Saturday, November 16, 2013

Confusion Over Why Youths Misuse Rx Opioids

Teenage Drug AbuseThe misuse of prescription opioid analgesics by young persons has garnered significant news-media coverage and created much concern, but there has been inadequate attention focused on the underlying motives for such behaviors. A new study among adolescent students revealed that most of the alleged medication misuse was for treating legitimate pain; however, there are some confusing aspects of this investigation that muddle the interpretation and usefulness of outcomes.

Researchers at the University of Michigan surveyed 2,964 students in Detroit, Michigan (grades 7-12; 51% female) during 2011 to 2012 to assess motives for medical misuse of prescription opioids, as well as substance abuse and diversion behaviors [McCabe et al. 2013]. “Medical misuse” of Rx opioids was defined as “the use of prescribed opioids by a patient with a prescription for an opioid analgesic who uses the prescription in a manner not intended by the prescriber (eg, higher or more frequent doses, using intentionally to get high, or coingesting with alcohol or other drugs).” Whereas, “nonmedical use” of the drugs was defined as any use of someone else's prescription opioids, whether for pain relief, to get high, or in conjunction with other drugs.

The following results were noted by the researchers:

  • Among all respondents, 13% (n=393) reported that they had been prescribed opioid analgesics during the past-year (although reasons for Rx, such as specific pain disorders, were not captured in the data).

  • Among those legitimately prescribed opioid medications, about 18% of them reported “medical misuse” (eg, using too much of their medication, using it to get high, or using it to increase alcohol or other drug effects).

  • Among the “medical misusers,” the most prevalent motives were “to relieve pain” (84%) and “to get high” (35%). As for “nonmedical users,” taking someone else’s medication, pain relief was cited as the primary motivation by nearly 88%.

  • Multivariate analyses indicated that females were almost twice as likely as males to report past-year “medical misuse” of opioids, but there were no gender differences seen in the prevalence of motives.

  • African Americans were more likely than whites to “medically misuse” opioids, and most of them (3 in 4) said they were motivated by pain relief.

  • “Medical misusers” driven by non–pain-relief motives were more likely to also exhibit substance abuse behaviors; more than 15 times greater odds as compared with nonusers (adjusted odds ratio = 15.2, 95% CI = 6.4–36.2, P<0.001).

  • No such differences in substance abuse behaviors existed between nonusers and appropriate medical users, or between nonusers and “medical misusers” motivated by pain relief only.

The researchers conclude that their findings improve our understanding of opioid medication misuse among adolescents and indicate a need for better education about appropriate medical use and appropriate pain management, as well as enhanced patient communication with prescribers. But, a most important concern brought out by this study might be the apparent undertreatment or mistreatment of pain in young persons.


As usual, attention-seeking and biased news stories depicted rampant Rx-opioid misuse by youths, which actually was not evidenced by this investigation. Several key points regarding this study by McCabe et al. [2013] are worthy of consideration….

  1. This was a relatively small study of students from a single geographic location; so, as the researchers acknowledge, the external validity of outcomes for a larger, broader population is doubtful. Along with that, relatively small percentages of the total 2,964 respondents were “medical misusers” (1.9%) or “nonmedical users” (4.9%), which decreases the statistical power and practical significance of subgroup analyses.

  2. As with a great deal of other epidemiological research in the pain field, the terminology and definitions used can be more confusing than helpful when it comes to a clear interpretation of the evidence. In this present study, distinctions between “medical misuse” and “nonmedical use” primarily involve opioid analgesics being prescribed for the student/patient (“medical”) as opposed to similar medication prescribed for somebody else (“nonmedical”).

    In either case, however, a student might be using the opioid for a medical reason to treat pain and/or for recreational purposes (eg, to get high or in conjunction with other substances of abuse). So, it becomes difficult to keep track of the differences between what is meant by “medical” vs “nonmedical,” as well distinctions between misuse for medical reasons (eg, pain relief) as opposed to abuse for recreational purposes (eg, to get high).

  3. Despite such linguistic consternations and possible misnomers, it is important to note overall that the most prevalent reason for either “medical misuse” or “nonmedical use” of Rx opioids was to relieve pain. Specifically, 84.2% of “medical misusers” and 87.6% of “nonmedical users” said their motivation was “because it relieves pain.” It is of further interest that when students “misused” Rx opioids for pain relief they were less likely to also use those medications in ways related to substance abuse; only 0.24% of all respondents claimed to be driven by an opioid-addiction problem.

