Early opioid prescriptions for adolescent increase the risk of developing a drug-related problem later in life

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Young adults and adolescents who are prescribed opioids for the first time may be at a slightly greater risk of developing a substance-related problem later in life, according to a new study co-authored by Indiana University researchers.

However, the risk may not be as high as previously thought.

The study was published today in JAMA Pediatrics and co-authored by Patrick Quinn, an assistant professor at the IU School of Public Health-Bloomington.

The researchers looked at the health and other national records of Swedish individuals age 13 to 29, from 2007 to 2013, who were prescribed an opioid for the first time.

Their goal was to further investigate whether prescribing opioids, such as codeine or oxycodone, during adolescence and young adulthood leads to a greater risk of substance-related problems.

They found that, compared with people who were not prescribed an opioid, 1 to 2 percent more of those prescribed an opioid for the first time developed a substance use disorder or other substance-related issue such an overdose or criminal conviction within five years of being prescribed.

“By using several rigorous research designs, we found that there was not a huge difference – in fact, the difference was smaller than some previous research has found.

But the study still shows that even a first opioid prescription may lead to some risk,” Quinn said.

“Our findings highlight the importance of screening for substance use disorders and other mental health conditions among patients with pain, including those receiving opioid therapy.”

Quinn and his team used health data from Sweden because the country has nationwide records, which makes it easier to document people’s prescriptions.

They conducted a number of tests, including comparing youth and adolescents who were prescribed opioids with those whose pain was treated with a non-opioid pain medication.

They also compared twins and other siblings of multiple births, one who was prescribed opioids and others who were not.

Across the board, the opioid recipients’ risk was 1 to 2 percent greater than other people’s risk. Quinn cautioned that further research is needed to determine how much of that risk is truly caused by opioid prescription and how much is caused by other factors, such as whether opioid recipients experienced more impairing pain.

The opioid epidemic in the U.S. has brought about welcome prescription policy changes, Quinn said, but it is important to have solid data that can help guide these decisions.

“Our goal is help patients and doctors understand the risks of opioid treatment for pain,” he said. “We need to have a good understanding of what those risks might be in order for patients and doctors to make informed decisions.”


Over the past two decades, opioid misuse and poisonings have emerged as a public health crisis in the US. Since 1999, rates of deaths secondary to opioids have tripled, and in 2017 alone, over 72,000 Americans died from opioid overdoses [1,2].

Children and adolescents have not been spared, with substantial increases over the past two decades in opioid-related emergency department visits, hospital and intensive care unit admissions, and deaths [3–6].

Opioid exposures accounted for over 12% of all deaths in 2016 among 15- to 24-year-olds, which represents a 4-fold increase since 2001 [7].

According to the Centers for Disease Control’s 2018 National Vital Statistics report, unintentional injuries are now the leading cause of death among adolescents and young adults, with poisonings the most common unintentional injury [8,9].

Among adults in the US, roughly 1 in 3 is estimated to use prescription opioids, with 4.7%, or 11.5 million, misusing them [10].

Opioid misuse in adults has been linked to several risk factors, including mood and anxiety disorders, male gender, educational attainment, and age at first misuse [11–13]. Among adolescents and young adults, data are sparser and less consistent, although prevalence of opioid use disorder appears to be steadily increasing [14,15].

A recent meta-analysis examining past-year prevalence of prescription opioid misuse among adolescents and young adults reported estimates ranging from 0.7% to 16.3% [16]. Two of the largest adolescent drug surveys in the US are the Youth Risk Behavior Survey, which asks about misuse of “pain medications” broadly, and Monitoring the Future, which asks about misuse of “narcotics other than heroin” [17,18].

These studies report lifetime prevalence of misuse of 17.0% and 6.8%, respectively, among 12th grade students in 2017. Risk factors identified among adolescents include earlier onset of use, educational attainment, and chronic pain, although these links are less robust than in adult studies [19–21]. Importantly, legitimate use of opioids during adolescence appears to predispose to later opioid misuse [19,22].

There is limited information on how adolescents and young adults are obtaining prescription opioids. Studies suggest an indirect link between opioid prescriptions in adults and exposures in adolescents, suggesting that households and family members may be a contributing source [23,24].

In one survey study conducted from 2008 to 2011, parents and friends from school were identified as the most common sources of prescription opioids for adolescents [25].

In this study, we analyzed data from a large, nationally representative survey collecting information on prescription opioids to measure prevalence of opioid use and misuse among US adolescents and young adults.

We also determined sources of prescription opioids and characterized opioid use and misuse according to additional use of other substances and drugs of abuse.

Results

The NSDUH included 27,857 adolescent and 28,213 young adult respondents during the survey years 2015 to 2016, corresponding to an estimated 119.3 million individuals in the extrapolated national population (49.8 million adolescents and 69.5 million young adults).

Overall, 27.5% of these respondents, corresponding to an estimated 32.8 million individuals, reported using a prescription opioid in the previous year, including 21.0% (95% CI 20.4–21.6) of adolescents and 32.2% (95% CI 31.4–33.0) of young adults (Table 1).

Table 1. Demographic characteristics of adolescents and young adults with past-year prescription opioid use, misuse, and use disordera.
https://doi.org/10.1371/journal.pmed.1002922.t001

Opioid misuse or use disorder in the past year was reported by 6.1% (95% CI 5.8–6.4) of respondents, corresponding to an estimated 1.9 million adolescents (3.8%; 95% CI 3.5–4.0) and 5.4 million young adults (7.8%; 95% CI 7.3–8.2; P < 0.001).

