Nonmedical Users Research Articles

Commentary on Maier et al. (2016): Language matters--a call for caution regarding research on non-medical use of prescription drugs.

Maier and colleagues' study of purported ‘pharmacological neuroenhancement’ (2015) is difficult to contextualize with prior studies. In the absence of evidence supporting stimulant medications’ cognitive benefits in individuals without diagnosable conditions, researchers should employ conservative terminology such as ‘non-medical drug use’ to avoid perpetuating unsubstantiated beliefs about such benefits, and adopt standardized measures. Maier et al. 1 present the results of a survey of Swiss employees and students that focused on the non-medical use of tranquilizers, antidepressants, attention deficit hyperactivity disorder (ADHD) medications, beta-blockers, modafinil and anti-dementia drugs for self-reported ‘pharmacological neuroenhancement’. Only 411 participants of the 10 171 had used any of these drugs for this purpose in their life-time. Non-medical use was elevated among students, individuals with a mental disorder (including ADHD, depression and anxiety) and individuals reporting poorer health and higher stress levels. This commentary discusses the possible reasons for differences in prevalence estimates across various settings and calls for judiciousness in the way researchers describe non-medical use. The authors place their findings in the context of other surveys conducted in other countries. Comparisons of prevalence estimates are difficult because of the variety of sampling methods used, the survey questions utilized, varying response rates and the characteristics of the individuals surveyed. Population-based estimates from the United States of non-medical use of prescription stimulants are lower than what has been reported in studies of college students from a single campus 2. Even among studies of US college students, these estimates can vary widely 3. Variations in availability and access to treatment, as well as regional differences in prescribing practices of various pharmacological formulations, can also influence prevalence estimates because some formulations are more often used non-medically than others (i.e. immediate versus extended release) 4. In addition to environmental-level conditions, such as availability, non-medical use of prescription drugs, such as the use of any other substance, is driven by a number of individual-level factors (e.g. risk-taking propensity, the balance between one's perception of risk and perception of benefit). An enticing label such as ‘pharmacological neuroenhancement’ as a substitute for a more traditional one such as ‘non-medical drug use’ can amplify public perceptions that non-medical use of these drugs is associated with improvements in cognitive functioning for individuals without a diagnosable condition. For example, while the therapeutic benefit of stimulant medications is established for ADHD patients 5, considerable debate exists regarding extra benefits for individuals without ADHD, especially with regard to executive function 6-8. Even if such effects could be demonstrated for task performance in placebo-controlled laboratory conditions, most agree that there is no evidence that non-medical prescription stimulant users achieve improvements that translate into real-world academic success 6, 9. In fact, nearly every study examining grade point average (GPA) as an outcome of non-medical prescription stimulant use has demonstrated quite the opposite—that non-medical use of prescription stimulants is associated with lower GPAs 3, 10-12. Our group has developed models based on longitudinal data from college students to understand more clearly the precursors of academic decline among non-medical prescription stimulant users. In short, we have found that escalations in excessive drinking and marijuana use appear to precede skipping class and decreases in GPA which, in turn, are associated with the non-medical use of prescription stimulants 10. The significant overlap between all forms of non-medical prescription drug use and other forms of drug use is a robust finding in the literature 3, 4, 13-15, and also observed in Maier's study 1. When prescription drugs are used purportedly for neurocognitive enhancement, it must be considered that the person who is using might be experiencing deficits in cognitive function due to other forms of drug use, and perhaps struggling with an untreated mental health condition. These are underlying problems that deserve our focused attention. Certainly, the motives behind non-medical drug use are interesting phenomena for researchers to understand and explain; but non-medical use of prescription drugs in the current historical context should not be equated with pharmacological neuroenhancement, regardless of purported motives. Perhaps other drugs will be developed in the future that will boost cognitive performance for individuals without a diagnosable condition 16. At a population level, we should continue to develop and use standardized methods for inquiry regarding non-medical prescription drug use. At a clinical level, non-medical use of prescription drugs should be viewed as a possible ‘red flag’ and signal a need for a more comprehensive assessment and possible intervention. None. This commentary was supported by the National Institute on Drug Abuse (NIDA, R01DA014845).

