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PHARMACOLOGY CONSULT

Teen use and abuse of prescription analgesics by Edward A. Bell, PharmD, BCPS

Opiate and opioid analgesics can eff ec- tively relieve pain in those with moder- ate-severe pain from trauma, surgery, oncologic or other disorders. Th e phar- macologic eff ects of these analgesics at opioid receptors not only diminish pain sensation, but also induce signifi cant se- dation and euphoria. Th ese eff ects result in a high potential for misuse and abuse.

Natural opiate analgesics include mor- phine and codeine; semi-synthetic opioids include hydrocodone (eg, Vicodin, Ab- bott Laboratories), oxycodone (eg, Oxy- Contin, Purdue Pharma; Percocet, Endo Pharmaceuticals) and hydromorphone (eg, Dilaudid, Purdue Pharma). Abuse of these analgesic medications by the gen- eral and adolescent populations have in- creased dramatically in recent years.

Consider the following information obtained from recently conducted sur- veys and data analyses about use of il- licit drugs in the US population:

● In 2010, an estimated 8.9% of the population — 22.6 million — had used an illicit drug during the pri- or month.

● Marijuana was the most commonly used illicit drug during the prior month at 17.4 million, followed by non-medical use of psychothera- peutic drugs (analgesics, tranquil- izers, stimulants, sedatives), at 7 million.

● In 2010, an estimated 22.1 million people were classifi ed with sub- stance 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), fol- lowed by pain relievers (1.9 million).

● Of 12th-graders surveyed, 54.2% reported that it is “fairly easy” or “very easy” to obtain opioid medi- cations.

● Deaths due to drug overdoses in 2008 — 36,450 — nearly equaled deaths from motor vehicle acci- dents — 39,973.

● Th e death rate of 11.9/100,000 in 2008 from drug overdoses has in- creased 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.

● Th e number of prescriptions for opi- oid analgesic agents has increased signifi cantly in recent years; from 1997 to 2007, the amount of opioid analgesic agents used per person in- creased 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 Sur- vey on Drug Use and Health (NSDUH) and the Monitoring the Future (MTF) survey. Th e 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 in- creased over 2008 (9.3%). Marijuana was most commonly used (7.4%), followed by non-medical use of psychotherapeutic agents (analgesics, tranquilizers, stimu- lants, sedatives), at 3%.

Th e source of prescription analgesics was determined for the surveyed popu- lation (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 fi rst time within the past 12 months. Th e 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 an-

algesics, 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 ob- tain opioids (other than heroin). Overall, students reported a low level of perceived risk for use of prescription psychothera- peutic agents.

Drug overdoses and ED visits Recently published data have addition-

ally evaluated fatal drug overdoses and visits to EDs for drug-related poisonings. Th e CDC recently reported on fatal drug overdoses, sales and abuse treatment ad- missions. In 2008, opioids were respon- sible 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. Th e Nationwide Emergency Department Sample describes characteristics of visits to EDs for drug-re- lated 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 anal- gesics/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 per- haps 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 “epidem- ic.” Awareness by clinicians of this prob- lem may be the most important means to aff ect its impact. Education of adoles- cents and their parents and caregivers by clinicians about the potential dan- gers of opioid analgesics will likely have a signifi cant eff ect. Prescription analge- sics are approved for use by the FDA as generally safe and eff ective, 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 frequent- ly 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 benefi cial.

Some communities and pharmacies off er take-back programs for medication products no longer needed in the home. Th e FDA recommends that some medi- cations, because of their signifi cant po- tential danger when used non-medically, be disposed of by fl ushing down a sink or toilet. Th is includes opioid analgesics, such as oxycodone. Less dangerous med- ications, such as antibiotics, should be disposed of by mixing (when taken out of its original container) with an undesir- able substance (such as coff ee 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. ■

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 Col- lege of Pharmacy, Blank Children’s Hospi- tal, in Des Moines, Iowa. Bell is also a mem- ber of the INFECTIOUS DISEASES IN CHILDREN Editorial Board. Disclosure: Dr. Bell reports no relevant fi nancial disclosures.

Edward A. Bell

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