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Original Investigation |

Nonmedical Prescription Opioid Use and Use Disorders Among Adults Aged 18 Through 64 Years in the United States, 2003-2013 FREE

Beth Han, MD, PhD, MPH1; Wilson M. Compton, MD, MPE2; Christopher M. Jones, PharmD, MPH3; Rong Cai, MS1
[+] Author Affiliations
1Substance Abuse and Mental Health Services Administration, Rockville, Maryland
2National Institute on Drug Abuse, the National Institutes of Health, Bethesda, Maryland
3Food and Drug Administration, Silver Spring, Maryland
JAMA. 2015;314(14):1468-1478. doi:10.1001/jama.2015.11859.
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Published online

Importance  Since 1999, the United States has experienced increases in morbidity and mortality associated with nonmedical use of prescription opioids.

Objective  To assess national trends in and characteristics of nonmedical prescription opioid use and use disorders and the national trend in related mortality.

Design, Setting, and Participants  Prevalence of nonmedical use and use disorders and related risk factors were based on data from 472 200 persons aged 18 through 64 years who participated in the 2003-2013 National Surveys on Drug Use and Health. Mortality was based on the 2003-2013 National Vital Statistics System’s Multiple Cause of Death Files.

Exposures  Prevalence of nonmedical use of prescription opioids.

Main Outcomes and Measures  Nonmedical prescription opioid use and use disorders.

Results  Among adults aged 18 through 64 years, the prevalence of nonmedical use of prescription opioids decreased from 5.4% (95% CI, 5.08%-5.70%) in 2003 to 4.9% (95% CI, 4.58%-5.22%) in 2013 (absolute difference, −0.5%; 95% CI, −0.11% to −0.89%), but the prevalence of prescription opioid use disorders increased from 0.6% (95% CI, 0.54%-0.76%) in 2003 to 0.9% (95% CI, 0.75%-1.01%) in 2013 (absolute difference, 0.3%; 95% CI, 0.03%-0.43%). The 12-month prevalence of high-frequency use (≥200 days) also increased from 0.3% (95% CI, 0.19%-0.35%) in 2003 to 0.4% (95% CI, 0.31%-0.48%) in 2013 (absolute difference, 0.1%; 95% CI, 0.01%-0.29%). Mortality assessed by drug overdose death rates involving prescription opioids increased from 4.5 per 100 000 (95% CI, 4.42-4.61) in 2003 to 7.8 per 100 000 (95% CI, 7.64-7.89) in 2013 (absolute difference, 3.3; 95% CI, 3.09-3.41) among adults aged 18 through 64 years. The mean number of days of nonmedical use of prescription opioids increased from 2.1 (95% CI, 1.83-2.37) in 2003 to 2.6 (95% CI, 2.27-2.85) in 2013 (absolute difference, 0.5, 95% CI, 0.05-0.86). The model-adjusted prevalence of having prescription opioid use disorders among nonmedical users increased to 15.7% (95% CI, 13.87%-17.67%) in 2010, 16.1% (95% CI, 14.36%-17.99%) in 2011, 17.0% (95% CI, 15.07%-19.12%) in 2012, and 16.9% (95% CI, 14.95%-19.03%) in 2013 from 12.7% (95% CI, 11.04%-14.53%) in 2003.

Conclusions and Relevance  During the 2003-2013 years, among adults aged 18 through 64 years, the percentage of nonmedical use of prescription opioids decreased. In contrast, the prevalence of prescription opioid use disorders, frequency of use, and related mortality increased.

Since 1999, the United States has experienced increases in morbidity and mortality associated with nonmedical use of prescription opioids.1,2 During this period, emergency department (ED) visits and drug overdose deaths involving these drugs have increased rapidly.25 The prevalence of people aged 12 years or older who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for prescription opioid dependence increased from 0.4% in 2003 to 0.6% in 2013.6 Moreover, the estimated rates of ED visits involving prescription opioids more than doubled from 82.5 per 100 000 in 2004 to 184.1 per 100 000 in 2011.7 Furthermore, age-adjusted rates for drug-poisoning deaths involving prescription opioids more than tripled from 1.4 per 100 000 population in 1999 to 5.1 in 2013.8 Also in 2013, prescription opioids were involved in more deaths (>16 200) than all illicit drugs combined (14 775).8 Due to these increases in morbidity and mortality, prescription opioid abuse has become a US epidemic.2,9,10

To fully understand the current status of the epidemic and to examine who is currently most affected, an examination of nationally representative US surveillance data is needed. To further develop a detailed picture of the public health implications, we used 2 national data sets to examine trends in the prevalence of nonmedical use of prescription opioids, prescription opioid use disorders, frequency of use, and drug overdose deaths involving prescription opioids. Because nonelderly adults are the main population at risk of chronic nonmedical use of prescription opioids and related morbidity and mortality,11 this study focused on adults aged 18 through 64 years.