Event-level analyses of sex-risk and injection-risk behaviors among nonmedical prescription opioid users

Event-level analyses of sex-risk and injection-risk behaviors among nonmedical prescription opioid users

Prevention of Opioid Misuse: A Summary with Suggestions from a Pain Working Group.

On November 6, 2014, a multidisciplinary group of experts and stakeholders attended a Prevention of Opioid Misuse Study Day in Toronto funded by the Canadian Institutes of Health Research (CIHR) under a Canada Research Initiative in Substance Misuse (CRISM, grant number CSM-133338). The goals were to clarify issues surrounding opioid medications, including a discussion of current facts and myths, produce a summary of evidence based information to guide health professionals on the best practices in managing acute and chronic pain, inform clinicians, government, and other stakeholders about opioid use/misuse and pain management issues. Specific Principles That Guided the Summary. The following are the specific principles that guided the summary: We recognize the rise in morbidity and mortality associated with opioid misuse and the risk of addiction. We recognize the importance of the International Association for Study of Pain, Montreal, 2010 declaration on the right of person with pain to get relief: http://www.iasp-pain.org/DeclarationofMontreal. We recognize that available alternatives to opioids should be used in first intention (e.g., nonsteroidal analgesics, pregabalin, mood related medication such as duloxetine, and physical and behavioral approaches). We endorse the 2010 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain: http://nationalpaincentre.mcmaster.ca/opioid/. These are solid and remain valid. We also deplore the low access to pain experts and other management options in Canada (mainly in rural areas or low income urban ones) and the absence of newer medications with high effectiveness and low harm. 2. Review of Current Issues on Pain and Its Relief One in five Canadians suffers from chronic pain [1, 2]. Many people living with chronic pain are “invisible” sufferers. Their quality of life is seriously compromised, and if their pain is not managed they are at greater risk of additional problems. Importantly, an association between opioid medication misuse and mood problems including depression and anxiety has been reported [3]. Furthermore, in the absence of adequate pain relief, the risk for suicide increases [4, 5]. Unfortunately, there are no magic cures for chronic pain. When all other alternatives have failed to provide acceptable control of pain, opioid analgesics (e.g., morphine, oxycodone, hydromorphone, and fentanyl) are increasingly being prescribed to relieve pain and improve the quality of life for people living with chronic pain so they can continue working and carrying out routine daily tasks. However, opioids if used inappropriately come with definite serious risks: addiction, fatal overdose, and harmful or even deadly effects when combined with other drugs or substances (particularly alcohol and antianxiety medications). The prevention of opioid misuse requires careful screening by educated prescribers, increased safety education to patients and population, and increased access to addiction and mental health services across all age groups and regions in Canada with a special attention to access to pain management and its prevention in nonurban sites [6]. It is important to distinguish between abuse, addiction, and physical dependence (see page 124 of the Canadian Guidelines: http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf): Abuse is any use of an illegal drug or the intentional self-administration of a medication for a nonmedical purpose such as altering one's state of consciousness, for example, “getting high.” Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Misuse of opioid is use of an opioid in ways other than those intended by a prescribing health professional. Physical dependence is a state of adaptation manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. The nonmedical use of any prescription medication, including opioids, is a major concern. All medications have adverse effects, but if opioids are inappropriately used they are potentially life-threatening due primarily to sedation and respiratory depression. It is important to address this problem and to implement appropriate solutions. The national Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) of the general population aged 15 years and older included nonmedical users who acknowledged using pain relievers more than they were supposed to or without a prescription. Starting in 2009, CADUMS has also asked respondents if they had used the medication “to get high.” The findings indicated that the prevalence of any use of a prescription opioid analgesic (POA) in Canada had decreased from roughly 20% to 17%, with use without a prescription at about 4.8–5% and use to get high at about 0.3%.

