1 Funding Funding Adolescents’ Nonmedical Use Adolescents’ Nonmedical Use of of Prescription Opioid Prescription Opioid Analgesics Analgesics Pain, Opioids, and Addiction: An Urgent Problem for Doctors and Patients Natcher Auditorium (NIH) March 5-6, 2007 Carol J. Boyd, PhD, MSN, FAAN Carol J. Boyd, PhD, MSN, FAAN Professor, Nursing and Women’s Studies Professor, Nursing and Women’s Studies Director, Institute for Research on Women Director, Institute for Research on Women & Gender & Gender University of Michigan, Ann Arbor University of Michigan, Ann Arbor [email protected][email protected]
Transcript
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FundingFunding
Adolescents’ Nonmedical Use Adolescents’ Nonmedical Use of of
Pain, Opioids, and Addiction: An Urgent Problem for Doctors and Patients Natcher Auditorium (NIH)
March 5-6, 2007
Carol J. Boyd, PhD, MSN, FAANCarol J. Boyd, PhD, MSN, FAANProfessor, Nursing and Women’s Studies Professor, Nursing and Women’s Studies
Director, Institute for Research on WomenDirector, Institute for Research on Women & Gender& GenderUniversity of Michigan, Ann ArborUniversity of Michigan, Ann Arbor
DA018239DA018239 (PI: McCabe with Boyd, Teter) (PI: McCabe with Boyd, Teter)
National Institute on Alcoholism National Institute on Alcoholism and Alcohol Abuse (NIAAA)and Alcohol Abuse (NIAAA)
AA014601 AA014601 (PI: Young with Boyd)(PI: Young with Boyd)
FundingFunding
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ContributorsContributors
James A. Cranford, PhD.James A. Cranford, PhD.Sean E. McCabe, PhD., MSW.Sean E. McCabe, PhD., MSW.Michele Morales, PhD, MSWMichele Morales, PhD, MSW
Christian Teter, PharmD Christian Teter, PharmD Amy B. Young, PhD.Amy B. Young, PhD.
______________________________________________________________________________________Also: Also: Scott Crawford, Survey Sciences GroupScott Crawford, Survey Sciences Group
Duston Pope, Market Strategies, IncDuston Pope, Market Strategies, IncAnonymous School District and UniversityAnonymous School District and University
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THE PURPOSETHE PURPOSE
To consider the conceptual implications of To consider the conceptual implications of the term the term nonmedical use of nonmedical use of prescription opioidsprescription opioids
To review data from four different studies: To review data from four different studies: National Survey on Drug Use and Health (NSDUH); National Survey on Drug Use and Health (NSDUH);
Monitoring the Future (MTF), Student Life Survey Monitoring the Future (MTF), Student Life Survey (SLS) and Secondary Student Life Survey (SSLS)(SLS) and Secondary Student Life Survey (SSLS)
To highlight characteristics of adolescent To highlight characteristics of adolescent nonmedical users of opioid analgesicsnonmedical users of opioid analgesics Focus on motivation (to use) and diversion (to whom)Focus on motivation (to use) and diversion (to whom)
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THE PROBLEMTHE PROBLEM
Studies indicate that the nonmedical use of Studies indicate that the nonmedical use of prescription medications is increasing in the U.S. prescription medications is increasing in the U.S. among adolescents and young adults.among adolescents and young adults. (See: Johnston et al., (See: Johnston et al., 2004, 2005; McCabe, et al., 2007; NSDUH, 2006)2004, 2005; McCabe, et al., 2007; NSDUH, 2006)
The nonmedical use of prescription medications is The nonmedical use of prescription medications is associated with higher rates of tobacco, alcohol and associated with higher rates of tobacco, alcohol and other drug use other drug use (See: Boyd, et al, 2004, 2006; McCabe, Boyd, et al 2005, 2006)(See: Boyd, et al, 2004, 2006; McCabe, Boyd, et al 2005, 2006)
The nonmedical use of opioid medication continues The nonmedical use of opioid medication continues to dominate to dominate (See NSDUH, 2005):(See NSDUH, 2005):
5% of 12 to 17 year olds reported nonmedical use of scheduled pain medications*;12% of 18 to 25 year olds reported nonmedical use of scheduled pain medications*.