Data Sources

First, we examined data of adults who participated in the 2003-2013 National Surveys on Drug Use and Health (NSDUH), which are conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). They provided nationally representative data on nonmedical use of prescription opioids and use disorders among the civilian, noninstitutionalized population aged 12 years or older in the United States. Excluded from NSDUH were persons without a household address (eg, homeless persons not living in shelters), active-duty military personnel, and institutional residents. The data collection protocol of the NSDUH was approved by the institutional review board at the Research Triangle Institute (RTI) International. Written informed consent was obtained from each study participant. The annual mean weighted response rate of the 2003-2013 NSDUH was 66.3% (range, 60.2%-70.2%),12 according to the definition of response rate 2 for in-person household surveys by the American Association for Public Opinion Research.13 Details regarding NSDUH data collection are provided elsewhere.12

Second, we examined data from the 2003-2013 Multiple Cause of Death Files from the National Vital Statistics System.14 Drug overdose deaths were those assigned an underlying cause of death using the International Classification of Diseases, Tenth Revision (ICD-10) codes X40-X44 (unintentional), X60-X64 (suicide), X85 (homicide), and Y10-Y14 (undetermined intent). Prescription opioid overdose deaths were those assigned specific ICD-10 codes T40.2-T40.4. Similar to NSDUH analyses. We limited analyses to drug overdose deaths among adults aged 18 through 64 years in the United States.

Measures

The NSDUH defined 12-month nonmedical use of prescription opioids as use in the prior 12 months without a prescription or as use with a prescription simply for the experience or feeling caused by opioids.12 If respondents reported using prescription opioids nonmedically in the past year, they were asked to state the number of days they used them nonmedically. Consistent with previous work,11,15,16 we defined frequent users as those with 100 days or more of nonmedical opioid use in the past year and highly frequent users as those with 200 days or more. For persons reporting nonmedical prescription opioid use, NSDUH collected sources of the medications, including given by a friend or a relative for free, prescribed by 1 or more physicians, stolen from a friend or a relative, bought from a friend or a relative, and bought from a drug dealer or stranger. Age at first nonmedical use of prescription opioids was also assessed (<18, 18-29, or ≥30 years).

The NSDUH estimated past 12-month major depressive episodes (MDE) and each specific substance use disorder (dependence on or abuse of alcohol, marijuana, cocaine, hallucinogens, heroin, inhalants, or nonmedical use of prescription pain relievers, sedatives, or stimulants) based on assessments of individual diagnostic criteria from the DSM-IV.17 Nicotine dependence among cigarette smokers was assessed using the nicotine dependence syndrome scale.18

Sociodemographic characteristics from NSDUH data included age, sex, race/ethnicity, educational attainment, employment status, marital status, health insurance, metropolitan statistical area, census region, and year. Race/ethnicity was NSDUH respondent’s self-classification of racial and ethnic origin and identification based on the classifications developed by the US Census Bureau. This study assessed race/ethnicity because prior research indicates racial/ethnic differences in prescription opioid–related mortality.5

Statistical Analyses

All analyses were conducted for persons aged 18 through 64 years. Between 2003 and 2013 for each examined year, descriptive analyses were conducted to estimate the 12-month prevalence of nonmedical use of prescription opioids and prescription opioid use disorders, the proportion of 12-month nonmedical opioid use initiates, the prevalence of frequent users and highly frequent users, and the mean number of days of nonmedical use among adults and among nonmedical users. Similarly, we estimated trends in the rates of overdose deaths involving prescription opioids between 2003 and 2013. For percentage estimates, bivariable logistic regression models were applied to assess the unadjusted annual prevalence, to test for differences between the 2003 estimate and the estimate in each year in 2004-2013 (using PREDMARG and PRED_EFF statements in SUDAAN,19,20 2-sided t test with a significance level of .05), and to test P values of β coefficients of the year variable. For mean numbers of days of nonmedical use, linear regression models were applied to examine differences between the 2003 estimate and the estimate in each year spanning 2004 through 2013 (using the REFLEVEL statement in SUDAAN,19 2-sided t test with a significance level of .05) and to test P values of β coefficients of the year variable. For drug overdose death rates, 2-tailed z tests (with a significance level of .05)21 were used to test differences between the 2003 rate and the rate in each year spanning 2004 through 2013. A Bonferroni correction was used to reduce chances of type I errors of testing overall trends. For each outcome, if the overall trend did not meet the statistical significance threshold after the Bonferroni correction, differences between the 2003 estimate and the estimates in other years were not reported.