Opioid Use Found to Be Decreasing, While Opioid-Related Deaths Increase

To reverse adverse outcomes associated with the illicit use of prescription opiates, guidelines are needed to address prescription practices for such drugs, experts say.

Racial and ethnic trends and correlates of non-medical use of prescription opioids among adolescents in the United States 2004–2013

PurposeOur objective was to elucidate the trends in non-medical use of prescription opioids (NMUPO) among whites, African-Americans, and Hispanic adolescents in the United States. An additional aim was to examine the sociodemographic, behavioral, and psychosocial correlates of NMUPO across each of these aforementioned racial and ethnic groups. MethodsData was derived from the National Survey on Drug Use and Health (NSDUH) involving non-Hispanic white, African American, and Hispanic respondents ages 12–17 (n = 164,028) and spanning the years 2004–2013. Consistent with prior NSDUH-based studies, respondents reporting use within the previous 12 months were classified as nonmedical prescription opioid users. Logistic regression was used to examine significance of trend year and correlates of NMUPO. ResultsNon-Hispanic white youth consistently reported higher levels of NMUPO as did older adolescents (ages 15–17) and females. However, there was a decrease in the prevalence of NMUPO overall driven largely by a significant decline (p < 0.001) in NMUPO among non-Hispanic whites of approximately 35% over the study period such that by 2013 no statistically significant differences across race/ethnicity remained. Further, logistic regression models found that externalizing behaviors such as comorbid drug use and fighting was associated with NMUPO and religiosity and parental involvement were identified as protective correlates. ConclusionsTo our knowledge, this is the first study to identify a declining trend in NMUPO among adolescents. Although the present study findings provide a source for optimism, there is still a relatively high prevalence of NMUPO and it remains to be seen whether our findings portend a long-term decline. Given the harm done by NMUPO, continued awareness and targeted prevention efforts should be implemented.

Sequences of substance use initiation among adolescent nonmedical users of prescription opioids and stimulants

Sequences of substance use initiation among adolescent nonmedical users of prescription opioids and stimulants

Differentiating patterns of prescription stimulant medical and nonmedical use among youth 10–18 years of age

ObjectiveTo assess the past 30-day prevalence of prescription stimulant use, report different forms of nonmedical use, and investigate different characteristics associated with Medical Users Only, Nonmedical Users Only, and youth who reported both medical and nonmedical use (MU+NMU youth). MethodsThe National Monitoring of Adolescent Prescription Stimulants Study recruited 11,048 youth aged 10–18 years from entertainment venues in 10 US cities. ResultsIn this study, 6.8% youth used prescription stimulants in the past 30 days, with 3.0% reporting Medical Use Only (MU Only), 1.1% reporting Both Medical and Nonmedical Use (MU+NMU), and 2.5% reporting Nonmedical Use Only (NMU Only). Use of other's stimulants was the most frequently reported form of nonmedical use (88.4%), followed by using more than prescribed (38.9%), and using outside of the prescribed route (32.2%). Medical Users Only and MU+NMU youth did not differ from Non-Users in cigarette, alcohol, and illicit drug use. MU+NMU youth tended to have more conduct problem behaviors compared to Medical Users Only (p=0.0011) and Nonmedical Users Only (p=0.0132). Compared to MU+NMU youth, Nonmedical Users Only were more likely to have close friends who tried Adderall (p=0.0123), endorse binge drinking (p=0.0118) and illicit drug use (p<0.0015). ConclusionsFuture research should investigate the sources of the nonmedically used prescription stimulants and how they were diverted. Intervention programs need to acknowledge the differences between MU+NMU youth and Nonmedical Users Only, and employ different strategies to prevent nonmedical use in these subgroups.

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

Since 1999, the United States has experienced increases in morbidity and mortality associated with nonmedical use of prescription opioids. To assess national trends in and characteristics of nonmedical prescription opioid use and use disorders and the national trend in related mortality. 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. Prevalence of nonmedical use of prescription opioids. Nonmedical prescription opioid use and use disorders. 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. 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.

