Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 1976-2015
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Trends in Medical and Nonmedical
Use of Prescription Opioids Among
US Adolescents: 1976–2015
Sean Esteban McCabe, PhD,a,b Brady T. West, PhD,c Phil Veliz, PhD,a Vita V.
McCabe, MD,d Sarah A. Stoddard, PhD,e Carol J. Boyd, PhDa,e,f
OBJECTIVES: Most US studies of national trends in medical and nonmedical use of prescription abstract
opioids have focused on adults. Given the limited understanding in these trends among
adolescents, we examine national trends in the medical and nonmedical use of prescription
opioids among high school seniors between 1976 and 2015.
METHODS: The data used for the study come from the Monitoring the Future study of
adolescents. Forty cohorts of nationally representative samples of high school seniors
(modal age 18) were used to examine self-reported medical and nonmedical use of
prescription opioids.
RESULTS: Lifetime prevalence of medical use of prescription opioids peaked in both 1989
and 2002 and remained stable until a recent decline from 2013 through 2015. Lifetime
nonmedical use of prescription opioids was less prevalent and highly correlated with
medical use of prescription opioids over this 40-year period. Adolescents who reported
both medical and nonmedical use of prescription opioids were more likely to indicate
medical use of prescription opioids before initiating nonmedical use.
CONCLUSIONS: Prescription opioid exposure is common among US adolescents. Long-
term trends indicate that one-fourth of high school seniors self-reported medical or
nonmedical use of prescription opioids. Medical and nonmedical use of prescription
opioids has declined recently and remained highly correlated over the past 4 decades.
Sociodemographic differences and risky patterns involving medical and nonmedical use
of prescription opioids should be taken into consideration in clinical practice to improve
opioid analgesic prescribing and reduce adverse consequences associated with prescription
opioid use among adolescents.
NIH
aInstitute for Research on Women and Gender, bSubstance Abuse Research Center, cSurvey Research Center, WHAT’S KNOWN ON THIS SUBJECT: Opioid analgesic
Institute for Social Research, eSchool of Nursing, and fAddiction Research Center, Department of Psychiatry, prescribing has increased in the United States
University of Michigan, Ann Arbor, Michigan; and dDepartment of Surgery, St Joseph Mercy Ann Arbor, Ann over the past 4 decades. To date, studies examining
Arbor, Michigan national trends in medical and nonmedical use of
Dr S. McCabe conceptualized and designed the study and drafted the initial manuscript; prescription opioids have focused primarily on adults
Dr West carried out the analyses and reviewed and revised the manuscript; Drs Veliz and Stoddard and relied on separate data sources.
interpreted data and critically reviewed the manuscript; Dr V. McCabe interpreted data and WHAT THIS STUDY ADDS: Medical use of prescription
critically reviewed the manuscript with a focus on the significance of the study for clinical
opioids was highly correlated with nonmedical use
practice; Dr Boyd conceptualized the study and critically reviewed the manuscript; and all authors
approved the final manuscript as submitted.
over the past 4 decades, especially among male
adolescents. Adolescents reporting both medical and
DOI: 10.1542/peds.2016-2387 nonmedical use of prescription opioids were more
Accepted for publication Dec 22, 2016 likely to initiate medical before nonmedical use.
Address correspondence to Sean Esteban McCabe, PhD, 204 South State St, Institute for Research
on Women and Gender, University of Michigan, Ann Arbor, MI 48109. E-mail: plius@umich.edu
To cite: McCabe SE, West BT, Veliz P, et al. Trends in Medical and Nonmedical
Use of Prescription Opioids Among US Adolescents: 1976–2015. Pediatrics.
2017;139(4):e20162387
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PEDIATRICS Volume 139, number 4, April 2017:e20162387 ARTICLEThe United States consumes the by their regional focus at single Review Board provided approval for
majority of the world’s prescription points in time. this study.
opioid supply, and multiple studies
Given these gaps in knowledge, Each of the 40 cohorts was an
have reported substantial increases
more national studies are needed to independent, cross-sectional,
in the prescribing of opioid
determine whether there are long- nationally representative sample
analgesics.1–7 One consequence of
term associations between changes of US high school seniors. The
an increase in the prescribing of
in medical use of prescription opioids demographic characteristics of the
opioids is a concomitant increase in
and NUPO among adolescents. population represented by these
opioid-related consequences such
Empirically demonstrating a long- cohorts varied over time. MTF
as nonmedical use, prescription sampling weights were applied in all
term relationship between medical
opioid use disorders, emergency use and NUPO will be particularly analyses to ensure that each sample
department admissions, and helpful in refining recommendations was representative of all high school
overdose deaths due to greater for safely prescribing opioid seniors in each cohort in terms of sex
availability of these medications.1,3–12 medications among adolescents and race and ethnicity. The modal age
These associations suggest that while reducing NUPO. Because of the in each cohort was 18 years old. The
the trends in nonmedical use of lack of available data on the long- sample size per cohort ranged from
prescription opioids (NUPO) should term trends among adolescents, the 2181 to 3791.
