# Presentation: 110149

## Funding

***Adolescents’ Nonmedical Use ***
***of ***
***Prescription Opioid 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**
**Professor, Nursing and Women’s Studies **
**Director, Institute for Research on Women** **& Gender**
**University of Michigan, Ann Arbor**
**caroboyd@umich.edu**

## Funding

**National Institute on Drug Abuse (NIDA)**
_**DA018271**_** (PI: Boyd with McCabe, Teter)**
_**T32DA07267**_** (PI: Boyd) McCabe, Teter & Young,  **
**(previous T32 post-doctoral fellows)**
_**DA018239**_** (PI: McCabe with Boyd, Teter)**
**National Institute on Alcoholism and Alcohol Abuse (NIAAA)**
_**AA014601 **_**(PI: Young with Boyd)**

**Funding**

## Contributors

**Contributors**

**James A. Cranford, PhD.**
**Sean E. McCabe, PhD., MSW.**
**Michele Morales, PhD, MSW**
**Christian Teter, PharmD **
**Amy B. Young, PhD.**
**___________________________________________**
**Also: ****	****Scott Crawford, Survey Sciences Group**
**	****	****Duston Pope, Market Strategies, Inc**
**	****	****Anonymous School District and University**

## THE PURPOSE

- To consider the conceptual implications of the term _***nonmedical use of prescription opioids***_
- To review data from four different studies:
- National Survey on Drug Use and Health (NSDUH);  Monitoring the Future (MTF), Student Life Survey (SLS)  and Secondary Student Life Survey (SSLS)
- To highlight characteristics of adolescent nonmedical users of opioid analgesics
- Focus on motivation (to use) and diversion (to whom)

## THE PROBLEM

- Studies indicate that the nonmedical use of prescription medications is increasing in the U.S. among adolescents and young adults. (See: Johnston et al., 2004, 2005; McCabe, et al., 2007; NSDUH, 2006)
- The nonmedical use of prescription medications is associated with higher rates of tobacco, alcohol and other drug use (See: Boyd, et al, 2004, 2006; McCabe, Boyd, et al 2005, 2006)
- The nonmedical use of opioid medication continues to dominate (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

## This is a  term that has been used by researchers to include such varied behavior as medication misuse, medication abuse, prescription drug misuse and prescription drug abuse.  

**What is ...****“NONMEDICAL USE OF PRESCRIPTION OPIOIDS?”**

## CONCEPTUAL CONFUSION

**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

## Prescription Drug Misuse (PDM)

**DEFINITION:**
- 	The intentional use of someone else’s prescription medication for the purpose of alleviating symptoms that may be related to a  health problem.

**ATTRIBUTES:**
- No legal prescription for the drug
- Use is intentional
- Perceived barriers to medical care ( e.g. a prescription is not available to the person)
- Motive is to relieve a condition for which the medication, when prescribed, is generally intended (e.g. pain).

## Case Example #1

- 	A 21 year old is working full-time as a line-cook in a restaurant.  He slices-off the tip of his finger.  The manager* takes the young man (and his fingertip) to the nearest ED; on the drive to the hospital the manager gives him a Vicodin saying, “you will be waiting a long time, you will need this”.  He takes the pill.  The young man is treated in the ED.  The ED physician gives the young man a prescription for Vicodin for pain and tells him to see his primary care provider in 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.

## Case Example #2

**Case Example #2**

- 	On a Friday afternoon, a 16-year-old teen, an honor student,  is planning to attend “Homecoming” with her new boyfriend.  Four hours before the event, she develops a severe migraine headache.  In tears, she asks her mother for help.  Her mother gives her a hydrocodone tablet (left over from her own surgery).  The teen went to the event and “had a great time.”

## Prescription Drug Abuse (PDA)

**	****DEFINITION:**** **
- 	The use of a scheduled prescription medication to experiment, to get high or to create an altered state.

**ATTRIBUTES:**
- No legal  prescription for the drug
- Use is intentional
- May involve use in combination with other drugs
- May involve delivering in a wrongful manner (e.g. IV, skin-popping, snorting or smoking).
- Motive to experiment, get high or to alleviate withdrawal symptoms

## Case Example

- 	A 22 year old girl with a history of alcohol abuse is given an oxycodone tablet by a friend; she wants to experiment to see “what it does”.  She crushes the pill and snorts it.  She continues to purchase the “Oxy” from a friend when she wants to party.