Age and Cohort Patterns of Medical and Nonmedical Use of Controlled Medication Among Adolescents.

We identified peak annual incidence rates for medical and nonmedical use of prescription opioid analgesics, stimulants, sedatives, and anxiolytics (controlled medication), and explored cohort effects on age of initiation. Data were gathered retrospectively between 2009 and 2012 from Detroit area students (n = 5185). Modal age at the last assessment was 17 years. A meta-analytic approach produced age-, year-, and cohort-specific risk estimates of first-time use of controlled medication. Cox regression models examined cohort patterns in age of initiation for medical and nonmedical use with any of 4 classes of controlled medication (opioid analgesics, stimulants, sedatives, or anxiolytics). Peak annual incidence rates were observed at age 16 years, when 11.3% started medical use, and 3.4% started using another person's prescription for a controlled medication (ie, engaged in nonmedical use). In the more recent birth cohort group (1996-2000), 82% of medical users and 76% of nonmedical users reported initiating such use by age 12 years. In contrast, in the less recent birth cohort group (1991-1995), 42% of medical users and 35% of nonmedical users initiated such use by age 12 years. Time to initiation was 2.6 times less in the more recent birth cohort group (medical use: adjusted hazard ratio [aHR] = 2.57 [95% confidence interval {CI} = 2.32-2.85]; nonmedical use: aHR = 2.57 [95% CI = 2.17-3.03]). Peak annual incidence rates were observed at age 16 years for medical and nonmedical use. More recent cohorts reported initiating both types of use at younger ages. Earlier interventions may be needed to prevent adolescent nonmedical use of controlled medication.

Prevalence and correlates of co-ingestion of prescription tranquilizers and other psychoactive substances by U.S. high school seniors: Results from a national survey

IntroductionNonmedical tranquilizer use (NMTU) is a concerning and understudied phenomenon in adolescents, despite being the second most prevalent form of nonmedical use in this population. Thus, this work aimed to examine the sociodemographic and substance use correlates of past-year co-ingestion of a prescription tranquilizer and another substance among adolescents. MethodsData were from the Monitoring the Future study, a nationally representative survey of U.S. high school students. Data from 11,444 seniors (12th graders) completing form 1 of the survey were used. The participants represented a population that was 52.7% female, 61.8% White, and had a modal age of 18. Weighted frequencies and Rao–Scott chi-square analyses were computed to describe the target population and examine associations of interest. ResultsAn estimated 5.3% of the population engaged in past-year NMTU during this time period, with an estimated 72.6% of those users engaged in past-year co-ingestion of a tranquilizer and another substance. Marijuana and alcohol were the most commonly co-ingested substances. Those engaged in co-ingestion were more likely than past-year nonmedical users without co-ingestion to be engaged in other substance or nonmedical use (including past year nonmedical Xanax® (alprazolam) use), have an earlier onset of NMTU, and endorse recreational motives. ConclusionsAdolescent nonmedical tranquilizer users engaged in co-ingestion may be a particularly vulnerable population, with higher rates of other substance use, other nonmedical use and problematic NMTU characteristics than nonmedical users without co-ingestion. Identification of and intervention with adolescent co-ingestion users are important avenues for future research and clinical practice.

Non-medical use of psychoactive drugs in relation to suicide tendencies among Chinese adolescents

