Background: Nonmedical use of opioids has become increasingly problematic in recent years with increases in overdoses, treatment admissions, and deaths. Use also appears to be contributing to heroin initiation, which has increased in recent years. Further research is needed to examine which adolescents are at highest risk for nonmedical use of opioids and heroin and to explore potential links between nonmedical opioid use and heroin use.
Methods: Data were analyzed from a nationally representative sample of American high school seniors in the Monitoring the Future study (2009-2013, Weighted N = 67,822). We examined associations between frequency and recency of nonmedical use of opioids and heroin. Sociodemographic correlates of use of each drug were also examined.
Results: 12.4% of students reported lifetime nonmedical opioid use and 1.2% reported lifetime heroin use. As frequency of lifetime nonmedical opioid use increased, so too did the odds for reporting heroin use, with over three-quarters (77.3%) of heroin users reporting lifetime nonmedical opioid use. Recent (30-day) nonmedical opioid use was a robust risk factor for heroin use and almost a quarter (23.2%) of students who reported using opioids >=40 times reported lifetime heroin use. Black and Hispanic students were less likely to report nonmedical opioid or heroin use than white students, but they were more likely to report heroin use in absence of nonmedical opioid use.
Discussion: Recent and frequent nonmedical opioid use are risk factors for heroin use among adolescents. Prevention needs to be targeted to those at highest risk.

Highlights:
12.4% of high school seniors reported lifetime nonmedical opioid use.
As frequency of opioid use increased, so too did the odds for reporting heroin use.
Over three-quarters (77.3%) of heroin users reporting lifetime nonmedical opioid use.
Females were consistently at low odds for reporting use of opioids and heroin.
Racial minority students were less likely to report opioid or heroin use.