Wednesday, September 16, 2009

Pain-Reliever Abuse/Addiction Stabilized in U.S.

No doubt about it — the United States has illicit-drug-use problems. However, according to the latest government data, news headlines and public outcries about mushrooming increases in pain-reliever misuse, abuse, and addiction are misleading. In fact, trends have remained stable for a number of years and pain relievers are a relatively small part of the problems.

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) just released the first data from their 2008 National Survey on Drug Use and Health (NSDUH). [See full document here.] In 2008, an estimated 20.1 million Americans aged 12 or older (8% of the population) were illicit-drug users, which was identical to the rate in 2007. Illicit drugs broadly include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, and the nonmedical use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives. Marijuana was the most commonly used illicit drug in 2008 (15.2 million past month users) in the age 12+ population. There were 6.2 million persons who used prescription-type drugs nonmedically, which was lower than in 2007 (6.9 million), and an estimated 4.7 million of those persons used pain relievers nonmedically in 2008.

Widespread concerns have focused on drug abuse and addiction. In 2008, an estimated 22.2 million persons (8.9% of the population aged 12 or older) were classified with either substance abuse or dependence (that is, addiction) based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Of these, the majority, 15.2 million, had abuse or addiction solely to alcohol, in 3.1 million both alcohol and illicit drugs were involved, and 3.9 million had abuse or addiction to illicit drugs only. There had been only a slight and non-significant increase in these numbers from 2002 to 2008.

NSDUH GraphAs the graph shows, of the 7.0 million persons aged 12 or older with abuse or addiction involving illicit drugs with or without alcohol in 2008, the greatest levels were for marijuana (4.2 million), followed by pain relievers (1.7 million) and cocaine (1.4 million). The rate of pain reliever abuse and addiction has remained essentially stable during the past 4 years. For the other categories — illicit drugs overall, cocaine, and marijuana — the trends have been stable since 2002.

IMPORTANT FLAWS/CONCERNS: The annual NSDUH survey generates an impressive array of data, often used by government agencies and civic organizations to justify their antidrug programs and research. However, there are a number of potential flaws and concerns that need to be recognized.
  • Approximately 67,500 persons are interviewed face-to-face for the survey each year; an impressive number but still less than 0.03% of the population in question. Even with statistical adjustments, it is risky to assume that the results are completely accurate in representing all of America.

  • The survey estimates that 4.7 million persons used pain relievers nonmedically in 2008. HOWEVER, the "nonmedical" use of these drugs is defined by the NSDUH as “use without a prescription of the individual's own or simply for the experience or feeling the drugs caused.” It does not account for the unauthorized use of analgesics to relieve pain, which we have called “medical misuse.” Proper attribution of motivations in this regard could make important differences in our understanding of problems with pain relievers.

  • For example, in a prior post [see 8/12/09] we noted research that found 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. So the “hidden problem” here could be untreated or mistreated pain in this population of young persons. And, while the research has not looked at this, it could be important as well to know how much marijuana use is for pain relief rather than recreational purposes.

  • In the NSDUH survey, 56% of respondents got pain relievers they misused from a friend or relative for free and 18% reported they got the drug from one doctor. Only about 5% got the drugs from a drug dealer or other stranger, or on the Internet. Among those who reported getting the pain relievers from a friend or relative, nearly 82% reported that the friend or relative had obtained the drugs from just one doctor. Therefore, a large proportion of “nonmedical” use actually may be the sharing of legitimately prescribed analgesics for unauthorized pain-relief purposes. This is a different sort of problem than the survey data seem to convey.

  • The accuracy of the NSDUH survey in clinically diagnosing substance abuse or addiction following DSM IV criteria should be questioned. However, an even greater concern than the 1.7 million persons revealed to have pain-reliever abuse or addiction could be the 15.2 million with alcohol abuse or addiction, plus the 3.1 million with abuse or addiction involving both alcohol and illicit drugs. These figures, combined with the 58 million persons who are binge drinkers and 17.3 million reporting heavy drinking (according to the survey), amounts to about 94 million Americans with alcohol-use problems. Combining alcohol with analgesics, as is commonly done, has a very high risk potential for overdose and death; so, unless alcohol-related problems are addressed there is little hope of reducing the hazards of analgesic misuse.

In sum, while there are important problems with pain-reliever misuse, abuse, and addiction in America these are only one part of the larger picture. And, as we’ve noted before [see blogpost 8/19/09], there already are a number of U.S. government agencies or research institutes concerned with alcohol and illicit drugs but there are virtually none specifically addressing pain and problems associated with the analgesics used to treat pain conditions. That should be corrected, don't you think? Add your comments below.