Self-Medicating Social Pain? Bullying, Suicidality, and Opioid-Specific Risk in US Adolescents

OBJECTIVE Many adversities predict adolescent substance use, but it is unknown which produce opioid-specific risk vs general substance use liability. We tested whether bullying, suicidality, polysubstance use, risk behavior, sexual victimization, household adversity, and community safety adversity show opioid-specific associations with nonmedical prescription opioid use (NMPOU). METHODS Using 2023 Youth Risk Behavior Survey data (N = 20 103), survey-weighted logistic regressions modeled 7 composite predictors. Average marginal effects quantified probability-scale associations. A stacked-outcome test compared associations across 5 substances (NMPOU, alcohol, marijuana, cigarettes, cocaine). Karlson-Holm-Breen decomposition quantified polysubstance mediation. RESULTS Predictor-substance associations differed significantly across substance types (P = .0075). Bullying was uniquely associated with NMPOU (3.8 percentage points [pp], 95% CI: 1.5 to 6; adjusted odds ratio [AOR] = 1.48, 95% CI: 1.18–1.86) and not with any other substance. Suicidality was associated with NMPOU (6.2 pp, 95% CI: 4.2 to 8.3; AOR = 1.89, 95% CI: 1.58–2.26) and marijuana but not alcohol, indicating partial opioid specificity. Polysubstance use had the largest overall association (6.3 pp, 95% CI: 4.1 to 8.5; AOR = 2.09, 95% CI: 1.63–2.66) but reflected general substance use liability. All 7 predictors were independently significant in the fully adjusted model (n = 9401). CONCLUSION Bullying and suicidality are associated with opioid-specific hazard, indicating why certain adolescents turn to opioids, whereas polysubstance use, sexual victimization, household adversity, and community safety adversity reflect general substance use liability. Where bullying or suicidality is identified, targeted opioid prevention is warranted; where NMPOU is present, clinicians should screen for bullying victimization and unmet mental health needs.