Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography.

Background and Aims Since its market release, gabapentin has been presumed to have no abuse potential and subsequently has been prescribed widely off-label, despite increasing reports of gabapentin misuse. This review estimates and describes the prevalence and effects of, motivations behind, and risk factors for gabapentin misuse, abuse, and diversion. Methods Databases were searched for peer-reviewed articles demonstrating gabapentin misuse, characterized by taking a larger dosage than prescribed or taking gabapentin without a prescription, and diversion. All types of studies were considered; grey literature was excluded. Thirty-three articles met inclusion criteria, consisting of 23 case studies and 11 epidemiological reports. Published reports came from the USA, the UK, Germany, Finland, India, South Africa, and France, and two analyzed websites not specific to a particular country. Results Prevalence of gabapentin misuse in the general population was reported to be 1%, 40–65% among individuals with prescriptions, and between 15–22% within populations of people who abuse opioids. An array of subjective experiences reminiscent of opioids, benzodiazepines, and psychedelics were reported over a range of doses, including those within clinical recommendations. Gabapentin was primarily misused for recreational purposes, self-medication, or intentional self-harm and was misused alone or in combination with other substances, especially opioids, benzodiazepines, and/or alcohol. Individuals with histories of drug abuse were most often involved in its misuse. Conclusions Epidemiological and case report evidence suggests that the antiepileptic and analgesic medication gabapentin is being misused internationally at a rate of about 1%, with substance abuse populations at special risk for misuse/abuse.

Objectives We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users. Methods This study included 394 injection drug users (IDUs) participating in a study of social networks and infectious disease risk in Appalachian Kentucky. Trained staff conducted HCV, HIV, and herpes simplex-2 virus (HSV-2) testing, and an interviewer-administered questionnaire measured self-reported risk behaviors and sociometric network characteristics. Results The prevalence of HCV infection was 54.6% among rural IDUs. Lifetime factors independently associated with HCV infection included HSV-2, injecting for 5 or more years, posttraumatic stress disorder, injection of cocaine, and injection of prescription opioids. Recent (past-6-month) correlates of HCV infection included sharing of syringes (adjusted odds ratio = 2.24; 95% confidence interval = 1.32, 3.82) and greater levels of eigenvector centrality in the drug network. Conclusions One factor emerged that was potentially unique to rural IDUs: the association between injection of prescription opioids and HCV infection. Therefore, preventing transition to injection, especially among prescription opioid users, may curb transmission, as will increased access to opioid maintenance treatment, novel treatments for cocaine dependence, and syringe exchange.

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