be considered in the larger context of primary aim of this study was to
medical availability of prescription assess the trends and correlations Measures
opioids. in the prevalence of medical use
The MTF study assesses a wide
of prescription opioids and NUPO
range of behaviors, attitudes, and
To date, studies examining national among US high school seniors from
values.22,23 We selected specific
trends in medical use of prescription 1976 to 2015.
measures for analysis in the current
opioids and NUPO have focused
study, including demographic
primarily on adults and relied on
characteristics (ie, sex and race) and
separate data sources.1,3–7 METHODS
standard measures of substance use
Four studies have examined the behaviors.
The Monitoring the Future (MTF)
association between medical use
study annually surveys a cross-
of prescription opioids and NUPO We assessed medical use of
sectional, nationally representative
among adolescents and found prescription opioids by asking
sample of US high school seniors
that the majority of medical users whether respondents had ever taken
attending ~135 public and private
reported no history of NUPO.10,13–15 prescription opioids because a doctor
schools, via self-administered
In contrast, most adolescents who told them to use the medication.
paper-and-pencil questionnaires in
report NUPO have a history of Respondents were informed that
classrooms. This study considered
medical use of prescription prescription opioids are prescribed
samples of high school seniors from
opioids.10,13–15 Despite the by doctors and sold in drugstores and
40 independent cohorts (senior years
aforementioned studies aimed are not supposed to be sold without a
1976–2015), each recruited through
at determining the associations prescription. These included Vicodin,
a multistage random-sampling
between medical use of prescription OxyContin, Percodan, Percocet,
design. The response rates ranged
opioids and NUPO, there is a paucity Demerol, Ultram, methadone,
from 77% to 86% between 1976 and
of research using repeated national morphine, opium, and codeine. The
2015. Because so many questions are
samples that assesses the long-term response options included 1, “No;" 2,
included in the MTF study, much of
trends, correlations, and patterns of "Yes, but I had already tried them on
the questionnaire content is divided
medical use of prescription opioids my own;" and 3, "Yes, and it was the
into 6 different forms, which are
and NUPO among adolescents.16–19 first time I took any.” The range of
randomly distributed. This approach
Furthermore, previous studies have missing data was 6.0% to 12.0% for
results in 6 identical subsamples.
medical use of prescription opioids.
examined race and sex differences in The measures most relevant for this
medical use of prescription opioids study were asked on form 1, so this We assessed NUPO by asking on
and generally found that female and study focuses on the cross-sectional how many occasions (if any) in
white adolescents were more likely subsamples receiving form 1 in each their lifetime the adolescent used
to be prescribed opioid analgesics of the 40 cohorts. Details about the prescription opioids on their own,
than male and black adolescents, MTF study design and methods that is, “without a doctor telling you
respectively.13,14,20,21 Unfortunately, are available elsewhere.22,23 The to take them.” The response options
these studies have often been limited University of Michigan Institutional ranged from 1, “no occasions,” to
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2 MCCABE et al7, “≥40 occasions.” The range of a given year was compared via the of association used; we report
missing data was 6.0% to 12.4% methods for comparing descriptive the Pearson correlation here (r =
for NUPO. Although the wording parameters in 2 subgroups defined in 0.50, P < .01). The estimated linear
of the medical and nonmedical use previous work.25 regression coefficients for medical
questions remained identical across use prevalence as a predictor of
Finally, given the weighted
all 40 cohorts, the list of examples NUPO prevalence were 0.552
prevalence estimates and linearized
of prescription opioids was updated (ordinary least squares, P < .01)
standard errors for each of the 40
over time. In 2002, Talwin, laudanum, and 0.450 (variance-weighted least
cohorts, we assessed the correlation
and paregoric had negligible rates of squares, P < .001).
of the estimated prevalence for
use by 2001 and were replaced with The lifetime medical use of
medical use of prescription opioids
Vicodin, OxyContin, and Percocet, prescription opioids tended to
and NUPO across the 40 cohorts by
which probably contributed to an be more prevalent among female
using 3 different methods. First, we
increase in medical and nonmedical adolescents relative to male
estimated a simple unweighted linear
use in 2002. Changes in wording adolescents (Fig 2). In contrast, the
regression coefficient predicting
in long-term studies represent a prevalence of NUPO differed less by
estimated NUPO prevalence as a
challenge to tracking cross-sectional sex. The Pearson correlation between
function of estimated medical use
behavioral trends related to medical use of prescription opioids
prevalence. Next, we fit the same
prescription opioids over time. It is and NUPO was much stronger for
model by using variance-weighted
noteworthy that identical wording male (r = 0.67, P < .001) than female
least squares and using the estimated
changes were made to both medical adolescents (r = 0.34, P < .05).