Bivariable and multivariable logistic regression modeling were applied to assess unadjusted and model-adjusted relative risk (using PREDMARG and PRED_EFF statements in SUDAAN19,20) for prescription opioid use disorders among nonmedical opioid users. Because major depressive episodes were unavailable in the 2003 NSDUH and because the source of opioids was unavailable in 2003 and 2004 NSDUHs, separate multivariable models were calculated for 2005-2013 with these additional variables included and for 2003-2013 without them. This study used SUDAAN software to account for the complex sample design and sampling weights of NSDUH data. Moreover, bivariable and multivariable zero-truncated negative binomial regression models were applied to examine factors associated with the number of days of nonmedical use of prescription opioids among nonmedical users. Stata statistical software22,23 was used for a zero-truncated negative binomial regression function that accounts for the complex sample design and sample weights of NSDUH. Multicollinearity (using variance inflation factors) and potential interaction effects between examined factors were assessed and were not identified in final multivariable models. Furthermore, for the prevalence of prescription opioid use disorders among nonmedical opioid users, we conducted tests for interaction effects for specific subgroup comparisons (eg, between non-Hispanic whites and non-Hispanic blacks, between non-Hispanic whites and Hispanics, etc). To test whether 2010 might be a pivotal year for the trends, we repeated these analyses by using the year 2010 as the reference group and examined whether each intensity outcome differed in each year spanning 2011 through 2013.

Based on 472 200 sampled persons, we found that among adults aged 18 through 64 years, the 12-month prevalence of nonmedical use of prescription opioids decreased from 5.4% (95% CI, 5.08%-5.70%) in 2003 to 4.9% (95% CI, 4.58%-5.22%) in 2013 (absolute difference, −0.5%; 95% CI, −0.11% to −0.89%), and the 12-month initiation rate decreased from 1.0% (95% CI, 0.86%-1.11%) in 2003 to 0.6% (95% CI, 0.52%-0.71%) in 2013 (absolute difference, −0.4%; 95% CI, −0.52% to −0.22%; Table 1). In contrast, the 12-month prevalence of prescription opioid use disorders increased from 0.6% (95% CI, 0.54%-0.76%) in 2003 to 0.9% (95% CI, 0.75%-1.01%) in 2013 (absolute difference, 0.3%; 95% CI, 0.03%-0.43%) (Table 1 and eFigure 1 in the Supplement). The 12-month prevalence of high-frequency use (≥200 days) also increased from 0.3% (95% CI, 0.19%-0.35%) in 2003 to 0.4% (95% CI, 0.31%-0.48%) in 2013 (absolute difference, 0.1%; 95% CI, 0.01%-0.29%). The drug overdose death rates involving prescription opioids increased from 4.5 per 100 000 (95% CI, 4.42-4.61) in 2003 to 7.8 per 100 000 (95% CI, 7.64-7.89) in 2013 (absolute difference 3.3, 95% CI, 3.09-3.41) (Table 1 and eFigure 2 in the Supplement).

Table Graphic Jump LocationTable 1.  Twelve-Month Prevalence Trends of Nonmedical Use of Prescription Opioids, Prescription Opioid Use Disorders, and Drug Overdose Deaths Involving Prescription Opioids, United States, 2003-2013a

Among users, the prevalence of prescription opioid use disorders increased from 11.9% (95% CI, 10.13%-13.94%) in 2003 to 17.8% (95% CI, 15.50%-20.40%) in 2013 (absolute difference, 5.9%; 95% CI, 2.76%-9.05%). The prevalence of frequent use (≥100 days) increased from 14.2% (95% CI, 12.17%-16.49%) in 2003 to 19.3% (95% CI, 16.69%-21.88%) in 2013 (absolute difference, 5.1%; 95% CI, 1.67%-8.33%; Table 1). The prevalence of high-frequency use (≥200 days) among users increased from 5.0% (95% CI, 3.72%-6.66%) in 2003 to 8.2% (95% CI, 6.65%-10.01%) in 2013 (absolute difference, 3.2%; 95% CI, 1.04%-5.36%).

The mean number of days of nonmedical use of prescription opioids increased from 2.1 (95% CI, 1.83-2.37) in 2003 to 2.6 (95% CI, 2.27-2.85) in 2013 (absolute difference, 0.5; 95% CI, 0.05-0.86; Table 1). Among users, it increased from 40.0 days (95% CI, 35.43-44.57) in 2003 to 54.2 days (95% CI, 48.97-59.43) in 2013 (absolute difference, 14.2 days; 95% CI, 7.29-21.21).

Among users, the model-adjusted prevalence of having prescription opioid use disorders was higher in each year during the 2010-2013 years: 15.7% (95% CI, 13.87%-17.67%) in 2010, 16.1% (95% CI, 14.36%-17.99%) in 2011, 17.0% (95% CI, 15.07%-19.12%) in 2012, and 16.9% (95% CI, 14.95%-19.03%) in 2013 than in 2003 (12.7%, 95% CI, 11.04%-14.53%; Table 2). Moreover, the model-adjusted prevalence was similar in each year spanning 2011 through 2013 compared with 2010.