## Epidemiological Sources:Adolescents and Young Adults

- National Survey on Drug Use and Health (NSDUH)
- Monitoring the Future (MTF)
- Student Life Survey (SLS)
- Secondary Student Life Survey (SSLS)

## NSDUH

- Nationally representative sample (& by State)
- Civilian, non-institutional population, Age 12+
- Face-to-face interview
- Computer-assisted, self-administered
- 68,308 respondents in 2005
- Data comparable with 2002, 2003, and 2004, but not with data prior to 2002

## National Survey of Drug Use and Health (NSDUH)

- Survey item:
- Have you ever taken medication that was not prescribed for you, or that you took for the experience or feeling it caused?
- (includes: any psychotherapeutics, pain relievers, sedatives, stimulants, tranquilizers)

**Medication**
** ****Abuse**

**Prescription **
**Drug**
** ****Misuse**

**Prescription **
**Drug**
** ****Abuse**

## Nonmedical Use of Prescription Medications, Ages 12-25

**Percent Using in Past Year**

***NSDUH, 2005***

## Monitoring the Future (MTF)

- Cross-sectional, school-based survey of U.S (embedded panel for college and beyond)
- Middle, high school and college students, began in 1970’s
- Nationally representative sample
- Questionnaire format, administered in class and through follow-up mail surveys
- 49, 347 respondents in 2005
- Began asking about specific Rx drugs in 2002

## Monitoring the Future

- Survey Item:
- 	In the past year have you taken amphetamines, narcotics other than heroin, etc.... “without a doctor’s orders?”
- (includes: amphetamines, tranquilizers, sedatives, narcotics other than heroin, OxyContin, Vicodin, Ritalin )

**Prescription **
**Drug**
** ****Misuse**

**Prescription **
**Drug**
** ****Abuse**

**Medication**
** ****Misuse**

**Medication**
** ****Abuse**

## Nonmedical Use of Prescription Medications:  Grades 8-12, 2005

**Percent Using in Past Year**

***Monitoring the Future***

- Please note that amphetamines are NOT just prescribed stimulants

## Annual Prevalence by Gender  

*Monitoring the Future, 2005    12**th** grade*

## Student Life Survey

- Random sample from a large, Midwestern university (began in 1999)
- The entire sample received e-mail invitations describing the study;  non-respondents were sent up to three e-mail reminders.
- Informed consent online before participation
- Clicked on a link to access the Web survey using a password (PIN).
- 4,580 respondents in 2005; Response rate = 66%
- Includes questions on specific classes of prescription drugs
- Students received a token incentive (2005) and became eligible for sweepstakes prizes (2003 & 2005).

## Student Life Survey

- 	“On how many occasions in your lifetime (or 12 months) have you used the following types of drugs, not prescribed to you?”
- 		(SKIP PATTERNS, EMBEDDED)
- 	Sleep (e.g., *Ambien*, *Halcion*, *Restoril*, temazepam, triazolam), sedative/anxiety medication (e.g., *Ativan*, *Xanax*, *Valium*, *Klonopin*, diazepam, lorazepam), stimulant medication (e.g., *Ritalin*, *Dexedrine*, *Adderall*, *Concerta*, methylphenidate) and pain medication (e.g., opioids *Vicodin*, *OxyContin*, *Percocet*, *Darvocet*, morphine, hydrocodone, oxycodone).

**Prescription **
**Drug**
** ****Misuse**

**Prescription **
**Drug Abuse**

## Past Year Medical Use    

**Past Year Medical Use****    **

- **

- **

- *

- *p < 0.05, ** p < 0.01 based on Pearson chi-square tests	        ***Source: McCabe, Teter, Boyd, 2006***

## Past Year Nonmedical Use    

**Past Year Nonmedical Use****    **

- **

- **

- *

- *p < 0.05, ** p < 0.01 based on Pearson chi-square tests	      ***Source: McCabe, Teter, Boyd, 2006***

## Specific Prescription Opioids Used Nonmedically (Past Year)

- The past year use was 2% or less for fentanyl, hydromorphone, meperidine, methadone, and tramadol.

**%**

_*Source*_*: *McCabe, Cranford, Boyd & Teter, 2007"*Addict Behav** 2006\7*

- SLS, 2005

## Substance Use by Source of Prescription Opioids 

**Substance Use by Source of Prescription Opioids **
**among College Women**

**Binge **
**drinking**

**Marijuana **
**use**

**Cocaine **
**use**

**nonmedical **
**drug index**

**Cigarette **
**smoking**

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

- %

_*Source*_*: **McCabe, Teter, Boyd **Drug Alcohol Depend 2005; 77:37-47. *

- SLS, 2003

## Substance Use by Source of Prescription Opioids 

**Substance Use by Source of Prescription Opioids **
**among College Men**

**Binge **
**drinking**

**Marijuana **
**use**

**Cocaine **
**use**

**nonmedical **
**drug index**

**Cigarette **
**smoking**

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

*******

- %

******

*Source: **McCabe, Teter, Boyd **Drug Alcohol Depend 2005; 77:37-47. *

- SLS, 2005

## Gender Differences in Sources for Prescription Opioids Not Prescribed (n=1,387)*

**Gender Differences in Sources for Prescription Opioids Not Prescribed (n=1,387)***

_**Peer**_ category consisted of friends, peers, roommate, boyfriend, girlfriend and teammate.
_**Family**_ category consisted of mother, family, parent, father, sibling, aunt, brother, husband and cousin.
_**Other**_ category consisted of don’t know, self, drug dealer and abroad.