SE of the nonmedical use prevalence
and nonmedical use questions in
to determine the weights. Finally, The prevalence of medical use of
the MTF study at the same time; in
we computed a Pearson correlation prescription opioids was consistently
addition, similar updates were made
coefficient describing the strength higher among white adolescents
to prescription opioid questions in
of the linear association between relative to black adolescents (Fig 3).
other national studies.
the 2 sets of prevalence estimates Similarly, NUPO was more prevalent
across the 40 cohorts. These 3 tests among white adolescents as
Statistical Analysis of association, designed to gauge compared with black adolescents.
the robustness of the associations, The Pearson correlation between
For each of the 40 cohorts, we first
were repeated for subpopulations medical use of prescription opioids
used the cohort-specific sampling
based on sex and race. All analyses and NUPO was robust for African
weights to estimate the prevalence of
lifetime medical use of prescription
were performed in Stata version 14.1 American (r = 0.79, P < .001) and
opioids and the prevalence of lifetime
(Stata Corp, College Station, TX). white adolescents (r = 0.65, P < .001).
NUPO, both overall and for male Next, we examined the long-term
and female adolescents separately. trends in patterns of lifetime medical
RESULTS
We also estimated the prevalence and nonmedical use history for
of medical use and NUPO for white Lifetime medical use of prescription prescription opioids among high
and black adolescents. We used opioids was more prevalent than school seniors (Fig 4). We found
a method outlined previously to lifetime NUPO among high school that the most prevalent pattern of
compute linearized estimates of seniors over the 1976 to 2015 exposure to prescription opioids was
standard errors for the weighted time period (Fig 1). The estimated medical use only (without a history
estimates reflecting the complex MTF lifetime prevalence of medical use of of NUPO) over the course of the study
sampling features.24 Next, for each prescription opioids increased from period, ranging from a low of 8.5%
cohort, we estimated the prevalence 16.0% (SE = 0.9) in 1976 to a peak of (SE = 0.9) in 2000 to a high of 14.4%
of the following 4 mutually exclusive 20.4% (SE = 1.1) in 1989, gradually (SE = 0.8) in 1989. Among those who
subgroups: lifetime medical use of declined to a low of 13.2% (SE = 1.0) report a history of both medical use
prescription opioids only, medical in 1997, held stable until a rapid of prescription opioids and NUPO, the
use of prescription opioids before increase to 20.0% (SE = 1.3) in 2002 most prevalent pattern was generally
NUPO, NUPO before medical use (partially influenced by a change in medical use before initiating NUPO,
of prescription opioids, and NUPO question wording; see the Measures ranging from a low of 2.6% (SE = 0.2)
only. We estimated the prevalence of section), and then remained stable in 1979 to a high of 5.4% (SE = 0.6) in
these subgroups overall as well as for until a decline after 2013. The 1990, and the least prevalent pattern
male and female adolescents in each lifetime NUPO was correlated with tended to be NUPO before initiating
cohort. Estimated prevalence for medical use of prescription opioids medical use of prescription opioids.
male and female adolescents within over time, regardless of the test Finally, the prevalence of NUPO
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PEDIATRICS Volume 139, number 4, April 2017 3FIGURE 1
Trends in lifetime medical and nonmedical use of prescription opioids among high school seniors, 1976–2015. The dotted line reflects the fact that the
list of examples of prescription opioids was updated in 2002, which probably contributed to an increase in medical and nonmedical use of prescription
opioids in 2002 (see the Measures section for details of the updates).
only has remained similar to that of Fig 5. Finally, there were the fewest decades. The recent declines in
medical use before initiating NUPO sex differences in medical use of medical use of prescription opioids
over the past decade. prescription opioids before engaging and NUPO from 2013 through 2015
in NUPO, with female adolescents found in the current study coincide
Additional analyses indicated that reporting higher prevalence rates with similar recent declines in US
medical use only was more prevalent than male adolescents in 2 of the opioid analgesic prescribing.7,26
among female than male adolescents 40 years (P < .05), see Supplemental Although medical use of prescription
in 19 out of 40 years (P < .05); see Fig 6.
