move onto heroin. Targeting this group may prevent future heroin initiation, and decrease the troubling trend nation-wide in opiate-related deaths.”  

Researcher Affiliations: Joseph J. Palamar,1,2 Jenni A. Shearston,1,4 Eric W. Dawson,1 Pedro Mateu-Gelabert,2,5 and Danielle C. Ompad2,3,4

1 New York University Langone Medical Center, Department of Population Health
2 Center for Drug Use and HIV Research, New York University College of Nursing
3 Center for Health, Identity, Behavior, and Prevention Studies, New York University
4 College of Global Public Health, New York University
5 National Development and Research Institutes

Acknowledgements: This project was funded by the NIH (K01 DA-038800, PI: Palamar). The Monitoring the Future principal investigators had no role in analysis, interpretation of results, or in the decision to submit the manuscript for publication. The author would like to thank the principal investigators of Monitoring the Future (PIs: Johnston, Bachman, O'Malley, and Schulenberg) at The University of Michigan, Institute for Social Research, Survey Research Center, and the Interuniversity Consortium for Political and Social Research for providing access to these data ( Monitoring the Future data were collected through a research grant (R01 DA-01411) from the National Institute on Drug Abuse (NIDA). J. Palamar and P. Mateu-Gelabert are funded by the National Institutes of Health (NIH) (NIDA K01 DA-038800 and NIDA R01DA-035146, respectively). D. Ompad is funded in part by the Center for Drug Use and HIV Research (CDUHR - P30 DA011041). E. Dawson was mentored under a grant Substance Abuse Research Education and Training (SARET) from the NIH (R25 DA-022461).

The mission of the Center for Drug Use and HIV Research (CDUHR) is to end the HIV and HCV epidemics in drug using populations and their communities by conducting transdisciplinary research and disseminating its findings to inform programmatic, policy, and grass roots initiatives at the local, state, national and global levels. CDUHR is a Core Center of Excellence funded by the National Institute on Drug Abuse (Grant #P30 DA011041). It is the first center for the socio-behavioral study of substance use and HIV in the United States and is located at the New York University College of Nursing. For more information, visit

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