* lifetime
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This is a term that has been used by This is a term that has been used by researchers to include such varied researchers to include such varied
behavior as medication misuse, behavior as medication misuse, medication abuse, prescription drug medication abuse, prescription drug
misuse and prescription drug abuse. misuse and prescription drug abuse.
What is …What is …“NONMEDICAL USE OF “NONMEDICAL USE OF
PRESCRIPTION PRESCRIPTION OPIOIDS?”OPIOIDS?”
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CONCEPTUAL CONCEPTUAL CONFUSIONCONFUSION
Non-medical use of Prescription Drugs
(NMUPD)
Medication Misuse
Medication Abuse
Prescription Drug Misuse
Prescription Drug Abuse
TODAY WE WILL FOCUS ONLY ON PRESCRIPTION DRUG MISUSE AND ABUSE
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Prescription Drug Prescription Drug Misuse (PDM)Misuse (PDM)
DEFINITION:DEFINITION:
The intentional use of The intentional use of someone else’s someone else’s prescription prescription medication for the medication for the purpose of alleviating purpose of alleviating symptoms that may be symptoms that may be related to a health related to a health problem. problem.
ATTRIBUTES:ATTRIBUTES:
No legal prescription No legal prescription for the drugfor the drug
Use is intentionalUse is intentional Perceived barriers to Perceived barriers to
medical care ( e.g. a medical care ( e.g. a prescription is not prescription is not available to the person)available to the person)
Motive is to relieve a Motive is to relieve a condition for which the condition for which the medication, when medication, when prescribed, is generally prescribed, is generally intended (e.g. pain). intended (e.g. pain).
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Case Example #1Case Example #1A 21 year old is working full-A 21 year old is working full-time as a line-cook in a time as a line-cook in a restaurant. He slices-off the restaurant. He slices-off the tip of his finger. The tip of his finger. The manager* takes the young manager* takes the young man (and his fingertip) to the man (and his fingertip) to the nearest ED; on the drive to nearest ED; on the drive to the hospital the manager the hospital the manager gives him a Vicodin saying, gives him a Vicodin saying, “you will be waiting a long “you will be waiting a long time, you will need this”. He time, you will need this”. He takes the pill. The young man takes the pill. The young man is treated in the ED. The ED is treated in the ED. The ED physician gives the young physician gives the young man a prescription for Vicodin man a prescription for Vicodin for pain and tells him to see for pain and tells him to see his primary care provider in his primary care provider in one week.**one week.**
* The manager is engaging in the diversion of a scheduled medication, this is illegal.**At any point, had the cook taken more than his prescribed dose to relieve pain, this would have been medication misuse; if he had saved his prescribed medication for a later time, then taken it to get a “buzz”, this would be medication abuse.
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Case Example #2Case Example #2
On a Friday afternoon, a On a Friday afternoon, a 16-year-old teen, an honor 16-year-old teen, an honor student, is planning to student, is planning to attend “Homecoming” attend “Homecoming” with her new boyfriend. with her new boyfriend. Four hours before the Four hours before the event, she develops a event, she develops a severe migraine severe migraine headache. In tears, she headache. In tears, she asks her mother for help. asks her mother for help. Her mother gives her a Her mother gives her a hydrocodone tablet (left hydrocodone tablet (left over from her own over from her own surgery). The teen went surgery). The teen went to the event and “had a to the event and “had a great time.”great time.”
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Prescription Drug Abuse Prescription Drug Abuse (PDA)(PDA)
DEFINITION:DEFINITION:
The use of a The use of a scheduled scheduled prescription prescription medication to medication to experiment, to get experiment, to get high or to create an high or to create an altered state. altered state.