Table Graphic Jump LocationTable 2.  Twelve-Month Model-Adjusted Prevalence of Prescription Opioid Use Disorders Among Adult Prescription Opioid Nonmedical Users in the United States

Consistent with Table 2 and based on the results of testing for interactions for subgroup comparisons, compared with non-Hispanic white users, both non-Hispanic blacks (P = .001) and Hispanics (P = .006) had lower prevalence of prescription opioid use disorders. The prevalence was lower among users with a college degree or beyond than among users without a high school diploma (P < .001). Compared with users with full-time employment, users who were disabled for work had higher prevalence of the disorders (P < .001). The prevalence was higher among users without health insurance (P = .008) and among users with Medicaid (P < .001) than among users with private health insurance only. Nonmedical users with nicotine dependence had higher prevalence of prescription opioid use disorders than users without (P < .001). The prevalences among those with alcohol, marijuana, cocaine, hallucinogen, heroin, stimulant, and sedative use disorders were higher than users without the corresponding disorders (with each subgroup comparison tested separately for interaction, P < .001). With data from 2005-2013 NSDUHs, users with major depressive episode had a higher prevalence of prescription opioid use disorders than users without (P < .001); and compared with users who obtained prescription opioids from friends or relatives for free, users who stole or bought them from friends or relatives, who were prescribed by physicians, or who bought them from drug dealers or strangers had higher prevalence of prescription opioid use disorders (with each subgroup comparison tested separately for interaction, P < .001).

Among users, the mean number of days of nonmedical use of prescription opioids was higher in every year spanning 2008 through 2013 than in 2003 (Table 3). The results of the zero-truncated negative binominal regression model show consistent results even after controlling for potential confounding factors (adjusted incidence rate ratios [IRRs], 1.19-1.29). Users in 2010 had similar number of days of nonmedical use of prescription opioids compared with users in each year spanning 2011 through 2013. Non-Hispanic black users took prescription opioids nonmedically more often than non-Hispanic white users (IRR, 1.22; 95% CI, 1.08-1.39). Users with high school education or higher used prescription opioids nonmedically less often than users without a high school diploma (IRRs, 0.46-0.80). Users who were disabled for work used prescription opioids nonmedically more often than users with full-time employment (IRR, 1.33; 95% CI, 1.14-1.55). Users without health insurance or users with Medicaid used prescription opioids nonmedically more often than users with private insurance only (IRRs, 1.26-1.36).

Table Graphic Jump LocationTable 3.  Modeled Number of Days of Nonmedical Use of Prescription Opioids in the Past 12 Months Among Prescription Opioid Nonmedical Adult Users in the United States

Users with nicotine dependence used prescription opioids nonmedically more often than users without (IRR, 1.54, 95% CI, 1.43-1.65). Users with cocaine, heroin, stimulant, and sedative use disorders used prescription opioids nonmedically more often than users without the corresponding disorders (IRRs, 1.46-1.96). The multivariable model based on 2005-2013 NSDUH data show that users who stole opioids from friends or relatives, who were prescribed by physicians, and who bought them from friends or relatives or from drug dealers or strangers used prescription opioids nonmedically more often than users who obtained prescription opioids from friends or relatives for free (IRRs, 1.28-2.81).

Using nationally representative data, we found during years 2003 through 2013, among adults aged 18 through 64 years, the percentage of nonmedical use of prescription opioids decreased. However, we found several measures of high-risk nonmedical prescription opioid use that either increased or persisted through 2013. Specifically, we found significant increases in high-intensity prescription opioid use (measured by both prevalence of prescription opioid use disorders and high frequency of use) among nonmedical prescription opioid users in each year from 2010 through 2013 compared with those in 2003, even after controlling for potential confounding factors. Furthermore, when compared with those in 2010, additional analyses at bivariable and multivariable levels consistently showed that both intensity outcomes did not decrease in any year from 2011 through 2013. These national increases also paralleled the increases in prescription opioid-related overdose death rates in the United States identified in our study using a separate national data set. These results are consistent with persistent high-risk nonmedical use among adults through at least 2013. The significant increases in high-intensity (and therefore especially high-risk) prescription opioid use contrast a slight downward trend in the overall percentage of nonmedical use.

A recent study, using indicators from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System, found that the abuse and diversion of prescription opioids increased between 2002 and 2010 and plateaued or decreased between 2011 and 2013.24 RADARS provides proprietary, nonnationally representative data but does not aim to estimate prevalence.24,25 For example, not all parts of the United States have prescription drug diversion agencies, and operational details and emphases of diversion agencies vary according to the needs of the community and local drug activity.24,25 Since the completeness and accuracy of RADARS is difficult to ascertain, the nationally representative results in our study may be especially important in providing an accurate picture of the current status of the epidemic.

