Friday, June 24, 2011

Misuse of Rx Pain Relievers by Young Adults

Briefly Noted Researchers from the University of Maryland conducted a longitudinal study to examine the extent to which medication nonadherence was related to diversion of prescription analgesics by young adults. Surprisingly, more than 4 in 10 misused their pain relievers, and a quarter diverted analgesics to others, which suggests that healthcare providers need to take a stronger role in counseling young patients regarding the potential risks of noncompliance and diversion.

Reporting in the journal Pain Medicine, the authors describe a cross-sectional analyses of data from the College Life Study, a prospective survey of young adults from the time they entered a large public university in the Mid-Atlantic United States. Participants in this current investigation included 192 persons aged 21 to 26 — 50% male, 71% white — who had been prescribed an analgesic to treat acute pain in the past year.

Subjects had been prescribed analgesics for acute pain conditions, such as dental procedures, broken bones, torn ligaments, or muscle spasms. The majority, 89% had been prescribed opioid analgesics, 6% were prescribed non-opioids (primarily NSAIDs), and 5% could not remember the type of analgesic prescribed.

The researchers found that only 58% were adherent, having faithfully followed prescribers’ instructions regarding their analgesic medication; of the 42% who did not follow directions, 27% under-used and 16% over-used their prescribed medication [these last 2 numbers do not add up properly to 42% in the report]. Overall, 27% of all participants reported diverting their medication — 29% of those prescribed opioids, and 17% prescribed non-opioids — with over-users being the most likely to divert (accounting for 63% of the total). Diversion was defined as the unauthorized sharing, trading, or selling of medication; although, further details regarding the mode of diversion and to whom were not collected.

Holding constant demographic characteristics and perceived harmfulness of nonmedical use, the odds of diverting analgesic medications were almost 5 times greater in over-users as compared with adherent users and 8 times greater in over-users than in under-users (P < 0.05). The researchers expressed concern that certain young adults are prescribed sufficient medication to both over-use it themselves and divert excess to others; assuming that the medication was prescribed for legitimate purposes to begin with. They recommend that physicians who are involved in pain management for acute conditions among young adults should take steps to monitor adherence and reduce diversion of prescription analgesics.

COMMENTARY: There are several weaknesses of this research that merit consideration…

  1. The authors note that their study included an “over-sampling” of students who used an illicit drug or nonmedically used a prescription drug at least once during high school. The reasons for and the extent of over-sampling are not explained, but this might have strongly biased the outcomes.

  2. Data for this investigation were taken from interviews during years 5, 6, and 7 of the larger College Life Study, and there might have been a recall bias, with subjects not accurately remembering drug type, instructions for use, and how they managed the medication.

  3. The authors acknowledge that their study population represented a small, homogenous sampling of the much larger and varied population of young adults in America, so external validity of the outcomes are questionable.

Those limitations aside, it appears that individuals who over-use their prescription analgesics also are at risk for diverting them to others, possibly due to a general propensity to engage in deviant behavior, the authors note. However, this research did not examine or help to identify characteristics of young adults who are most likely to over-use or divert prescribed analgesics. As might be expected, over-users were more likely to perceive the nonmedical use of analgesics as carrying no or slight risks of harm; whereas, adherent users and under-users perceived that there were moderate to great risks of misusing these drugs.

If anything, this study highlights the importance of prescribers taking the time to counsel younger patients about the dangers of nonadherence with instructions and/or sharing analgesics with others. This may be of particular importance for dentists, who routinely write opioid prescriptions for tooth extractions or other procedures, and orthopedists or others, who write them for sports injuries among young adults.

It also should be noted that the new Opioid-REMS recently mandated by the U.S. FDA — requiring opioid-prescriber education and patient counseling — applies only to long-acting and extended-release opioid analgesics [see UPDATES here]. Therefore, the short-acting opioids involved in this present study would not be affected and the counseling of young adults recommended above would be voluntary, yet critical. The exclusion in the REMS of short-acting opioids prescribed for acute pain could turn out to be significantly short-sighted.

REFERENCE: Arria AM, Garnier-Dykstra LM, Caldeira KM, et al. Prescription Analgesic Use Among Young Adults: Adherence to Physician Instructions and Diversion. Pain Medicine. 2011(Jun);12(6):898–903 [abstract here].