Supplemental Fig 5. In contrast, opioids without any history of NUPO
NUPO only was more prevalent was the most prevalent exposure
(P < .05) among male than female to prescription opioids between
DISCUSSION 1976 and 2015, we found that the
adolescents in 6 of the 40 years (see
Supplemental Fig 6). There were We found that the medical use of majority of adolescents indicating
fewer sex differences in NUPO before prescription opioids was highly NUPO also had a history of medical
initiating medical use of prescription correlated with NUPO among high use of prescription opioids. Among
opioids, with male adolescents school seniors between 1976 and adolescents who report both medical
reporting higher prevalence rates 2015. The prevalence of lifetime use of prescription opioids and
than female adolescents in 4 of the medical use or NUPO ranged from NUPO, medical use before initiating
40 years (P < .05); see Supplemental 16.5% to 24.1% over the past 4 NUPO tended to be most prevalent,
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4 MCCABE et alFIGURE 2
Trends in lifetime medical and nonmedical use of prescription opioids among high school seniors by sex, 1976–2015. The dotted line reflects the fact that
the list of examples of prescription opioids was updated in 2002, which probably contributed to an increase in medical and nonmedical use of prescription
opioids in 2002 (see the Measures section for details of the updates).
and this pattern may be driven by the findings among adults.1,3–7 Notably, nonmedical users are more likely
one-third of adolescents who report we found that the correlation was to obtain prescription opioids from
NUPO involving leftover opioid much stronger for male than female family members.31,32 The higher rate
medications from their own previous adolescents. of peer-to-peer diversion among
prescriptions.22,27,28 male adolescents may increase
Based on past research, there the risk of NUPO when medical
The medical use of prescription are several possible reasons why availability increases.
opioids was generally more prevalent medical use of prescription opioids
among female adolescents, whereas is more highly correlated with Second, male nonmedical users
NUPO differed little by sex. Although NUPO among male adolescents than are more likely to use prescription
sex differences in medical use of female adolescents. First, NUPO is opioids nonmedically to get high,
prescription opioids have been directly related to the availability whereas female nonmedical users
documented,13,14,21,29 the current of prescription opioids, and several are more likely to use for physical
study extended previous research previous studies have shown pain relief.20,32,34 The higher rate
by examining long-term trends. The sex differences in the diversion of non–pain relief motives among
medical use of prescription opioids associated with NUPO among male adolescents could partially
was found to be highly correlated adolescents.30–33 For instance, male account for the stronger correlation
with NUPO across the 40 cross- nonmedical users are more likely between medical use of prescription
sectional samples among high school to obtain prescription opioids opioids and NUPO. The findings of
seniors, consistent with previous from their peers, whereas female the current study reinforce the need
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PEDIATRICS Volume 139, number 4, April 2017 5FIGURE 3
Trends in lifetime medical and nonmedical use of prescription opioids among US high school seniors by race, 1983–2015. Based on changes in the
response options to the race question between early cohort years (1976–1982) and more recent cohort years (1983–2015), we examined race trends
starting in 1983 to have consistent race categories over time. The dotted line reflects the fact that the list of examples of prescription opioids was updated
in 2002, which probably contributed to an increase in medical and nonmedical use of prescription opioids in 2002 (see the Measures section for details
of the updates).
for prevention and intervention Second, past studies have shown pain was least prevalent during these
efforts to reduce NUPO to take into racial differences in the motives and 2 time periods, whereas NUPO to
account the reasons and diversion diversion sources associated with reduce negative affect (eg, relieve
sources associated with NUPO among NUPO.31,33,38 For instance, black tension) rose to its highest level in the
adolescents, especially among male adolescents were more likely than early 2000s.34 The abuse potential
adolescents. white adolescents to be motivated of prescription opioids has changed
Medical use of prescription opioids solely by pain relief.36 Thus, the over time, and this potential may play
and NUPO were more prevalent lower prevalence of medical use a role in the current opioid epidemic
among white adolescents than of prescription opioids and NUPO that deserves more attention.