The epidemic has evolved over time. The increases in the prevalence of adults with prescription opioid use disorders and high-frequency use identified in our study are a major public health concern. Furthermore, the increases in high-intensity prescription opioid use occurred in the context of increased prescribing of prescription opioids.15 Previous studies have shown a strong relationship between inappropriate opioid prescribing and negative health outcomes.26 The percentage of prescription opioid users who used an opioid stronger than morphine or morphine-equivalent increased from 57.6% in the years 1999 through 2002 to 80.0% in the years 2011 through 2012.27 Also, usage of higher amounts of prescription opioids is a significant risk factor for overdose death.28

We identified characteristics associated with 2 intensity outcomes that may help clinicians detect problematic prescription opioid use and use disorders and eventually reduce morbidity and mortality involving prescription opioids alone or in combinations with other drugs. For example, users with sedative use disorders were at the highest risk of both intensity outcomes, which may help explain the increasing morbidity and mortality due to prescription opioid and benzodiazepine use.29 Users who were disabled for work and users with Medicaid health insurance coverage were at higher risk of both intensity outcomes, which were consistent with previous studies showing that these populations were more likely to be prescribed and to use prescription opioids in higher-risk ways and were at increased risk of opioid-related mortality.30 These results can be incorporated into clinician training programs to facilitate effective identification and interventions for high-risk nonmedical users of prescription opioids. Moreover, clinicians can use prescription drug–monitoring programs31,32 to identify patterns of inappropriate receipt of prescription opioids and screen and treat patients with prescription opioid use disorders as well as other associated specific substance use disorders, nicotine dependence, and depression.

Receiving treatment for substance use disorders is particularly critical. Most adults with prescription opioid use disorders or other substance use disorders neither receive treatment nor perceive a need for treatment.33 In 2013, more than three-fourths of adults aged 18 through 64 years who had prescription opioid use disorders did not receive any substance use treatment.6 Particularly, policy and societal barriers prevent broad dissemination, access, and adoption of highly effective medication-assisted therapies for people with prescription opioid use disorders.2,10,33

This study has several limitations. First, the cross-sectional nature of NSDUH data precludes drawing causal inferences from reported associations. Second, except for the results on drug overdose deaths involving prescription opioids, our results only applied to the civilian, noninstitutionalized population because NSDUH does not cover institutionalized populations, homeless people not living in shelters, and active-duty military personnel. Third, although methods to assess nonresponse bias vary and each has its limitations,34,35 the SAMHSA compared NSDUH estimates with other population surveys such as the Monitoring the Future, the Youth Risk Behavior Survey, the Behavioral Risk Factor Surveillance System, the National Health and Nutrition Examination Survey, and the National Health Interview Survey. The SAMHSA found comparable trends even though the estimates themselves differ in magnitude (mostly due to differences in survey designs).36,37 For example, NSDUH and Monitoring the Future trends in nonmedical use of prescription opioids, cigarette use, and alcohol use between 2003 and 2013 showed consistent patterns.37 Fourth, NSDUH is a self-report survey and is subject to recall bias. Fifth, approximately 25% of drug overdose death certificates did not specify the type of drugs involved in the death on the death certificate. The death rates reported in this study may be underestimated.38

Despite these limitations, we found a significangt decrease in the precentage of nonmedical use of prescription opioids, as well as significant increases in the prevalence of prescription opioid use disorders, high-frequency use, and related mortality among adults aged 18 through 64 years in the United States over the past decade. Furthermore, the increases identified in this study occurred in the context of increasing heroin use and heroin-related overdose deaths in the United States,39 supporting a need to address nonmedical use of prescription opioid and heroin abuse in a coordinated and comprehensive manner.31,33,40

During the 2003-2013 years, among adults aged 18 through 64 years, the percentage of nonmedical use of prescription opioids decreased. In contrast, the prevalence of prescription opioid use disorders, frequency of use, and related mortality increased.

Corresponding Author: Beth Han, MD, PhD, MPH, Substance Abuse and Mental Health Services Administration, One Choke Cherry Rd, Room 2-1079, Rockville, MD 20857 (beth.han@samhsa.hhs.gov).

Author Contributions: Dr Han had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Han, Compton, Jones.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Han, Compton, Jones.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Han, Jones, Cai.

Study supervision: Han.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Compton reported owning stock in General Electric Co, 3M Co, and Pfizer Inc. No other disclosures were reported.

Funding/Support: This study was jointly sponsored by the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, and the US Food and Drug Administration. The National Surveys on Drug Use and Health were supported by contracts from the Substance Abuse and Mental Health Services Administration.

Role of the Funder/Sponsors: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation of the manuscript; or decision to submit the manuscript for publication. The sponsors reviewed and approved the manuscript.

Disclaimers: The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, the Food and Drug Administration, or the US Department of Health and Human Services.