ATTRIBUTES:ATTRIBUTES:
No legal prescription No legal prescription for the drugfor the drug
Use is intentionalUse is intentional May involve use in May involve use in
combination with other combination with other drugsdrugs
May involve delivering May involve delivering in a wrongful manner in a wrongful manner (e.g. IV, skin-popping, (e.g. IV, skin-popping, snorting or smoking).snorting or smoking).
Motive to experiment, Motive to experiment, get high or to alleviate get high or to alleviate withdrawal symptoms withdrawal symptoms
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Case ExampleCase Example
A 22 year old girl with a A 22 year old girl with a history of alcohol abuse history of alcohol abuse is given an oxycodone is given an oxycodone tablet by a friend; she tablet by a friend; she wants to experiment to wants to experiment to see “what it does”. She see “what it does”. She crushes the pill and crushes the pill and snorts it. She snorts it. She continues to purchase continues to purchase the “Oxy” from a friend the “Oxy” from a friend when she wants to when she wants to party. party.
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Epidemiological Sources:Epidemiological Sources:Adolescents and Young AdultsAdolescents and Young Adults
National Survey on Drug Use and National Survey on Drug Use and Health (NSDUH)Health (NSDUH)
Monitoring the Future (MTF)Monitoring the Future (MTF) Student Life Survey (SLS)Student Life Survey (SLS) Secondary Student Life Survey Secondary Student Life Survey
(SSLS)(SSLS)
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NSDUHNSDUH Nationally representative sample (& by Nationally representative sample (& by
State)State)
Civilian, non-institutional population, Age Civilian, non-institutional population, Age
Questionnaire format, administered in class and Questionnaire format, administered in class and
through follow-up mail surveysthrough follow-up mail surveys
49, 347 respondents in 200549, 347 respondents in 2005
Began asking about specific Rx drugs in 2002 Began asking about specific Rx drugs in 2002
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Monitoring the FutureMonitoring the Future
Survey Item:Survey Item:
In the past year have you taken In the past year have you taken amphetamines, narcotics other than amphetamines, narcotics other than heroin, etc.… “without a doctor’s heroin, etc.… “without a doctor’s orders?”orders?”
(includes: amphetamines, tranquilizers, sedatives, narcotics other than heroin, OxyContin, Vicodin, Ritalin )
Prescription Drug
Misuse
Prescription Drug
Abuse
Medication Misuse
Medication Abuse
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Nonmedical Use of Nonmedical Use of Prescription Medications:Prescription Medications:
Grades 8-12, 2005Grades 8-12, 2005Percent Using in Past Year
Monitoring the FuturePlease note that amphetamines are NOT just prescribed stimulants
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Annual Prevalence by Annual Prevalence by Gender Gender
0
2
4
6
8
10
12
OxyContin Vicodin Tranquilizers Ritalin
Women Men
Monitoring the Future, 2005 12th grade
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Student Life SurveyStudent Life Survey
Random sample from a large, Midwestern university (began Random sample from a large, Midwestern university (began
in 1999)in 1999) The entire sample received e-mail invitations describing the The entire sample received e-mail invitations describing the
study; non-respondents were sent up to three e-mail study; non-respondents were sent up to three e-mail reminders.reminders.
Informed consent online before participation Informed consent online before participation Clicked on a link to access the Web survey using a password (PIN).Clicked on a link to access the Web survey using a password (PIN).
4,580 respondents in 2005; Response rate = 66%4,580 respondents in 2005; Response rate = 66%
Includes questions on specific classes of prescription drugsIncludes questions on specific classes of prescription drugs
Students received a token incentive (2005) and became Students received a token incentive (2005) and became
eligible for sweepstakes prizes (2003 & 2005).eligible for sweepstakes prizes (2003 & 2005).
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Student Life SurveyStudent Life Survey
““On how many occasions in your lifetime (or On how many occasions in your lifetime (or 12 months) have you used the following types 12 months) have you used the following types of drugs, not prescribed to you?” of drugs, not prescribed to you?”
