Teen use and abuse of prescription analgesics

Opiate and opioid analgesics can effectively relieve pain in those with moderate-severe pain from trauma, surgery, oncologic or other disorders. The pharmacologic effects of these analgesics at opioid receptors not only diminish pain sensation, but also induce significant sedation and euphoria. These effects result in a high potential for misuse and abuse.

Natural opiate analgesics include morphine and codeine; semi-synthetic opioids include hydrocodone (eg, Vicodin, Abbott Laboratories), oxycodone (eg, OxyContin, Purdue Pharma; Percocet, Endo Pharmaceuticals) and hydromorphone (eg, Dilaudid, Purdue Pharma). Abuse of these analgesic medications by the general and adolescent populations have increased dramatically in recent years.

Consider the following information obtained from recently conducted surveys and data analyses about use of illicit drugs in the US population:

• In 2010, an estimated 8.9% of the population — 22.6 million — had used an illicit drug during the prior month.
• Marijuana was the most commonly used illicit drug during the prior month at 17.4 million, followed by non-medical use of psychotherapeutic drugs (analgesics, tranquilizers, stimulants, sedatives), at 7 million.
• In 2010, an estimated 22.1 million people were classified with substance dependence or abuse in the past year (based on criteria from the Diagnostic and Statistical Manual of Mental Disorders) — marijuana was most common (4.5 million), followed by pain relievers (1.9 million).
• Of 12th-graders surveyed, 54.2% reported that it is “fairly easy” or “very easy” to obtain opioid medications.
• Deaths due to drug overdoses in 2008 — 36,450 — nearly equaled deaths from motor vehicle accidents — 39,973.
• The death rate of 11.9/100,000 in 2008 from drug overdoses has increased nearly 400% since 1999, with most of this increase due to prescription drug overdoses.
• Drug overdose deaths in 2008 due to opioid medications exceed that of overdose deaths due to heroin and cocaine combined.
• In 2010, enough opioid analgesic agents were sold to medicate every American adult with a typical dose of 5 mg hydrocodone (eg, Vicodin) every 4 hours for 1 month.
• The number of prescriptions for opioid analgesic agents has increased significantly in recent years; from 1997 to 2007, the amount of opioid analgesic agents used per person increased from 74 mg to 369 mg — an increase of more than 400%.
• Sales of oxycodone from 1997 to 2005 increased 588%.
• Sales of hydrocodone from 1997 to 2005 increased 198%.

Abuse of opioid analgesics by youth

Data about the use and abuse of illicit drugs and prescription medications are largely obtained from the National Survey on Drug Use and Health (NSDUH) and the Monitoring the Future (MTF) survey. The NSDUH is the primary source of information on the use of illicit drugs, alcohol and tobacco in the civilian US population of those aged 12 years and older. It is sponsored by a federal agency, the Substance Abuse and Mental Health Services Administration. Data from the 2010 survey were recently published and reveal that 10.1% of youths (aged 12 to 17 years) reported being current users of illicit drugs, a rate similar to 2009, but increased over 2008 (9.3%). Marijuana was most commonly used (7.4%), followed by non-medical use of psychotherapeutic agents (analgesics, tranquilizers, stimulants, sedatives), at 3%.

The source of prescription analgesics was determined for the surveyed population (aged 12 years and older): 71.2% of prescription psychotherapeutics were obtained from family or friends, either at no cost (55%), purchased or stolen. In 2010, an estimated 3 million people (aged 12 years and older) used an illicit drug for the first time within the past 12 months. The most common drug used initially was marijuana (61.8%), followed by psychotherapeutic agents (26.2%), with analgesics the most commonly used psychotherapeutic agent (17.3%).