Additional Contributions: We thank Peter Lurie, MD, MPH, of the Food and Drug Administration, Neil Russell, PhD, Art Hughes, MS, and Kathryn Piscopo, PhD, of the Substance Abuse and Mental Health Services Administration, and Wenxing Zha, PhD, of the National Institute on Alcohol Abuse and Alcoholism for their comments. None of them received compensation for their roles in this study.

Compton  WM, Volkow  ND.  Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend. 2006;81(2):103-107.
PubMed   |  Link to Article
Compton  WM, Boyle  M, Wargo  E.  Prescription opioid abuse: Problems and responses. Prev Med. 2015;S0091-7435(15)00103-6. doi:10.1016/j.ypmed.2015.04.003.25871819
PubMed
Centers for Disease Control and Prevention (CDC).  Prescription drug overdoses—a US epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10-13.
PubMed
Centers for Disease Control and Prevention.  Emergency department visits involving nonmedical use of selected prescription drugs—United States, 2004-2008. MMWR Morb Mortal Wkly Rep. 2010;59(23):705-709.
PubMed
Centers for Disease Control and Prevention.  Overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
PubMed
Center for Behavioral Health Statistics and Quality. 2013 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network: national estimates of drug-related emergency department visits. http://www.samhsa.gov/data/sites/default/files/Nation_2011_NMUP.xls. Accessed July 28, 2015.
Centers for Disease Control and Prevention. National Center for Health Statistics, 2014. Multiple cause-of-death data, 1999–2013. http://wonder.cdc.gov/mcd.html. Accessed July 4, 2015.
The White House Office of National Drug Control Policy. White House Drug Policy Office and National Institute on Drug Abuse unveil new training materials to combat national prescription drug abuse epidemic [press release]. http://www.drugabuse.gov/news-events/news-releases/2012/white-house-drug-policy-office-national-institute-drug-abuse-unveil-new-training-materials-to-combat. October 1, 2012. Accessed July 5, 2015.
Volkow  ND, Frieden  TR, Hyde  PS, Cha  SS.  Medication-assisted therapies—tackling the opioid-overdose epidemic. N Engl J Med. 2014;370(22):2063-2066.
PubMed   |  Link to Article
Jones  CM.  Frequency of prescription pain reliever nonmedical use: 2002-2003 and 2009-2010. Arch Intern Med. 2012;172(16):1265-1267.
PubMed   |  Link to Article
Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health. http://www.samhsa.gov/data/population-data-nsduh/reports. Accessed July 28, 2015.
American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys.8th ed. Lenexa, KS: AAPOR; 2015:52-53.
National Center for Health Statistics. National Vital Statistics system. http://www.cdc.gov/nchs/deaths.htm. Accessed March 5, 2015.
Jones  CM, Paulozzi  LJ, Mack  KA.  Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA Intern Med. 2014;174(5):802-803.
PubMed   |  Link to Article
Jones  CM.  Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.
PubMed   |  Link to Article
Diagnostic and Statistical Manual of Mental Disorders.4th ed. Washington, DC: American Psychiatric Association. 2000.
Shiffman  S, Waters  A, Hickcox  M.  The nicotine dependence syndrome scale: a multidimensional measure of nicotine dependence. Nicotine Tob Res. 2004;6(2):327-348.
PubMed   |  Link to Article
Research Triangle Institute. SUDAAN Release 11.0.1. Research Triangle Park, NC: RTI International; 2015.
Bieler  GS, Brown  GG, Williams  RL, Brogan  DJ.  Estimating model-adjusted risks, risk differences, and risk ratios from complex survey data. Am J Epidemiol. 2010;171(5):618-623.
PubMed   |  Link to Article
Murphy  SL, Xu  J, Kochanek  KD.  Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61(4):1-117.
PubMed
StataCorp. STATA Statistical Software: Release 13. College Station, TX: StataCorp LP; 2014.
Hilbe  JM. Negative Binomial Regression. Cambridge, UK: Cambridge University Press; 2007.
Dart  RC, Surratt  HL, Cicero  TJ,  et al.  Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372(3):241-248.
PubMed   |  Link to Article
The Researched Abuse. Diversion and Addiction-Related Surveillance (RADARS) System web page. http://www.radars.org/ Accessed July 5, 2015.
Modarai  F, Mack  K, Hicks  P,  et al.  Relationship of opioid prescription sales and overdoses, North Carolina. Drug Alcohol Depend. 2013;132(1-2):81-86.
PubMed   |  Link to Article
Frenk  SM, Porter  KS, Paulozzi  LJ.  Prescription opioid analgesic use among adults: United States, 1999-2012. NCHS Data Brief. 2015;189(189):1-8.
PubMed
Gwira Baumblatt  JA, Wiedeman  C, Dunn  JR, Schaffner  W, Paulozzi  LJ, Jones  TF.  High-risk use by patients prescribed opioids for pain and its role in overdose deaths. JAMA Intern Med. 2014;174(5):796-801.
PubMed   |  Link to Article
Jones  CM, McAninch  JK.  Emergency department visists and overdose deaths from the combined use of opioids and benzodiazepines. Am J Prev Med. 2015;49(4):493-501.
PubMed   |  Link to Article
Mack  KA, Zhang  K, Paulozzi  L, Jones  C.  Prescription practices involving opioid analgesics among Americans with Medicaid, 2010. J Health Care Poor Underserved. 2015;26(1):182-198.
PubMed   |  Link to Article
Reifler  LM, Droz  D, Bailey  JE,  et al.  Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med. 2012;13(3):434-442.
PubMed   |  Link to Article
Jones  CM, Lurie  P, Woodcock  J.  Addressing prescription opioid overdose: data support a comprehensive policy approach. JAMA. 2014;312(17):1733-1734.
PubMed   |  Link to Article
Olsen  Y, Sharfstein  JM.  Confronting the stigma of opioid use disorder—and its treatment. JAMA. 2014;311(14):1393-1394.
PubMed   |  Link to Article
Groves  RM.  Nonresponse rates and nonresponse bias in household surveys. Public Opin Q. 2006;70:646-675.
Link to Article
Tourangeau  R, Plewes  TJ, eds. Nonresponse in Social Science Surveys: A Research Agenda. Washington, DC: The National Academies Press; 2013.
Center for Behavioral Health Statistics and Quality. National Survey on Drug Use and Health (NSDUH): Summary of Methodological Studies, 1971–2014. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
Paulozzi  LJ, Warner  M, Jones  CM.  Defining controlled substances overdoses: some challenges. J Clin Toxicol. 2013;3:175. doi:10.4172/2161-0495.1000175.
Jones  CM, Logan  J, Gladden  RM, Bohm  MK.  Vital Signs: demographic and substance use trends among heroin users—United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719-725.
PubMed
The Office of National Drug Control Policy. National Drug Control Strategy. http://www.whitehouse.gov/sites/default/files/ondcp/2012_ndcs.pdf. Published 2012. Accessed March 18, 2015.

