Both medical and nonmedical (misuse or abuse) use of prescription opioids has been declining among adolescents, according to a study published in the April 2017 issue of Pediatrics. However, prescription opioid exposure is still common, with adolescents who reported both medical and nonmedical use more likely to have started with medical use. Medical use of prescription opioids among teens peaked in 1989 and 2002 and stayed level until a decline that began in 2013.

The study, “Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 1976–2015,” is by Sean Esteban McCabe, Ph.D., and colleagues. McCabe is with the Institute for Research on Women and Gender at the University of Michigan.

Especially among male teens, there is a high correlation between medical and nonmedical use of prescription opioids.

Most medical users of prescription opioids do not move on to nonmedical use — this is true for adults and adolescents. However, most adolescents who report nonmedical use started with medical use.

There is a lack of research assessing long-term trends among adolescents, however. McCabe and colleagues wanted to determine whether there is a relationship over time in the medical use of prescription opioids and the nonmedical use. Medical use was assessed by asking whether the high school seniors had ever taken prescription opioids based on a doctor’s advice. They were told prescription opioids must be prescribed and sold in drugstores. Response options included “No,” “Yes but I had already tried them on my own” and “Yes and it was the first time I took any.” Nonmedical use was assessed by asking on how many occasions — if any — in their lifetime they had used prescriptions on their own, “without a doctor telling you to take them.” Response options ranged from “no occasions” to “more than 40 occasions.”

Results

Lifetime medical use (16.0 percent in 1976 to a peak of 20.4 percent in 1989, down to 13.2 percent in 1997) was more prevalent than nonmedical use (although not listed in the results nonmedical use was about 10 percent in 1976 down to about 7 percent in 2015; it rose sharply in 2002 due to a change in definition).

Prevalence of medical use was higher among white relative to black teens; the correlation between medical and nonmedical use was stronger for males than females and for whites than blacks.

Looking at long-term trends, the researchers found that the most prevalent pattern of exposure was medical use only without any history of nonmedical use. For teens who reported both medical and nonmedical use, the prevalent pattern was medical use first.

The prevalence of nonmedical use only was similar to that of nonmedical use following medical use.

Declines in both medical and nonmedical use among adolescents during 2013–2015 mirror the similar declines in opioid prescribing during that same time period, the researchers wrote.

Implications

One-third of the teens who reported using prescription opioids nonmedically were using their own leftover prescriptions. A different survey, the National Household Survey on Drug Use and Health, found that 62 percent of people who misuse prescription opioids do so for pain relief.

The correlation between nonmedical and medical use was twice as high for males as for females. The researchers suggested several possibilities. First, male nonmedical users are more likely to obtain prescription opioids from their peers, whereas female nonmedical users are more likely to obtain them from family members.

It’s more likely for male nonmedical users than for males to misuse prescription opioids to get high, whereas females are more likely to misuse them for pain relief, the researchers wrote. This could account for the stronger correlation between medical and nonmedical use among males relative to females, the researchers write.

The researchers suggest two interconnected for medical and nonmedical use of prescription opioids being more prevalent among white than black adolescents: (1) pharmacies in low-income ZIP codes are less likely to have sufficient opioids compared to pharmacies in white ZIP codes and (2) black adolescents are more likely than white adolescents to misuse opioids specifically for pain relief. If black adolescents are less likely to receive adequate treatment for pain, they are more likely to seek relief without the prescriptions; conversely, white adolescents might be getting overprescribed these medications, resulting in misuse.

The researchers recommend increased use of prescription drug monitoring programs, discussing the importance of proper storage and monitoring of prescription opioids with teens and parents, screening for substance use disorders, prescribing the lowest effective doses and avoiding concurrent prescription of sedatives.

Limitations include those involved with the Monitoring the Future study, upon which the data was based. First of all, the study is a long-self-report survey, subject to both recall bias and subject burden. It doesn’t ask about age of onset, dose, duration, pain condition or efficacy. It doesn’t ask about potential confounders such as opioid use disorders and family health history. Finally, students who dropped out or were absent on the survey day did not participate, and these students are more likely to report substance use. Finally, the results are limited in terms of causation, with more prospective studies needed to assess longitudinal associations between medical use and nonmedical use of prescription opioids.

Still, the findings provide evidence that there is a correlation among medical and nonmedical use of prescription opioids in teens, especially among males.

“Prescribing practices that increase vigilance and monitoring of prescription opioids among adolescents, including education about proper disposal when medical use has concluded, warrant more investigation,” the researchers concluded. (Monitoring the Future is an annual school-based survey conducted by the University of Michigan for the National Institute on Drug Abuse.)