A similar prior study by McCabe and colleagues [2009; discussed in an UPDATE here] was much larger, examining responses from more than 12,000 high school seniors. They found that only about 1 in 8 of the students (12.3%) had used opioids in ways other than had been prescribed for them. At the same time, however, a large percentage (45%) of those who did misuse opioid analgesics — whether involving their own or someone else’s medication — were trying to relieve physical pain. Also, it was found that when pain relief was a primary motivation for “misusing” opioids the students were less likely to also use other drugs of abuse, including alcohol.

Another interesting finding in the current study by McCabe et al. [2013] is that, among the 393 students that had been prescribed opioid analgesics in the past year, the most prevalently prescribed drug was codeine (38%), followed in the distance by hydrocodone (18%), oxycodone (9%), and morphine (7%). As reported in an earlier UPDATE [here], an exhaustive Cochrane Systematic Review found codeine to be probably the least effective and most problematic of all analgesics; so, why this medication was so frequently prescribed in this population might be questioned. However, it also should be noted that roughly 31% of the students prescribed opioids did not even know the name of the agent they were taking, which itself is troublesome in suggesting a lack of patient education and communication that accompanies prescribing for adolescents.

Overall, it is important to emphasize that more than 4 of every 5 (82%) adolescents prescribed opioid analgesics used them appropriately. Among those who used them in an un-prescribed manner, the relief of physical pain was a primary motivating force. While it should not be overlooked that significant percentages (but relatively small absolute numbers) of “medical misusers” and “nonmedical users” were motivated by non-pain-relief choices, a bigger question might be, “Why are so many youths inadequately treated (or mistreated) for pain that they resort to potentially hazardous self-treatment strategies?”

The data in this and other epidemiological studies on this topic do not provide clear answers. Perhaps, as McCabe et al. suggest, there should be better education and communication when addressing the pain management needs of young patients. However, there also could be access-to-care issues, along with the underdiagnosis and inadequate treatment of pain in adolescents to begin with, accompanied by inappropriate prescribing and insufficient monitoring. In any case, the solutions would most likely center on providing more and better pain relief in youngsters who are identified as needing it, rather than limiting access or setting arbitrary restrictions (unsupported by best evidence) on the prescribing of effective and safe analgesics, whether opioid or nonopioid.

REFERENCE: McCabe SE, West BT, Boyd CJ. Motives for Medical Misuse of Prescription Opioids Among Adolescents. J Pain. 2013(Oct);14(10):1208-1216 [abstract here].

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Anonymous said...

I am not surprised with 100 million people in pain daily. The population is the largest ever in history and more people have pain now, more than ever before.

Janice Reynolds said...

Regarding the prescribing of codeine, I am sure a large part of it is the misconception that it is somehow “safer.” This has been an ongoing problem with hydrocodone/acetaminophen until recently. Also there has been an incorrect pairing of it with “moderate” pain. Because of the media overblown idea of prescription drug abuse epidemic and the hideously poor study by the CDC prescribing pain medication for adolescents is perilous with a boogieman around every corner (or pill).
What would be interesting also would be a look at whether adolescents abuse non-prescription medications as well. Yes they are not addicting however they have some terrible adverse effects if taken in excess or not carefully. When I was still working as a nurse I would talk to nursing students (young ones) who take 3-4 extra-strength acetaminophen or 5-6 ibuprofen at a time because otherwise wouldn’t touch their pain (many times headaches but also menstrual cramps, skeletal muscular pain, etc.) When I shadowed a school nurse (Junior High) for a project I was appalled that most parents would send in ibuprofen for their child if needed (kept by the school nurse); most kids would just dry swallow it. It would be interesting if they were aware of adverse effects (or had the belief that the young do they are invincible), if there has been any problems, and whether they default to OTC because health professionals don’t listen to them or provide appropriate medication.

Myron Shank, M.D., Ph.D. said...

Assuming that the authors used the same definition of "nonmedical" use of opioids that they did in their earlier report for high school seniors (McCabe Sean Esteban, Boyd Carol J., Cranford James A., Teter Christian J. Motives for nonmedical use of prescription opioids among high school seniors in the United States: self-treatment and beyond. Archives of Pediatrics & Adolescent Medicine 2009; 163:739-744.), they counted use of one's own prescription for a different episode of pain as "nonmedical" use. At worst, this constitutes "self-medication" with a medication to which one is legally entitled, for the same purpose (if not the same event)for which it was prescribed. While I appreciate the work that these authors have done, clarifying the legitimate motives of most students for taking opioid analgesics, I cannot accept their misleading use of the term "nonmedical."