among black adolescents. There are among black relative to white The implications for clinical
probably several reasons for these adolescents could result from a lack practice given these data and
findings. First, previous work has of adequate treatment, insufficient the current opioid epidemic are
documented health disparities for availability, overprescribing multiple: (1) use of prescription
receiving prescription opioids among among white populations, or drug monitoring programs to assist
racial minority patients.35–37 For underprescribing among nonwhite in identifying misuse as routine
example, in a study that considered populations. practice; (2) clinical decision-
a sample of pharmacies in Michigan The current study indicates making with adolescents and
located in low-income zip codes, previous peaks in the medical parents or guardians about risks
pharmacies in predominantly white use of prescription opioids and and benefits of pain management
zip codes (defined as ≥70% white NUPO that preceded the current with and without prescription
residents) had odds of carrying opioid crisis. There are several opioids, including the importance
sufficient opioid analgesics that were possible explanations for these of proper storage, monitoring, and
54 times higher than the odds for different trends. Although NUPO for disposal of prescription opioids;
pharmacies in predominantly racial recreational reasons (eg, to get high) (3) screening for NUPO, substance
minority zip codes (defined as ≥70% was most prevalent in the late 1970s use disorders, and other mental
racial minority residents).35 and early 2000s, NUPO to relieve health disorders; (4) prescribing
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6 MCCABE et alFIGURE 4
Trends in patterns of lifetime use history for prescription opioids among US high school seniors, 1976–2015. The dotted line reflects the fact that the list of
examples of prescription opioids was updated in 2002, which probably contributed to an increase in medical and nonmedical use of prescription opioids
in 2002 (see the Measures section for details of the updates).
the lowest effective dosage and the onset, dose, duration, pain condition, adolescents not enrolled in school.
minimum quantity with concomitant or efficacy related to medical use of Finally, the results were based on 40
use of acetaminophen or ibuprofen prescription opioids. Third, the MTF independent cross-sectional surveys,
to decrease opioid requirement study does not assess some potential which limited the ability to draw
when not contraindicated; and (5) confounding variables in 12th grade, conclusions about causation. More
avoiding concurrent prescription of such as opioid use disorders and prospective research is needed to
sedatives per the Centers for Disease family mental health history. Fourth, examine the longitudinal associations
Control and Prevention best practice students who dropped out of school between medical use of prescription
recommendations.39 or were absent on the day of data opioids, NUPO, and opioid use
collection did not participate in the disorders over the life span.
The current study has some study, and these students are more
limitations that must be taken likely to report substance use.22
into account for considering the Thus, students who experienced CONCLUSIONS
implications of the findings. First, the most serious consequences This study examined long-term
the MTF study is a long self-report associated with NUPO are probably trends in the relationships between
survey and is subject to recall bias underrepresented in the sample, the medical use of prescription
and respondent burden. Second, resulting in underestimates and a opioids and NUPO in a large
the MTF study did not assess age of need for comparable research among multicohort national study over the
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PEDIATRICS Volume 139, number 4, April 2017 7past 4 decades. The findings provide mortality, and overdoses in the evaluate for preventive interventions
compelling evidence that medical use United States despite recent declines among adolescents, with the ultimate
of prescription opioids and NUPO are in NUPO.9,40 Sex and race differences goal of reducing prescription opioid
highly correlated, especially among in the medical availability of misuse while improving the safety
male adolescents. The recent declines prescription opioids should be taken of pain management. Prescribing
in medical use of prescription into consideration in clinical practice practices that increase vigilance
opioids and NUPO from 2013 and in efforts to provide adequate and monitoring of prescription
through 2015 found in the current pain treatment and reduce NUPO. opioids among adolescents, including
study provide additional evidence We found that the majority of NUPO education about proper disposal
for the continuation of previous involved a history of medical use, when medical use has concluded,
declines reported in opioid analgesic and this finding should provide some warrant more investigation.
prescribing and NUPO but must be concern to health professionals
placed into the larger context of the who prescribe opioid medications
current opioid crisis.2,26,40 to adolescents, given the serious ABBREVIATIONS
At least 2 studies have found recent health consequences associated with
MTF: Monitoring the Future
increases in prescription opioid– NUPO.8–12,37–40 The findings provide
NUPO: nonmedical use of pre-
related consequences such as some valuable insights into different
scription opioids
prescription opioid use disorders, patterns of NUPO to target and
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Development of this article was supported by research grants R01DA031160 and R01DA036541 from the National Institute on Drug Abuse, National
Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug
Abuse or the National Institutes of Health. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion for this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-0209.
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PEDIATRICS Volume 139, number 4, April 2017 9Trends in Medical and Nonmedical Use of Prescription Opioids Among US
Adolescents: 1976−2015
Sean Esteban McCabe, Brady T. West, Phil Veliz, Vita V. McCabe, Sarah A.
Stoddard and Carol J. Boyd
Pediatrics originally published online March 20, 2017;
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Downloaded from www.aappublications.org/news by guest on October 16, 2021Trends in Medical and Nonmedical Use of Prescription Opioids Among US
Adolescents: 1976−2015
Sean Esteban McCabe, Brady T. West, Phil Veliz, Vita V. McCabe, Sarah A.
Stoddard and Carol J. Boyd
Pediatrics originally published online March 20, 2017;
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