IntroductionTo investigate the prevalence of non-medical use of psychoactive prescription drug (NMUPD) among adolescents and to explore the associations between non-medical psychoactive prescription drug use and depressive symptoms, poor sleep quality, deliberate self-harm, and suicide. MethodsA two-stage stratified cluster sample design produced a representative sample of 12–19-year-old students in grades 1–6 who attended public middle schools in Guangdong province. Prevalence estimates (SE) of non-medical psychoactive prescription drug use were calculated, and logistic regression was used to examine its association with depressive symptoms, poor sleep quality, deliberate self-harm, and suicide. ResultsOverall, 7.5% of adolescents reported non-medical use of opioids, and 4.8% of adolescents reported non-medical use of sedatives. Lifetime, last-year, and last-month non-medical use of opioids and sedatives were positively associated with depressive symptoms, poor sleep quality, deliberate self-harm, suicidal ideation, and suicidal attempts among different gender and age-group adolescents. Those who reported last month non-medical use of opioids and sedatives had the greatest odds of reporting depressive symptoms, poor sleep quality, deliberate self-harm, suicidal ideation, and suicidal attempts. Males who were last month non-medical users of opioids or sedative had 8.9 or 10.7 times greater odds of reporting a suicidal attempt, and 8.8 or 9.8 times greater odds of reporting a suicidal attempt were observed among adolescents aged 16–19 who were last-month non-medical users of opioids or sedatives. ConclusionsThese findings provide evidence for improving adolescents' suicide prevention strategy by targeting supervision on high risk current non-medical users of psychoactive drug.

Fatal opioid poisoning: a counterfactual model to estimate the preventive effect of treatment for opioid use disorder in England

A counterfactual model was used to estimate the number of fatal opioid-related poisonings prevented by public treatment services for opioid use disorder (OUD) in England between April 2008 and March 2011. Patient OUD treatment episode data recorded by the English National Drug Treatment Monitoring System were linked to data on opioid deaths recorded by the Office for National Statistics. The source population was the official estimate of non-medical opioid users (aged 15-64 years; approximately 260 000 each year). The target population was all individuals (aged 15-64 years) treated for OUD in the study period (n = 220 665). The outcome measure was fatal opioid-related poisoning (opioid death). The opioid death rate [per 100 person-years (PY)] and mortality rate ratios (MRR) were computed for study year, age group (15-24, 25-34, 35-64 years) and for three treatment-related states: time spent 'prior to treatment', 'during treatment' and 'after treatment'. Between April 2008 and March 2011, there were 3731 opioid deaths in the study: 741 during treatment (0.20 per 100 PY; referent category); 2722 prior to treatment [0.77 per 100 PY; MRR = 3.76, 95% confidence interval (CI) = 3.18-4.44]; and 268 after treatment (0.41 per 100 PY; MRR = 1.99, 95% CI = 1.64-2.41). By counterfactual estimation, national OUD treatment services prevented an average of 880 opioid deaths each year (95% CI = 702-1084). Between April 2008 and March 2011, a counterfactual model shows that the English public treatment system for opioid use disorder prevented an average of 880 deaths each year from opioid-related poisoning. Counterfactual models of mortality prevention can be used for outcome and performance monitoring of substance use disorder treatment systems.

The Misuse of Prescription Opioids: A Threat for Europe?

In the the past two decades the medical use of prescription opioids (POs), in particular oxycodone, increased up to 14-fold in the U.S. and Canada. The high consumption of these pain relievers also led to non-medical use and abuse of these substances which in turn resulted in a dramatic increase in the number of PO related fatalities and opioid dependent subjects. In the U.S. POs became the second most prevalent type of abused drug (4.5 million abusers; 1.7% of the population) after marijuana (8 million abusers) with currently 1.9 million (0.7% of the population) people dependent on opioid pain relievers. Pain relief was the leading motive for non-medical use in about 40% of the cases, but about half of non-medical PO users reported non-pain relief motives only, like to get high or to relax. Since 2011, there is a decline in the use and misuse of POs and reduction in painkiller overdose deaths in the U.S. probably due to the introduction of a variety of restrictive regulations. In Europe, the medical use of POs is increasing as well, but at a much slower rate than in the U.S. Moreover, in Europe non-medical use of POs and fatal PO incidents are (still) rare. The paper highlights and discusses the differences between Europe versus U.S. and Canada in an attempt to assess the risk of a PO abuse and overdose epidemic in Europe. It is concluded that the risk in Europe seems to be rather limited but vigilance is needed.

