Non-prescribed use of pain relievers among adolescents in the United States
Introduction
In the United States, both prescribed and non-prescribed use of prescription pain relievers, as well as rates of opioid-related mortality and admissions to emergency departments, have increased in the last few years (Gilson et al., 2004, Paulozzi et al., 2006, Zacny et al., 2003). For the purposes of this paper, the terms “non-prescribed use” and “use of non-prescribed pain relievers” refer to the use of a prescription pain reliever(s) that was not prescribed for an individual or that an individual took only for the experience or feeling that it caused (e.g., nonmedical use). Prescription pain relievers include opioids, such as preparations containing oxycodone (Oxycontin®, Percocet®), hydrocodone (Lortab®, Vicodin®), codeine (Tylenol with codeine®), propoxyphene (Darvon®), methadone (Dolophine®), and hydromorphone (Dilaudid®). Data from the U.S. Drug Abuse Warning Network (DAWN) and the Treatment Episode Data Set (TEDS) show an upward trend in opioid-related admissions to emergency departments (Gilson et al., 2004, Novak et al., 2004; SAMHSA [Substance Abuse and Mental Health Services Administration], 2003) and publicly funded substance abuse treatment facilities (SAMHSA, 2004). For example, an analysis of data from the 1997 to 2002 DAWN report indicates an increase in opioid-related visits to emergency departments: 642% for fentanyl, 347% for oxycodone, and 342% for hydromorphone (Gilson et al., 2004). The rate of drug-overdose deaths associated with prescription opioid misuse has also increased, and, in 2002, it was greater than the rate associated with heroin or cocaine use (Paulozzi et al., 2006).
Similarly, surveys of the general population and students have shown that non-prescribed use of prescription pain relievers is a growing public health problem in the United States (Compton and Volkow, 2006, Johnston et al., 2006). In 2005, an estimated 2.2 million Americans used pain relievers nonmedically for the first-time within the preceding year, and more than one third (36%) of these first-time or new users were adolescents aged 12–17 years (SAMHSA, 2006). The Monitoring the Future (MTF) survey has studied the extent of drug use among American 12th graders annually since 1975. The survey was expanded in 1991 to include 8th and 10th graders. The recent MTF report shows that lifetime non-prescribed use of pain relievers among 12th graders increased from about 6% in the early 1990s to close to 13% in 2005 (Johnston et al., 2006). Non-prescribed use of OxyContin® was not included in MTF until 2002, and only past year use was assessed. Past year prevalence of non-prescribed use of OxyContin® increased from 1.3% in 2002 to 1.8% in 2005 among 8th graders and from 4.0% to 5.5% among 12th graders (Johnston et al., 2006).
Despite the evident increase in prevalence rates, patterns and correlates of non-prescribed use of pain relievers (and gender-specific patterns of use in particular) have received limited research attention. To date, only a few studies have examined non-prescribed use of pain relievers among adolescents using representative population-based samples. Boyd and colleagues (2006a) examined non-prescribed use of prescription pain relievers among 1017 students in grades 5 through 10 from a Detroit-area public school district and found that 22% of females reported lifetime non-prescribed use of pain relievers compared with 10% of males (Boyd et al., 2006a). McCabe and colleagues (2007a) examined prescribed and non-prescribed medication use among 1086 students in grades 7 through 12 from a Detroit-area public school district. In their sample, 44.7% of students reported a history of prescribed use of pain relievers. They found that females generally were more likely than males to report both prescribed and non-prescribed use of prescription drugs and that both prescribed and non-prescribed use of pain relievers (14.3% of the study sample) was more common than non-prescribed use of pain relievers only (3.4% of the study sample). Non-prescribed use of pain relievers was also found to be associated with increased odds of probable drug abuse in this sample of secondary school students (McCabe et al., 2007a).
Using data from the 2002 National Survey on Drug Use and Health (NSDUH), Sung and colleagues (2005) reported historical trends and correlates of past year nonmedical use of prescription opioids among adolescents aged 12–17 years. They defined “nonmedical use” using the same question from the NSDUH as we use in the present study (i.e., use of a prescription pain reliever[s] that was not prescribed for the respondent or that the respondent took only for the experience or feeling that it caused). Sung et al. (2005) reported a significant increase in the prevalence of nonmedical use of prescription opioids in the mid 1990s, continuing into 2002, when it reached a prevalence of 11%. They also noted a slightly higher prevalence of past year nonmedical use among females compared with males (7.8% vs. 6.9%). Low parental involvement, selling of illicit drugs, and use of alcohol and drugs were associated with increased odds of nonmedical use of prescription opioids (Sung et al., 2005). Sung et al. (2005) indicated that use of illicit drugs was the best predictor of nonmedical use of prescription opioids.
