Monday, March 1, 2010

Friends, Relatives Key Source of Misused Opioids

According to a new study, patients are compliant for the most part in not overusing opioid medications, but they save any leftover drugs. And, almost all persons who illicitly obtain opioid pain relievers get the drugs from a friend or relative who has a prescription. In most cases, however, the purpose is “medical misuse” to treat pain rather than drug abuse. The true problem is a failure to educate.

The study conducted by researchers at the Utah Department of Health involved a randomized telephone survey in 2008 of more than 5,300 adults aged 18 years or older. It was published in the U.S. Center for Disease Control and Prevention's Morbidity and Mortality Weekly Report [Porucznik et al. 2010] and also reported in Healthday News [Reinberg 2010]. Here are highlights of the findings:
  • Slightly more than 1 in 5 persons (20.8%) had been prescribed an opioid analgesic during the preceding 12 months; 71% for acute pain, 15% long-term pain, 14% both long- and short-term pain.

  • Only about 3% of all respondents admitted to using their medication more frequently or in higher doses than had been prescribed, and 72% had leftover opioid medication. Roughly a quarter said that they disposed of leftover medication; however, 2.3% gave it away to someone else and 71% kept the excess opioids for themselves.

  • Almost 2% of survey respondents said they had taken an opioid pain medicine not prescribed for them during the past year, and 97% of the time the drug came from a friend or relative. In most cases, roughly 85%, the medication was willingly shared, but 10% of the time the medication was pilfered and in 4% of cases it was purchased from a friend or relative.

  • Importantly, the vast majority of persons who obtained opioids from a friend or relative did so to relieve pain (72.4%) and another 5.8% wanted to relieve anxiety or another physical symptom; about 15% abused diverted opioids “for fun.” Opioid misuse of any type was most common among person aged 45 to 54 years, although there were no statistically significant differences across age groups or by sex.
COMMENTARY: It is not surprising that so many persons (72%) had leftover pain medication or that the excess was saved by most of them; after all, people pay for these drugs and may need them again (so they believe). Who among our readers does not have a drawer or cabinet with at least a few containers of leftover prescription medications? Should prescribers be faulted for not anticipating precisely how much pain medication their patients will need? Here are several additional observations about this study report…
  1. Overdoses and associated deaths from opioids, largely due to drug misuse, have risen during the past 10 years and are of great concern, which prompted this study in Utah. Yet, as we noted in a recent blogpost [here], such cases are very complex and fatalities attributed to opioids may be inaccurate in many reports.

  2. The frequency of opioid prescribing noted in this Utah study (20.8%) seems quite high, and telephone surveys such as this, which covered only 0.2% of the population, can have wide margins of error. Extrapolating from study data, there were about 569,000 opioid prescriptions written during 2008 in a state with a population of only about 2.7 million persons that year. However, an editorial accompanying the study in MMWR noted that a nationwide U.S. study in 2002 similarly found an 18.4% rate of opioid prescribing among insured persons age 18 or over.

  3. It is interesting to note that only 3% of respondents admitted to misusing their opioids; that is, 97% were compliant with the prescribed dose and frequency. This could indicate a deficiency in the survey methodology, as other studies have found as many as 48% of patients are noncompliant, with most (34%) underusing their opioid analgesics [see our earlier blogpost]. This would better explain why so many persons in Utah have leftover medication.

  4. It is of further importance that in nearly 8 out of 10 cases of opioid “diversion” to a friend or relative it was for pain relief or other medical purpose rather than for recreational abuse. Clearly, this is “medical misuse” of the medication — use for a medicinal purpose other than intended and/or by a person other than for whom the drug was prescribed. Similarly, studies of opioid misuse among teenagers found that nearly half of them did so to relieve untreated pain [see earlier blogpost with data]. Such findings point to systemic problems in society, involving the undertreatment of pain along with casual attitudes toward the sharing and use of analgesics.

  5. Finally, as is usually the case, the mass media grossly slanted their reporting of the Utah study. For example, the Healthday News article focused on OxyContin® as a primary culprit, yet the study itself only noted oxycodone (not the long-acting ‘Contin’ formulation) and hydrocodone was the primary opioid in question — it was prescribed more than twice as often as oxycodone. Further, the article quotes a psychiatrist from North Carolina lamenting the Utah study as more evidence of increasing problems with opioids in the United States; he noted, “This problem is costing lives, including the lives of young healthy people." Yet, the study addressed neither opioid fatalities nor the impact on youth, and only relatively small proportions of opioids were non-prescribed (2%) or being abused for nonmedical purposes (15%). He also said, "Education of both physicians and the public is needed." With that, we heartily agree.
Even though the “sharing” of prescription medications is against the law, and there are many good reasons for safely disposing of unused drugs, the fact is that these are not widely accepted concepts among the general population. Government agencies at all levels as well as community organizations have failed to educate the public regarding these issues, and there is even widespread confusion about how to safely dispose of medications in an environmentally-friendly manner.

> Porucznik CA, Sauer BC, Johnson EM. Adult use of prescription opioid pain medications — Utah, 2008. MMWR. 2010[Feb 19];59(6);153-157 [
see article].
> Reinberg S. Oxycontin abusers often rely on 'leftover' meds from friends. Healthday News [online] February 18, 2010 [see article].