Dynamic model of nonmedical opioid use trajectories and potential policy interventions

Background: Nonmedical use of pharmaceutical opioid analgesics (POA) increased dramatically over the past two decades and remains a major health problem in the United States, contributing to over 16 000 accidental poisoning deaths in 2010. Objectives: To create a systems-oriented theory/model to explain the historical behaviors of interest, including the various populations of nonmedical opioid users and accidental overdose mortality within those populations. To use the model to explore policy interventions including tamper-resistant drug formulations and strategies for reducing diversion of opioid medicines. Methods: A system dynamics model was constructed to represent the population of people who initiate nonmedical POA usage. The model incorporates use trajectories including development of use disorders, transitions from reliance on informal sharing to paying for drugs, transition from oral administration to tampering to facilitate non-oral routes of administration, and transition to heroin use by some users, as well as movement into and out of the population through quitting and mortality. Empirical support was drawn from national surveys (NSDUH, TEDS, MTF, and ARCOS) and published studies. Results: The model was able to replicate the patterns seen in the historical data for each user population, and the associated overdose deaths. Policy analysis showed that both tamper-resistant formulations and interventions to reduce informal sharing could significantly reduce nonmedical user populations and overdose deaths in the long term, but the modeled effect sizes require additional empirical support. Conclusion: Creating a theory/model that can explain system behaviors at a systems level scale is feasible and facilitates thorough evaluation of policy interventions.

Patterns of concurrent substance use among adolescent nonmedical ADHD stimulant users

ObjectivesThere are growing concerns about nonmedical use of ADHD stimulants among adolescents; yet, little is known whether there exist heterogeneous subgroups among adolescents with nonmedical ADHD stimulant use according to their concurrent substance use. MethodsWe used latent class analysis (LCA) to examine patterns of past-year problematic substance use (meeting any criteria for abuse or dependence) in a sample of 2203 adolescent participants from the National Surveys on Drug Use and Health 2006–2011 who reported past-year nonmedical use of ADHD stimulants. Multivariable latent regression was used to assess the association of socio-demographic characteristics, mental health and behavioral problems with the latent classes. ResultsThe model fit indices favored a four-class model, including a large class with frequent concurrent use of alcohol and marijuana (Alcohol/marijuana class; 41.2%), a second large class with infrequent use of other substances (Low substance class, 36.3%), a third class characterized by more frequent misuse of prescription drugs as well as other substances (Prescription drug+class; 14.8%), and finally a class characterized by problematic use of multiple substances (Multiple substance class; 7.7%). Compared with individuals in Low substance class, those in the other three classes were all more likely to report mental health problems, deviant behaviors and substance abuse service use. ConclusionsAdolescent nonmedical ADHD stimulants users are a heterogeneous group with distinct classes with regard to concurrent substance use, mental health and behavioral problems. The findings have implications for planning of tailored prevention and treatment programs to curb stimulant use for this age group.

Abuse and Diversion of Gabapentin Among Nonmedical Prescription Opioid Users in Appalachian Kentucky

Gabapentin (Neurontin®) is FDA-approved as an adjunctive anti-epileptic for refractory partial seizures and as an analgesic for post-herpetic neuralgia. It is presumed to interact with calcium channels to regulate various neurotransmitter release (1) and is commonly prescribed off-label for other pain syndromes as well as mood and anxiety disorders (2), with few reports of abuse (2–5). However, with decreasing availability of commonly abused prescription opioids, it has been suggested that non-medical users of prescription opioids are substituting other licit (6) and illicit (7) drugs for abuse.

Racial/ethnic differences in trends in heroin use and heroin-related risk behaviors among nonmedical prescription opioid users