- **p<.01, ***p<.001

- ***

- **

_*Source*_*: **McCabe, Teter, Boyd **Drug Alcohol Depend 2005; 77:37-47. *

- * 2003 data; check all that apply

## Nonmedical Use of Prescription Opioids by 

**Nonmedical Use of Prescription Opioids by **
**Age of Initiation of Medical Use**

**Annual**
**nonmedical**
**use**
**of RX**
**opioids**
**(%)**

**Men**

- ***

- ***

- ***

- ***

- ***

- ***

**Women**

_*Source*_*: **McCabe, Teter, Boyd **Drug Alcohol Depend 2005; 77:37-47. *

- SLS, 2003

## Gender Differences in Motives for nonmedical Use of Prescription Opioids

- ***

- ***

- *p<.05, **p<.01, ***p<.001

_*Source*_*: **McCabe *Cranford, Boyd & Teter, Add Behaviors, 2007

- SLS, 2005; check all that apply

## Motives for Nonmedical Use of Prescription Opioids: DAST-10 Scores

**n=1936   n=140   n=181**

**Motives for Nonmedical Use of Prescription Opioids: DAST-10 Scores**

- ***

- ***

**% reporting drug abuse based on DAST-10**

***Source: McCabe, Cranford, Boyd & Teter, 2007***

- SLS, 2005

## PEERS

- (female, White, sophomore)

- “*My mother has Tylenol 3 with codeine and I had a headache one day.  She gave that to me so the headache would go away*.” (male, Asian, junior).

*“...**a friend had some and thought it would be fun to split a Vicodin while drinking...” *
- (female, White, junior)

*“**I tried one pill and had 4 beers.”*
- (male, White, junior)

- “*My father is a virtual pharmacy from all his surgeries.  If I'm in pain, he is going to give me pain medication*.”
- (female, Hispanic, junior).

- _PEERS_

- _FAMILY_

_*Source*_*: **McCabe, Teter, Boyd **Drug Alcohol Depend 2005; 77:37-47. *

## Secondary Student Life Survey

- Random sample of single, ethnically diverse, school district in southeastern Michigan
- Administered to grades 7-12
- Web-based, self-administered
- 1,086 respondents in 2005; Response rate = 68%
- Includes questions on specific classes of prescription drugs

## Secondary Student Life Survey

- 	“On how many occasions in your lifetime (or 12 months) have you used the following types of drugs, not prescribed to you?”
- 	(SKIP PATTERNS EMBEDDED)
- 	(e.g., *Ambien*, *Halcion*, *Restoril*, temazepam, triazolam), sedative/anxiety medication (e.g., *Ativan*, *Xanax*, *Valium*, *Klonopin*, diazepam, lorazepam), stimulant medication (e.g., *Ritalin*, *Dexedrine*, *Adderall*, *Concerta*, methylphenidate) and pain medication (e.g., opioids such as *Vicodin*, *OxyContin*, *Percocet*, *Darvocet*, morphine, hydrocodone, oxycodone).

**Prescription **
**Drug**
** ****Abuse**

**Prescription **
**Drug**
** ****Misuse**

## Past Year Use  of Prescription Opioidsby Gender, 7th-12th grade

**% reporting past year prescription opioid use **

**n=110                  n=235                  n=41                    n=85**

***Source: Boyd, McCabe, Cranford, Young,  2006***

- SSLS, 2005

## Secondary Student Life Survey

**The lifetime prevalence of nonmedical use was highest for pain medication (17.5%):**
- Sleeping medication (5.8%), sedative/anxiety mediation (3.5%), and stimulant medication (2.5%).
**Girls were significantly more likely  to report nonmedical use of pain medication** (22.2% vs. 12.0%, χ2 = 19.0, df = 1, p < 0.001).
- No gender differences in nonmedical use of the other classes of prescription drugs.
**White students were more likely than Black students to report nonmedical use of prescription sedative/anxiety*** **and stimulant medications****
-  *(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).

