Wednesday, August 12, 2009

Rx-Opioid Misuse by Students – REMS Won’t Help

A recently-reported study found that about 1 in 8 U.S. high-school seniors have misused prescription opioid drugs for “nonmedical” purposes, but nearly half of them were illicitly using the medications for self-treating physical pain. This raises questions about public health issues that go beyond Rx-opioid misuse — problems that probably would not be resolved by FDA-mandated Risk Evaluation and Mitigation Strategies [REMS] for opioids.

The report, published in the August 2009 issue of the Archives of Pediatrics and Adolescent Medicine, combined U.S. government surveys spanning 2002 to 2006 that questioned 12,441 high-school seniors [McCabe et al. 2009]. About half the sample was female, most were 18 years of age, 62% were white, 10% African American, and 28% were from other racial groups. Students were asked a series of questions relating to how often, if at all, they used prescription opioids on their own without doctors’ orders; most importantly, the questions assessed their motivations for doing so.

The surveys revealed that 12.3% of the students had used opioids for “nonmedical” reasons. The medications involved included hydrocodone, oxycodone, hydromorphone, meperidine, morphine, opium, and codeine (methadone was not listed). The top reasons were what might be expected: to relax or relieve tension (named as a motive by 56%), to feel good or get high (54%), to experiment (52%), or to have a good time with friends (30%) — more than one reason could be named.

Surprisingly, however, a large percentage of students (45%) said that they used the drugs specifically to relieve physical pain. This is not a new problem; past studies, between 1976 and 1984, mentioned by the study authors had similarly found that 50% of high-school seniors were motivated to misuse Rx-opioids for self-medicating physical pain. Another noteworthy finding in the present study was that when pain relief was a primary reason for misusing opioids the students were less likely to use other addictive drugs, alcohol, or marijuana. This appears to confirm that these young persons were specifically seeking analgesic effects afforded by opioids, which raises several concerns:

  • First, this and prior survey studies raise a very serious public health question: Why are so many young persons suffering from untreated (or mistreated) physical pain, causing them to illicitly seek remedies on their own? Resolving this vital issue, perhaps by providing better medical care for these youngsters along with education on the perils of misusing medications, might decrease Rx-opioid-use problems by half.

  • Second, solutions being pursued by the FDA as part of their opioid-REMS initiatives would have little impact in diminishing these problems. In prior blogposts we have noted that remedies such as Medication Guides are ineffective [7/25/09], and that highly restrictive REMS approaches may limit access to opioid medications for everyone [7/17/09]. In fact, as an unintended consequence of REMS, the substance misuse problems in these young persons might shift from opioid analgesics to abuse of alcohol, marijuana, or other drugs, including heroin — anything that will help them to self-medicate their pain.

  • Third, the term “Nonmedical Use” as used in this and similar studies seems to be a misnomer that biases an understanding of the data. Rather, “Medical Misuse” would more accurately reflect the intended medical purpose (analgesia) but without authorization (eg, prescription) for such use, and this could be important for properly assessing the problems and finding solutions. Other surveys, essentially assessing medical misuse behaviors, have used terms such as “Abuse” or “Diversion” to record this, depending on the government agency, which further impedes an understanding of the problems.
From the data in this study it appears that Rx-opioid misuse problems are not centered on males more than females, or more in minority populations. But the study examined only high-school seniors, and the prevalence of these problems across all age groups could be extensive. There is a need to interpret available data from perspectives of motivations driving Rx-opioid misuse, and to think through all of the potential consequences of actions intended to resolve the problems. REMS, in principle, may seem to offer solutions but also could make matters worse.

Reference: McCabe SE, Boyd CJ, Cranford JA, Teter CJ. Motives for nonmedical use of prescription opioids among high school seniors in the United States. Arch Pediatr Adolesc Med. 2009(Aug);163(8):739-744.