Prevalence of opioid misuse without use disorder was higher in young adults compared with adolescents (21.1% [95% CI 19.8–22.3] versus 15.2% [95% CI 13.9–16.5], respectively; P < 0.001), with similar prevalence of opioid use disorder in the two groups.

Considering both age groups together, female respondents were more likely to have had any prescription opioid use compared with males (30.3% [95% CI 29.7–30.9] versus 24.8% [95% CI 24.2–25.4], P < 0.001), but male respondents were more likely to have opioid misuse without use disorder compared with females (23.2% [95% CI 21.6–24.8] versus 15.8% [95% CI 14.7–16.9], respectively; P < 0.001).

Non-Hispanic white and black respondents reported higher prevalence of past-year opioid use compared with Hispanic respondents (P < 0.001), but prevalence of misuse without and with use disorder were similar between groups. Insurance status was not a significant determinant of opioid use, but uninsured respondents were more likely to report opioid misuse without use disorder compared with those with Medicaid.

Among those with prescription opioid misuse, 25.4% (95% CI 23.5–27.2) obtained them from the healthcare system, 55.7% (95% CI 53.7–57.6) from friends or relatives, and 18.9% (95% CI 17.4–20.5) through other means (Table 2).

Adolescents with opioid misuse obtained opioids most commonly for free from a friend or relative (33.5%; 95% CI 28.7–38.3) or by prescription from a single doctor (19.2%; 95% CI 16.4–22.1).

Far fewer obtained them by stealing from a healthcare facility (1.7%; 95% CI 0.5–2.8), through prescriptions from multiple doctors (2.2%; 95% CI 1.3–3.2), or by buying them from a drug dealer or stranger (6.5%; 95% CI 4.4–8.6). S

ources of opioids for young adults with opioid misuse were similar to adolescents, with free procurement from friends or relatives (41.4%; 95% CI 38.8–44.1) and prescription from a single doctor (24.0%; 95% CI 22.1–25.9) the most common sources.

Table 2. Extrapolated population estimates of source of prescription opioids among adolescents and young adults with opioid misusea.
https://doi.org/10.1371/journal.pmed.1002922.t002

Additional substance use and drug abuse associated with prescription opioid use is shown in Table 3. Among adolescents and young adults with prescription opioid use without misuse, 50.5% (95% CI 49.2–51.7) had previously used tobacco, 70.5% (95% CI 69.3–71.7) had used alcohol, and 43.9% (95% CI 42.7–45.1) had used marijuana.

These prevalence rates were significantly higher for respondents with opioid misuse, with 78.4% (95% CI 76.7–80.1; P < 0.001) reporting use of tobacco, 90.1% (95% CI 89.0–91.3; P < 0.001) use of alcohol, and 80.7% (95% CI 79.2–82.2; P < 0.001) use of marijuana.

For cocaine, heroin, hallucinogen, and inhalant use, differences in prevalence of use between those with opioid use without misuse and those with opioid misuse were even more pronounced.

Prevalence of cocaine use increased greater than 4-fold from 7.9% (95% CI 7.1–8.7) to 35.5% (95% CI 33.1–38.0; P < 0.001) for respondents with opioid use without misuse compared with those with opioid misuse.

Similarly, the prevalence in these populations increased from 0.9% (95% CI 0.6–1.1) to 8.7% (95% CI 7.1–10.2; P < 0.001) for heroin use, 13.1% (95% CI 12.3–13.9) to 49.4% (95% CI 46.9–51.8; P < 0.001) for hallucinogen use, and 12.1% (95% CI 11.3–12.8) to 30.4% (95% CI 28.1–32.8; P < 0.001) for inhalant use.

Table 3. Additional substance use and drug abuse among adolescents and young adults with prescription opioid usea.
https://doi.org/10.1371/journal.pmed.1002922.t003

Among adolescents and young adults with opioid misuse, prevalence of additional substance use was significantly higher among young adults for all substances except inhalant use (Table 4).

These differences were seen both for past month use and for any prior use of substances. Among adolescents, past month use of tobacco, alcohol, and cannabis was 31.2% (95% CI 28.4–34.1), 36.7% (95% CI 32.9–40.5), and 35.3% (95% CI 32.5–38.0), respectively. These prevalence rates increased to 63.9% (95% CI 61.3–66.5; P < 0.001), 77.4% (95% CI 75.3–79.5; P < 0.001), and 55.0 (95% CI 52.4–57.5; P < 0.001), respectively, among young adults.

For cocaine and hallucinogens, lifetime prevalence of using the substance more than doubled between adolescents (11.5% [95% CI 9.3–13.7] and 25.4% [95% CI 22.2–28.6], respectively) and young adults (43.9% [95% CI 40.8–47.0], P < 0.001; and 57.7% [95% CI, 54.7–60.7], P < 0.001, respectively) with opioid misuse.

Table 4. Additional substance use and drug abuse stratified by age group for adolescents and young adults who misuse prescription opioidsa.
https://doi.org/10.1371/journal.pmed.1002922.t004

More information: Patrick D. Quinn et al, Association of Opioid Prescription Initiation During Adolescence and Young Adulthood With Subsequent Substance-Related Morbidity, JAMA Pediatrics (2020). DOI: 10.1001/jamapediatrics.2020.2539

reference link : https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002922

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