Gender and prescription opioids: Findings from the National Survey on Drug Use and Health
Introduction
For millennia, opium has been used to relieve pain and other physical ailments. Since the early 19th century, when Sertürner isolated morphine from opium, opioids have been a mainstay in the implementation of surgical procedures and in the treatment of post-operative and chronic pain (Brownstein, 1993, Sertuerner, 1817). The most commonly prescribed medication of any category in the United States is hydrocodone/acetaminophen, surpassing over 100 million other medications, including cholesterol-lowering atorvastastin and the antibiotic amoxicillin (Kuehn, 2007). Unfortunately, as the number of prescriptions for the legitimate use of opioids has increased, so has their illegitimate use (Kuehn, 2007, McLellan and Turner, 2008).
The non-medical use, abuse and dependence on prescription opioids has experienced alarming growth over the past 10 years and poses a serious public health concern (Kuehn, 2007, Blanco et al., 2007, Compton and Volkow, 2006, Zacny et al., 2003, Wunsch et al., 2009). Prescription opioids have been shown to surpass all other illicit drugs as the most commonly initiated drug within the past year (Substance Abuse and Mental Health Services Administration, 2007). Furthermore, rates of prescription opioid-related Emergency Department (ED) visits have surged (Paulozzi, 2006, Hall et al., 2008, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2008). Data from the Drug Abuse Warning Network (DAWN) estimates that from 2004 to 2006, ED visits related to opioid analgesics rose 43% and opioid analgesic-related suicide attempts rose 34% (SAMHSA, 2008). Overall, central nervous system (CNS) agents accounted for 50% of the 741,425 ED visits involving non-medical use of pharmaceuticals in 2006, and the most common CNS agents were opioid analgesics (33% of all non-medical use visits). Finally, one study investigating unintentional pharmaceutical overdose fatalities (N = 295) found that opioid analgesics were taken by almost all (93.2%) of descendants, and that less than half actually had a prescription for opioid analgesics (Hall et al., 2008).
Putative reasons for the observed increase in prescription opioid misuse include, for example, the significant increase in the production and availability of prescription opioids and expanded use of prescription opioids in primary care settings (Goodman and Glassman, 2005, Reid et al., 2002). In comparison to other illicit drugs, prescription opioids may be less closely monitored by law enforcement and are less easily detectable by others (e.g., odorless) (Compton & Volkow, 2006). Furthermore, many individuals are susceptible to the mistaken belief that because opioids are prescribed by physicians and used to treat legitimate medical conditions, they are “safer” than other illicit drugs (Compton and Volkow, 2006, Ling et al., 2003). Given these unique characteristics, the prevention and treatment of non-medical prescription opioid use, abuse and dependence present a formidable challenge to physicians and health care providers, and there is a critical need to better understand factors involved in susceptibility.
A robust literature surrounding gender and other substances of abuse (e.g., alcohol, cocaine, nicotine), demonstrates important differences between men and women with regard to a number of characteristics, such as, risk of susceptibility, age of substance use initiation, reasons for using substances, treatment entry rates and outcomes, and physiological consequences of substance use (Brady, Back & Greenfield, 2009). To date, the role of gender with regard to prescription opioid misuse and dependence has received little attention. In a recent pilot study of gender differences in aberrant drug taking behaviors among 121 chronic pain patients (Back et al., 2009), our group found that women were significantly more likely than men to hoard unused medications and to use additional medications to enhance the effectiveness of pain medication. Higher rates of alternative routes of medication administration, such as crushing and snorting pain medication, were observed among men as compared to women. A retrospective cohort study (Banta-Green, Merrill, Doyle, Boudreau & Calsyn, 2009) examining prescription opioid use problems among 704 pain patients participating in an integrated medical practice found that males were more likely than females (OR = 1.95) to endorse addictive behaviors (e.g., requested an early refill, had a doctor refuse to prescribe the medication due to abuse concerns, used the medication for other symptoms such as sleep or anxiety). Using an even larger sample (N = 27,816) of individuals seeking treatment for addiction, Carise et al. (2007) found that men were significantly more likely than women to report abusing Oxycontin. Of particular relevance to the current study, Tetrault et al. (2008) utilized data from the 2003 National Survey on Drug Use and Health (NSDUH; N = 55,023) to examine risk factors for prescription opiate non-medical use, stratified by gender. Illicit drug use, younger age, and emergency room visits were found to be associated with prescription opiate non-medical use among both men and women. Gender-specific correlates of prescription opiate use included serious mental illness and cigarette use among women, and inhalant use among men. Notably, the Tetrault et al. study focused on prescription opiate use only; correlates of prescription opiate abuse or dependence were not examined.
To further investigate the role of gender, the current study used a large nationally-representative sample to examine differences in correlates, sources and predictors of prescription opioid non-medical use, as well as abuse or dependence. While previous studies have examined gender differences in prescription opiate use or abuse/dependence, no study to our knowledge has examined and contrasted both conditions. As rates of prescription opioid use, abuse and dependence continue to rise in the United States, it is important to develop effective methods for identifying individuals most at risk. Furthermore, correlates of non-medical use and abuse/dependence can inform the design of secondary and tertiary interventions directed toward reducing harmful prescription opioid use.
Section snippets
Participants and data source
Data were drawn from the Substance Abuse and Mental Health Services Administration's (SAMHSA) 2006 NSDUH (N = 55,279), formerly the National Household Survey on Drug Abuse. The NSDUH is a self-report survey conducted annually in the United States that collects information on the prevalence and correlates of drug use among non-institutionalized civilians aged 12 years and older, using a cross-sectional design. The survey sample employed a 50-state design with an independent, multistage area
Demographic characteristics of the sample
Table 1 presents the demographic characteristics by gender (N = 55,279; 26,746 men, 28,533 women). The majority of the participants were over 35 years of age, Caucasian, employed, and married.
Rates of prescription opioid non-medical use
Overall rates of lifetime and current (i.e., past year) prescription opioid non-medical use were 13.6% and 5.1%, respectively. As can be seen in Table 1, significantly more men than women endorsed lifetime (15.9% vs. 11.2%; p < 0.0001) and past-year (5.9% vs. 4.2%; p < 0.0001) non-medical use.
Rates of prescription opioid abuse or dependence
Among the full
Discussion
The current study extends the limited extant research on gender differences regarding prescription opioids. This study provides information from a more recent NSDUH than previous publications which is an important consideration when dealing with a growing public health problem. In addition, the study has unique value in that it addresses an important knowledge gap in the literature by 1) contrasting factors associated with non-medical use as compared to abuse/dependence, and 2) examining gender
Conclusions
The current findings reveal that prescription opioid non-medical use is a common and growing public health problem, with an estimated 33 million individuals reporting lifetime non-medical use and over 13% of current users having abuse/dependence. The findings help alert clinicians to characteristics that may confer greater risk of use or abuse/dependence, including male gender, younger age, serious psychological distress, and other substance use, in particular non-medical use of tranquilizers
Role of funding source
This work was partially supported by Mentored Career Development Awards from the National Institute on Drug Abuse to S. Back (K23 DA021228) and K. Brady (K24 DA00435). NIDA and NIH had no further role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors
Authors Back, Payne and Brady designed the study. Authors Back, Payne and Simpson conducted literature searches. Author Simpson conducted the statistical analyses. Authors Back, Payne, Simpson and Brady wrote the manuscript.
Conflict of interest
No authors have any conflict of interest to disclose.
Acknowledgement
The authors wish to thank Ms. Katie Lawson for her assistance with manuscript preparation.
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