Together, the available data suggest that non-prescribed use of pain relievers is more prevalent among girls than among boys (e.g., Boyd et al., 2006a, McCabe et al., 2007a). In addition, the use of non-prescribed pain relievers may be influenced by medical exposure to pain relievers, by health conditions that could lead to non-prescribed use for self-medication purposes, and by the prior use of alcohol and other commonly used drugs (e.g., marijuana and inhalants) (Boyd et al., 2006a, McCabe et al., 2007a, Sung et al., 2005). Given that sources of prescription pain relievers and reasons for initial non-prescribed use may differ from sources of illicit drugs (medical exposures vs. illicit channels) and reasons for nonmedical use (self-treatment for pain vs. getting a high), it would be important to determine whether non-prescribed use of pain relievers occurred among adolescents who had never initiated use of common drugs, such as marijuana or inhalants (Wu et al., 2005). Such a pattern of findings would suggest that non-prescribed use of pain relievers may be related to self-medication of health-related conditions by some adolescents, which is not necessarily an antecedent of deviant behaviors (e.g., illicit drug use).
Previous studies have not examined gender-specific use of specific categories of non-prescribed pain relievers, use of alcohol and specific drug classes, age of onset of alcohol and other specific drug classes, and correlates of non-prescribed use (Boyd et al., 2006a, McCabe et al., 2007a, Sung et al., 2005). Additionally, physical health-related variables appear to be important correlates of non-prescribed use of pain relievers among adolescents (Boyd et al., 2006b, McCabe et al., 2007a) but are not examined by Sung et al. (2005). Examining both deviance-related (e.g., criminality and other drug use) and health-related variables would help determine deviant and non-deviant patterns of use of non-prescribed pain relievers.
In this study, we extend prior research suggesting an increase in non-prescribed use of pain relievers (Sung et al., 2005) by using more recent data to ascertain whether the rise in non-prescribed use has continued beyond 2002, and to study gender-specific patterns and correlates of non-prescribed use, including use of multiple pain relievers, frequency of use, and onset of first use. By using what is currently the largest available sample of American adolescents who participated in the 2005 NSDUH (SAMHSA, 2006), we were able to examine gender-specific patterns and correlates of non-prescribed use. Specifically, we investigated whether non-prescribed use of pain relievers is associated with risk factors from multiple domains, including: (1) perceived health status and health care use (e.g., related to self-medication and medical exposures); (2) general risk factors for drug use (e.g., a history of foster care placement and criminality); (3) use of mental health treatment services (e.g., related to self-medication); and (4) use of other substances (e.g., alcohol, marijuana, and inhalants) (Boyd et al., 2006a, Khantzian, 1985, Wu et al., 2005, Wu et al., 2006, Pilowsky and Wu, 2006, Sung et al., 2005). We also determined the extent of alcohol and other specific drug use among users of non-prescribed pain relievers compared with never users and onset of first non-prescribed use of pain relievers compared with onset of first use of alcohol and other drugs. Findings from this study may help identify subgroups of non-prescribed users for targeting intervention and prevention efforts.
Section snippets
Data source
This study is based on data from the public use file of the 2005 NSDUH (SAMHSA, 2006). NSDUH is designed to provide population estimates of substance use and related disorders in the U.S. general population. It utilizes multistage area probability sampling methods to select a representative sample of the U.S. civilian, noninstitutionalized population aged 12 years or older for participation in the study. Participants include household residents; residents of shelters, rooming houses, and group
Study sample
A total of 18,678 adolescents aged 12–17 years were identified from the public use data file of 2005 NSDUH. In this sample, 51% were females; 33% were young adolescents aged 12–13 years; 39% were members of nonwhite groups (non-Hispanic black, 15%; Hispanic, 17%; American Indian or Alaska Native, 0.7%; Asian, 4.2%; other Pacific Islander or Native Hawaiian, 0.7%; persons reporting more than one race, 1.5%); 98% were students; and 18% reported an annual family income of less than $20,000.
Prevalence of lifetime non-prescribed use of pain relievers
Discussion
Approximately one in 10 (9.8%) non-institutionalized American adolescents aged 12–17 years reported a history of non-prescribed use of prescription pain relievers in 2005, compared with a slightly higher lifetime prevalence (11.2%) in the 2002 survey (Sung et al., 2005), suggesting that non-prescribed use of these substances may have stabilized. In this sample, first-time use of non-prescribed pain relievers occurred in early adolescence, with 60.6% reporting their first non-prescribed use
Conflict of interest
Dr. Patkar has received grant support from Pfizer, Forest Laboratories, Cephalon and Titan Pharmaceuticals and is on the speakers bureau of Cephalon and Reckitt-Benckiser. The other authors declare that they have no conflicts of interest.
Acknowledgements
Role of Funding Source: Data analysis and the preparation for this paper were supported by a research grant (DA015938, Dr. L-T Wu) from the U.S. National Institute on Drug Abuse, National Institute of Health. The Substance Abuse and Mental Health Data Archive and the Inter-university Consortium for Political and Social Research provided the public use data files for NSDUH, which was sponsored by SAMHSA's Office of Applied Studies. The opinions expressed in this paper are solely those of the
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