Substance Use by Source of Prescription Opioids Substance Use by Source of Prescription Opioids among College Womenamong College Women
Binge drinking
Marijuana use
Cocaine use
nonmedical drug index
Cigarette smoking
***
***
***
***
***
***
***
***
***
***
***
***
***
***
%
SourceSource: : McCabe, Teter, Boyd McCabe, Teter, Boyd Drug Alcohol Depend 2005; 77:37-47. Drug Alcohol Depend 2005; 77:37-47. SLS, 2003
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0
10
20
30
40
50
60
70
80
No use (n=2929) Family (n=66) Peer (n=366)
Other (n=34) Unspecified (n=335)
Substance Use by Source of Prescription Opioids Substance Use by Source of Prescription Opioids among College Menamong College Men
Binge drinking
Marijuana use
Cocaine use
nonmedical drug index
Cigarette smoking
***
***
***
***
***
***
***
***
***
***
***
***
***
%
**
Source: Source: McCabe, Teter, Boyd McCabe, Teter, Boyd Drug Alcohol Depend 2005; 77:37-47. Drug Alcohol Depend 2005; 77:37-47. SLS, 2005
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26
5
11
23
4
23
50
58
0 20 40 60
Unspecified
Other
Family
Peer
Men Women
Gender Differences in Sources for Prescription Gender Differences in Sources for Prescription Opioids Not Prescribed (n=1,387)*Opioids Not Prescribed (n=1,387)*
PeerPeer category consisted category consisted of friends, peers, of friends, peers, roommate, boyfriend, roommate, boyfriend, girlfriend and teammate.girlfriend and teammate.
FamilyFamily category category consisted of mother, consisted of mother, family, parent, father, family, parent, father, sibling, aunt, brother, sibling, aunt, brother, husband and cousin.husband and cousin.
OtherOther category consisted category consisted of don’t know, self, drug of don’t know, self, drug dealer and abroad.dealer and abroad.
**p<.01, ***p<.001
***
**
SourceSource: : McCabe, Teter, Boyd McCabe, Teter, Boyd Drug Alcohol Depend 2005; 77:37-47. Drug Alcohol Depend 2005; 77:37-47.
* 2003 data; check all that apply
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0
2
4
6
8
10
12
14
16
18
20
No prescribed use (n=3958) Elementary school (n=298)
Secondary school (n=3154) College (n=1036)
Nonmedical Use of Prescription Opioids by Nonmedical Use of Prescription Opioids by Age of Initiation of Medical UseAge of Initiation of Medical Use
Annualnonmedical
useof RX
opioids
(%)
Men
*** ***
*** ******
***
Women
SourceSource: : McCabe, Teter, Boyd McCabe, Teter, Boyd Drug Alcohol Depend 2005; 77:37-47. Drug Alcohol Depend 2005; 77:37-47.
SLS, 2003
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Gender Differences in Motives for Gender Differences in Motives for nonmedical Use of Prescription Opioidsnonmedical Use of Prescription Opioids
1,086 respondents in 2005; Response rate = 68%1,086 respondents in 2005; Response rate = 68%
Includes questions on specific classes of prescription Includes questions on specific classes of prescription
drugsdrugs
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Secondary Student Life Secondary Student Life SurveySurvey
““On how many occasions in your lifetime On how many occasions in your lifetime (or 12 months) have you used the (or 12 months) have you used the following types of drugs, not prescribed following types of drugs, not prescribed to you?” to you?” (SKIP PATTERNS EMBEDDED)(SKIP PATTERNS EMBEDDED)
Past Year Use of Prescription OpioidsPast Year Use of Prescription Opioidsby Gender, 7by Gender, 7thth-12-12thth grade grade
0
10
20
30
40
50
Medical Use Males Medical Use FemalesNonmedical use Males Nonmedical Use Females
% r
epo
rtin
g p
ast
yea
r p
res
crip
tio
n o
pio
id u
se
n=110 n=235 n=41 n=85
Source: Boyd, McCabe, Cranford, Young, 2006
SSLS, 2005
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Secondary Student Life SurveySecondary Student Life Survey The lifetime prevalence of nonmedical use was The lifetime prevalence of nonmedical use was
highest for pain medication (17.5%):highest for pain medication (17.5%): Sleeping medication (5.8%), sedative/anxiety mediation Sleeping medication (5.8%), sedative/anxiety mediation
(3.5%), and stimulant medication (2.5%). (3.5%), and stimulant medication (2.5%). Girls were significantly more likely to report Girls were significantly more likely to report
nonmedical use of pain medicationnonmedical use of pain medication (22.2% vs. 12.0%, χ2 = 19.0, df = 1, p < (22.2% vs. 12.0%, χ2 = 19.0, df = 1, p < 0.001).0.001).