MTF is a long-term study of drug use by adolescents, college students and adults aged up to 50 years. Results from the 2010 survey of eighth-, 10th- and 12th-graders (n=46,500) revealed that marijuana was the most commonly used illicit drug. Use of two prescription analgesics, OxyContin (oxycodone) and Vicodin (hydrocodone), were assessed for students in 12th-grade, with reported use of rates of 5.1% and 8%, respectively. For these students, 54.2% reported that it was “fairly easy” or “very easy” to obtain opioids (other than heroin). Overall, students reported a low level of perceived risk for use of prescription psychotherapeutic agents.

Drug overdoses and ED visits

Recently published data have additionally evaluated fatal drug overdoses and visits to EDs for drug-related poisonings. The CDC recently reported on fatal drug overdoses, sales and abuse treatment admissions. In 2008, opioids were responsible for 73.8% (14,800) of drug overdoses due to prescription medications. Deaths due to any drug overdose totaled 36,450 in 2008, which nearly equaled deaths due to motor vehicle accidents. The Nationwide Emergency Department Sample describes characteristics of visits to EDs for drug-related poisonings. Data obtained from 970 hospital-based EDs in 27 states from 2007 were recently published. An estimated 669,123 visits to EDs nationwide occurred in 2007 for drug-related poisonings. As might be expected, children aged 0 to 5 years had the highest rate of unintentional poisoning. Psychotropic agents and analgesics/antipyretics/antirheumatics were responsible for 43.7% of all poisonings, with analgesics accounting for 23.1%.

Role of clinicians

Data from these national surveys and studies provide important, and perhaps bewildering, information about the use and abuse of illicit drugs and FDA-labeled prescription medications by the US population and adolescents. Increases in the abuse of prescription psychotherapeutic agents, including opioid analgesics, have been described in the medical literature as an “epidemic.” Awareness by clinicians of this problem may be the most important means to affect its impact. Education of adolescents and their parents and caregivers by clinicians about the potential dangers of opioid analgesics will likely have a significant effect. Prescription analgesics are approved for use by the FDA as generally safe and effective, and thus, adolescents and the general public may view these medications as relatively safe (as compared with illicit drugs, such as cocaine or heroin).

A recently published study on the non-medical use of opioids by adolescents found that youths were less likely to abuse opioid analgesics when they perceived strong disapproval of marijuana use from their parents, when their parents frequently reviewed their homework, or when they had frequently been commended by their parents. Most opioid analgesics used non-medically by adolescents are easily obtained from relatives and friends. Educating parents and caregivers to store opioid analgesics safely in the home and to dispose of medications no longer used or needed is also likely to be beneficial.

Some communities and pharmacies offer take-back programs for medication products no longer needed in the home. The FDA recommends that some medications, because of their significant potential danger when used non-medically, be disposed of by flushing down a sink or toilet. This includes opioid analgesics, such as oxycodone. Less dangerous medications, such as antibiotics, should be disposed of by mixing (when taken out of its original container) with an undesirable substance (such as coffee grounds or cat litter) and placing in a disposable container. Families should realize the importance of regularly cleaning their medicine cabinet of expired medications, or medications no longer needed.

For more information:

• American Psychiatric Association. DSM-IV-TR® Diagnostic and Statistical Manual of Mental Disorders. 4th ed., American Psychiatric Association. Washington, DC. 2000; doi: 10.1176/appi.books.9780890423349.11470.
• CDC. MMWR. 2011;60:1487-1492.
• Johnston LD. Monitoring the future: national survey on drug use, 1975-2010. Available at: www.monitoringthefuture.org/pubs/monographs/mtf-vol1_2010.pdf.
• Substance Abuse and Mental Health Services Administration. National survey on drug use and health, 2010. US Department of Health and Human Services, 2010. Available at: www.oas.samhsa.gov.
• Sung HE. J Adolesc Health. 2005;37:44-51.
• Xiang Y. Am J Emerg Med. 2011 [Published online ahead of print Feb. 28].

Edward A. Bell, PharmD, BCPS, is professor of clinical sciences at Drake University College of Pharmacy, Blank Children’s Hospital, in Des Moines, Iowa. Bell is also a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Bell reports no relevant financial disclosures.

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