***Source: Boyd, McCabe, Cranford, Young, 2006***

## Motivations to Misuse: Reasons Varied by Drug Class

- Students responded about motivations to misuse of opioid analgesics:
- 80% for the purpose of relieving pain;
- 16% for the purpose of helping to sleep;
- 20% for the purpose of getting high;
- 3% because they are safer than street drugs.
- 						(2005 SSLS Data; Check all that apply; Girls=127; Boys=58)

***Source: Boyd, McCabe, Cranford, Young, 2006***

## Gender Differences: Reasons for Nonmedical Use

**Gender Differences: ****Reasons for Nonmedical Use**

***Source: Boyd, McCabe, Cranford, Young, 2006***

- SSLS, 2005; check all that apply

## Drug Abuse Screening Test Results by Lifetime Prescription Opioid Use, 7th-12th grades

- ***

- ***

**% reporting two or more DAST-10 items**

- *** 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, 2007***

- SSLS, 2005

## Nonmedical Use of Opioid Analgesics: Association with Substance Abuse Problems

**When the number of motives increased  DAST-10 scores increased.**
**For every**** ****additional motive endorsed, the DAST-10**** ****increased by a factor of 1.8****.**
- The group that endorsed more than one motive was significantly more likely to engage in greater marijuana and alcohol use as well.

***Source: Boyd, McCabe, Cranford, Young, 2006***

- SSLS, 2005

## Drug Abuse Screening Test Results by Lifetime Prescription Drug Use, 7th-12th grades

- ***

- ***

**% reporting two or more DAST-10 items**

- *** p < 0.001 based on logistic regression using non-users as reference group and adjusting for gender, race/ethnicity and grade level.

**n=499                  n=329                    n=183                   n=35**

***Source: McCabe, Boyd, Young, 2007***

- SSLS, 2005

## Diversion (7th-12th grades) 

- Thirty-six percent of students reported having a recent prescription for one of the 4 drug classes.
- A higher percentage of girls gave away their medications than boys (27.5% vs. 17.4%, respectively; χ2 9 1 = 6.7; *P*<.05);
- Girls were significantly more likely than boys to divert to female friends (64.0% vs. 21.2%, respectively; χ2 11 1 = 17.5; *P*<.01) while boys diverted to male friends (45.5% vs. 25.6%, respectively; χ2 12 1 = 4.4; *P*<.05).
- Ten percent diverted their drugs to parents.

***Source: Boyd, McCabe, Cranford, Young, 2007***

- SSLS, 2005

## 
The nonmedical use of prescription medications is increasing in the U.S. among adolescents and young adults. (See: Johnston et al., 2004, 2005; McCabe, et al., 2007; NSDUH, 2006)

Students who abuse or misuse prescription medications are significantly more likely to smoke cigarettes, use marijuana and use other illegal drugs.  (Boyd, Teter, McCabe, 2004; Boyd, McCabe, Teter, 2006; Boyd, McCabe Teter, 2005)

College men and high school boys are more likely than their female counterparts to obtain prescription opioid medications from peer sources, while girls/ women from family.   ((Boyd, McCabe, Cranford, Young, 2007; McCabe, Teter & Boyd, 2005; ) 

Student NOT obtaining prescription drugs directly via the internet but they learn about them from the Internet/TV/print media, peers and family. (Boyd, McCabe, Teter, 2006; McCabe & Boyd, 2005)

- The nonmedical use of prescription medications is increasing in the U.S. among adolescents and young adults. (See: Johnston et al., 2004, 2005; McCabe, et al., 2007; NSDUH, 2006)
- Students who abuse or misuse prescription medications are significantly more likely to smoke cigarettes, use marijuana and use other illegal drugs.  *(Boyd, Teter, McCabe, 2004;* *Boyd, McCabe, Teter, 2006; Boyd, McCabe Teter, 2005)*
- College men and high school boys are more likely than their female counterparts to obtain prescription opioid medications from peer sources, while girls/ women from family.   *((Boyd, McCabe, Cranford, Young, 2007; McCabe, Teter & Boyd, 2005; ) *
- Student NOT obtaining prescription drugs directly via the internet but they learn about them from the Internet/TV/print media, peers and family. *(Boyd, McCabe, Teter, 2006; McCabe & Boyd, 2005)*

**Summary**

## Summary

**Summary**

- 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 challenges traditional ideas about substance abusers.
- Self-treatment appears to be one motivation for the nonmedical use of prescription opioid analgesics *(Boyd, McCabe, Cranford, 2006)*
- Unlike users of many street drugs, there appears to be at least two groups of nonmedical users of prescription medications:
- 	 Those to Self-treat;  those to get High/Experiment/>Performance”