No gender differences in nonmedical use of the other No gender differences in nonmedical use of the other classes of prescription drugs. classes of prescription drugs.
White students were more likely than Black White students were more likely than Black students to report nonmedical use of prescription students to report nonmedical use of prescription sedative/anxiety*sedative/anxiety* and stimulant medications**and stimulant medications**
*(4.5% vs. 2.2%, χ2 = 4.2, df = 1, p < 0.05)*(4.5% vs. 2.2%, χ2 = 4.2, df = 1, p < 0.05) **(3.3% vs. 1.3%, χ2 = 4.2, df = 1, p < 0.05). **(3.3% vs. 1.3%, χ2 = 4.2, df = 1, p < 0.05).
Source: Boyd, McCabe, Cranford, Young, 2006
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Motivations to Misuse: Motivations to Misuse: Reasons Varied by Drug ClassReasons Varied by Drug Class
Students responded about motivations to Students responded about motivations to misuse of opioid analgesics:misuse of opioid analgesics:
80% for the purpose of relieving pain; 80% for the purpose of relieving pain; 16% for the purpose of helping to sleep;16% for the purpose of helping to sleep; 20% for the purpose of getting high; 20% for the purpose of getting high; 3% because they are safer than street drugs.3% because they are safer than street drugs.
(2005 SSLS Data; Check all that apply; (2005 SSLS Data; Check all that apply; Girls=127; Boys=58)Girls=127; Boys=58)
Source: Boyd, McCabe, Cranford, Young, 2006
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0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Relieves Pain Helps Me Sleep Helps DecreaseAnxiety
Gives Me AHigh
CounteractsOther Drugs
Safer ThanStreet Drugs
Experimentation Because I'mAddicted
Females (n=126)
Males (n=58)
*p < .05.
Gender Differences: Gender Differences: Reasons for Nonmedical Reasons for Nonmedical
UseUse
Source: Boyd, McCabe, Cranford, Young, 2006SSLS, 2005; check all that apply
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Drug Abuse Screening Test Results by Drug Abuse Screening Test Results by Lifetime Prescription Opioid Use, 7Lifetime Prescription Opioid Use, 7thth-12-12thth grades grades
0
5
10
15
20
25
Non-user Medical user only Medical and nonmedical user Nonmedical user only
******
% r
epo
rtin
g t
wo
or
mo
re D
AS
T-1
0 it
ems
*** p < 0.001 based on logistic regression using non-users as reference group and adjusting for gender, race/ethnicity and grade level.
n=535 n=313 n=147 n=35
Source: McCabe, Boyd, Young, 2007SSLS, 2005
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Nonmedical Use of Opioid Analgesics: Nonmedical Use of Opioid Analgesics: Association with Substance Abuse ProblemsAssociation with Substance Abuse Problems
When the number of motives increased DAST-When the number of motives increased DAST-10 scores increased.10 scores increased. For everyFor every additional motive additional motive
endorsed, the DAST-10endorsed, the DAST-10 increased by a factor of 1.8increased by a factor of 1.8..
The group that endorsed more than one motive The group that endorsed more than one motive was significantly more likely to engage in was significantly more likely to engage in greater marijuana and alcohol use as well.greater marijuana and alcohol use as well.