Figures

Tables

Table Graphic Jump LocationTable 1.  Twelve-Month Prevalence Trends of Nonmedical Use of Prescription Opioids, Prescription Opioid Use Disorders, and Drug Overdose Deaths Involving Prescription Opioids, United States, 2003-2013a
Table Graphic Jump LocationTable 2.  Twelve-Month Model-Adjusted Prevalence of Prescription Opioid Use Disorders Among Adult Prescription Opioid Nonmedical Users in the United States
Table Graphic Jump LocationTable 3.  Modeled Number of Days of Nonmedical Use of Prescription Opioids in the Past 12 Months Among Prescription Opioid Nonmedical Adult Users in the United States

References

Compton  WM, Volkow  ND.  Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend. 2006;81(2):103-107.
PubMed   |  Link to Article
Compton  WM, Boyle  M, Wargo  E.  Prescription opioid abuse: Problems and responses. Prev Med. 2015;S0091-7435(15)00103-6. doi:10.1016/j.ypmed.2015.04.003.25871819
PubMed
Centers for Disease Control and Prevention (CDC).  Prescription drug overdoses—a US epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10-13.
PubMed
Centers for Disease Control and Prevention.  Emergency department visits involving nonmedical use of selected prescription drugs—United States, 2004-2008. MMWR Morb Mortal Wkly Rep. 2010;59(23):705-709.
PubMed
Centers for Disease Control and Prevention.  Overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
PubMed
Center for Behavioral Health Statistics and Quality. 2013 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network: national estimates of drug-related emergency department visits. http://www.samhsa.gov/data/sites/default/files/Nation_2011_NMUP.xls. Accessed July 28, 2015.
Centers for Disease Control and Prevention. National Center for Health Statistics, 2014. Multiple cause-of-death data, 1999–2013. http://wonder.cdc.gov/mcd.html. Accessed July 4, 2015.
The White House Office of National Drug Control Policy. White House Drug Policy Office and National Institute on Drug Abuse unveil new training materials to combat national prescription drug abuse epidemic [press release]. http://www.drugabuse.gov/news-events/news-releases/2012/white-house-drug-policy-office-national-institute-drug-abuse-unveil-new-training-materials-to-combat. October 1, 2012. Accessed July 5, 2015.
Volkow  ND, Frieden  TR, Hyde  PS, Cha  SS.  Medication-assisted therapies—tackling the opioid-overdose epidemic. N Engl J Med. 2014;370(22):2063-2066.
PubMed   |  Link to Article
Jones  CM.  Frequency of prescription pain reliever nonmedical use: 2002-2003 and 2009-2010. Arch Intern Med. 2012;172(16):1265-1267.
PubMed   |  Link to Article
Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health. http://www.samhsa.gov/data/population-data-nsduh/reports. Accessed July 28, 2015.
American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys.8th ed. Lenexa, KS: AAPOR; 2015:52-53.
National Center for Health Statistics. National Vital Statistics system. http://www.cdc.gov/nchs/deaths.htm. Accessed March 5, 2015.
Jones  CM, Paulozzi  LJ, Mack  KA.  Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA Intern Med. 2014;174(5):802-803.
PubMed   |  Link to Article
Jones  CM.  Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.
PubMed   |  Link to Article
Diagnostic and Statistical Manual of Mental Disorders.4th ed. Washington, DC: American Psychiatric Association. 2000.
Shiffman  S, Waters  A, Hickcox  M.  The nicotine dependence syndrome scale: a multidimensional measure of nicotine dependence. Nicotine Tob Res. 2004;6(2):327-348.
PubMed   |  Link to Article
Research Triangle Institute. SUDAAN Release 11.0.1. Research Triangle Park, NC: RTI International; 2015.