Source: Boyd, McCabe, Cranford, Young, 2006
SSLS, 2005
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Drug Abuse Screening Test Results by Drug Abuse Screening Test Results by Lifetime Prescription Drug Use, 7Lifetime Prescription Drug Use, 7thth-12-12thth grades grades
0
5
10
15
20
25
Non-user Medical user only Medical and nonmedical user Nonmedical user only
******
% r
epo
rtin
g t
wo
or
mo
re D
AS
T-1
0 it
ems
*** p < 0.001 based on logistic regression using non-users as reference group and adjusting for gender, race/ethnicity and grade level.
Thirty-six percent of students reported Thirty-six percent of students reported having a recent prescription for one of having a recent prescription for one of the 4 drug classes. the 4 drug classes. A higher percentage of girls gave away their A higher percentage of girls gave away their
medications than boys medications than boys (27.5% vs. 17.4%, respectively; χ2 9 1 (27.5% vs. 17.4%, respectively; χ2 9 1
= 6.7; = 6.7; PP<.05<.05);); Girls were significantly more likely than Girls were significantly more likely than
boys to divert to female friends boys to divert to female friends (64.0% vs. 21.2%, (64.0% vs. 21.2%,
respectively; χ2 11 1 = 17.5; respectively; χ2 11 1 = 17.5; PP<.01)<.01) while boys diverted to while boys diverted to male friends male friends (45.5% vs. 25.6%, respectively; χ2 12 1 = 4.4; (45.5% vs. 25.6%, respectively; χ2 12 1 = 4.4; PP<.05).<.05).
Ten percent diverted their drugs to parents.Ten percent diverted their drugs to parents.
The nonmedical use of prescription medications is increasing in the The nonmedical use of prescription medications is increasing in the U.S. among adolescents and young adults.U.S. among adolescents and young adults. (See: Johnston et al., 2004, 2005; McCabe, et al., 2007; (See: Johnston et al., 2004, 2005; McCabe, et al., 2007; NSDUH, 2006)NSDUH, 2006)
Students who abuse or misuse prescription medications are Students who abuse or misuse prescription medications are significantly more likely to smoke cigarettes, use marijuana and use significantly more likely to smoke cigarettes, use marijuana and use other illegal drugs.other illegal drugs. (Boyd, Teter, McCabe, 2004;(Boyd, Teter, McCabe, 2004; Boyd, McCabe, Teter, 2006; Boyd, McCabe Teter, 2005)Boyd, McCabe, Teter, 2006; Boyd, McCabe Teter, 2005)
College men and high school boys are more likely than their female College men and high school boys are more likely than their female counterparts to obtain prescription opioid medications from peer counterparts to obtain prescription opioid medications from peer sources, while girls/ women from family.sources, while girls/ women from family. ((Boyd, McCabe, Cranford, Young, 2007; McCabe, ((Boyd, McCabe, Cranford, Young, 2007; McCabe, Teter & Boyd, 2005; ) Teter & Boyd, 2005; )
Student NOT obtaining prescription drugs directly via the internet but Student NOT obtaining prescription drugs directly via the internet but they learn about them from the Internet/TV/print media, peers and they learn about them from the Internet/TV/print media, peers and family.family. (Boyd, McCabe, Teter, 2006; McCabe & Boyd, 2005)(Boyd, McCabe, Teter, 2006; McCabe & Boyd, 2005)
SummarySummary
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SummarySummary
There are measurement issues that make if difficult to determine the extent of the problem:
To what extent are respondents abusing their own prescriptions as opposed to someone else’s?
This form of scheduled medication use/misuse/abuse This form of scheduled medication use/misuse/abuse challenges traditional ideas about substance abusers. challenges traditional ideas about substance abusers.
Self-treatment appears to be one motivation for the Self-treatment appears to be one motivation for the nonmedical use of prescription opioid analgesicsnonmedical use of prescription opioid analgesics (Boyd, McCabe, (Boyd, McCabe,
Cranford, 2006)Cranford, 2006)
Unlike users of many street drugs, there appears to be at least Unlike users of many street drugs, there appears to be at least two groups of nonmedical users of prescription medications: two groups of nonmedical users of prescription medications:
Those to Those to Self-treatSelf-treat; those to get ; those to get High/Experiment/>PerformanceHigh/Experiment/>Performance””