Bieler  GS, Brown  GG, Williams  RL, Brogan  DJ.  Estimating model-adjusted risks, risk differences, and risk ratios from complex survey data. Am J Epidemiol. 2010;171(5):618-623.
PubMed   |  Link to Article
Murphy  SL, Xu  J, Kochanek  KD.  Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61(4):1-117.
PubMed
StataCorp. STATA Statistical Software: Release 13. College Station, TX: StataCorp LP; 2014.
Hilbe  JM. Negative Binomial Regression. Cambridge, UK: Cambridge University Press; 2007.
Dart  RC, Surratt  HL, Cicero  TJ,  et al.  Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372(3):241-248.
PubMed   |  Link to Article
The Researched Abuse. Diversion and Addiction-Related Surveillance (RADARS) System web page. http://www.radars.org/ Accessed July 5, 2015.
Modarai  F, Mack  K, Hicks  P,  et al.  Relationship of opioid prescription sales and overdoses, North Carolina. Drug Alcohol Depend. 2013;132(1-2):81-86.
PubMed   |  Link to Article
Frenk  SM, Porter  KS, Paulozzi  LJ.  Prescription opioid analgesic use among adults: United States, 1999-2012. NCHS Data Brief. 2015;189(189):1-8.
PubMed
Gwira Baumblatt  JA, Wiedeman  C, Dunn  JR, Schaffner  W, Paulozzi  LJ, Jones  TF.  High-risk use by patients prescribed opioids for pain and its role in overdose deaths. JAMA Intern Med. 2014;174(5):796-801.
PubMed   |  Link to Article
Jones  CM, McAninch  JK.  Emergency department visists and overdose deaths from the combined use of opioids and benzodiazepines. Am J Prev Med. 2015;49(4):493-501.
PubMed   |  Link to Article
Mack  KA, Zhang  K, Paulozzi  L, Jones  C.  Prescription practices involving opioid analgesics among Americans with Medicaid, 2010. J Health Care Poor Underserved. 2015;26(1):182-198.
PubMed   |  Link to Article
Reifler  LM, Droz  D, Bailey  JE,  et al.  Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med. 2012;13(3):434-442.
PubMed   |  Link to Article
Jones  CM, Lurie  P, Woodcock  J.  Addressing prescription opioid overdose: data support a comprehensive policy approach. JAMA. 2014;312(17):1733-1734.
PubMed   |  Link to Article
Olsen  Y, Sharfstein  JM.  Confronting the stigma of opioid use disorder—and its treatment. JAMA. 2014;311(14):1393-1394.
PubMed   |  Link to Article
Groves  RM.  Nonresponse rates and nonresponse bias in household surveys. Public Opin Q. 2006;70:646-675.
Link to Article
Tourangeau  R, Plewes  TJ, eds. Nonresponse in Social Science Surveys: A Research Agenda. Washington, DC: The National Academies Press; 2013.
Center for Behavioral Health Statistics and Quality. National Survey on Drug Use and Health (NSDUH): Summary of Methodological Studies, 1971–2014. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
Paulozzi  LJ, Warner  M, Jones  CM.  Defining controlled substances overdoses: some challenges. J Clin Toxicol. 2013;3:175. doi:10.4172/2161-0495.1000175.
Jones  CM, Logan  J, Gladden  RM, Bohm  MK.  Vital Signs: demographic and substance use trends among heroin users—United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719-725.
PubMed
The Office of National Drug Control Policy. National Drug Control Strategy. http://www.whitehouse.gov/sites/default/files/ondcp/2012_ndcs.pdf. Published 2012. Accessed March 18, 2015.
CME


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Supplement.

eFigure 1. Prevalence of nonmedical use of prescription opioids for 100 days or more and prescription opioid use disorders among adults aged 18-64 in the United States, 2003-2013

eFigure 2. Rate of drug overdose deaths involving prescription opioids among adults aged 18-64 in the United States, 2003-2013

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