BackgroundThis study examines changing patterns of past-year heroin use and heroin-related risk behaviors among individuals with nonmedical use of prescription opioids (NMUPO) by racial/ethnic groups in the United States. MethodsWe used data from the National Survey on Drug Use and Health (NSDUH) from 2002 to 2005 and 2008 to 2011, resulting in a total sample of N=448,597. ResultsPast-year heroin use increased among individuals with NMUPO and increases varied by frequency of past year NMUPO and race/ethnicity. Those with NMUPO in the 2008–2011 period had almost twice the odds of heroin use as those with NMUPO in the 2002–2005 period (OR=1.89, 95%CI: 1.50, 2.39), with higher increases in non-Hispanic (NH) Whites and Hispanics. In 2008–2011, the risk of past year heroin use, ever injecting heroin, past-year heroin abuse or dependence, and the perception of availability of heroin increased as the frequency of NMUPO increased across respondents of all race/ethnicities. ConclusionIndividuals with NMUPO, particularly non-Hispanic Whites, are at high risk of heroin use and heroin-related risk behaviors. These results suggest that frequent nonmedical users of prescription opioids, regardless of race/ethnicity, should be the focus of novel public health efforts to prevent and mitigate the harms of heroin use.

Clearly written, easily comprehended? The readability of websites providing information on epilepsy

There is a general need for high-quality, easily accessible, and comprehensive health-care information on epilepsy to better inform the general population about this highly stigmatized neurological disorder. The aim of this study was to evaluate the health literacy level of eight popular English-written websites that provide information on epilepsy in quantitative terms of readability. Educational epilepsy material on these websites, including 41 Wikipedia articles, were analyzed for their overall level of readability and the corresponding academic grade level needed to comprehend the published texts on the first reading. The Flesch Reading Ease (FRE) was used to assess ease of comprehension while the Gunning Fog Index, Coleman–Liau Index, Flesch–Kincaid Grade Level, Automated Readability Index, and Simple Measure of Gobbledygook scales estimated the corresponding academic grade level needed for comprehension. The average readability of websites yielded results indicative of a difficult-to-fairly-difficult readability level (FRE results: 44.0±8.2), with text readability corresponding to an 11th academic grade level (11.3±1.9). The average FRE score of the Wikipedia articles was indicative of a difficult readability level (25.6±9.5), with the other readability scales yielding results corresponding to a 14th grade level (14.3±1.7). Popular websites providing information on epilepsy, including Wikipedia, often demonstrate a low level of readability. This can be ameliorated by increasing access to clear and concise online information on epilepsy and health in general. Short “basic” summaries targeted to patients and nonmedical users should be added to articles published in specialist websites and Wikipedia to ease readability.

The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction

Public health authorities have described, with growing alarm, an unprecedented increase in morbidity and mortality associated with use of opioid pain relievers (OPRs). Efforts to address the opioid crisis have focused mainly on reducing nonmedical OPR use. Too often overlooked, however, is the need for preventing and treating opioid addiction, which occurs in both medical and nonmedical OPR users. Overprescribing of OPRs has led to a sharp increase in the prevalence of opioid addiction, which in turn has been associated with a rise in overdose deaths and heroin use. A multifaceted public health approach that utilizes primary, secondary, and tertiary opioid addiction prevention strategies is required to effectively reduce opioid-related morbidity and mortality. We describe the scope of this public health crisis, its historical context, contributing factors, and lines of evidence indicating the role of addiction in exacerbating morbidity and mortality, and we provide a framework for interventions to address the epidemic of opioid addiction.

The Prevalence of Common Infectious Diseases among Nonmedical Prescription Opioid Users: Preliminary Findings from the National Prescription Opioid Misuse, Abuse, and Diversion (NOMAD) Study

Background: Little population data exist on the lifetime prevalence of risk-based infectious diseases, both those that are sexually transmitted and blood-borne via needle sharing among persons using prescription opioids for nonmedical purposes, such as those using for euphoria and/or to self-treat medical conditions. Objective: This study examined the lifetime prevalence and characteristics of persons reporting Common Infectious Diseases (CID) related to sexual risk and drug use in a national study of persons engaging in past-year nonmedical prescription opioid use (NMPOU) in the United States. Methods: The Nonmedical Prescription Opioid Misuse, Abuse, and Diversion (NOMAD) study collected selfreported survey assessments via an online questionnaire (ages 18+). Participants were recruited from online advertisements as well as referrals from ongoing research studies of prescription drug abusers in the United States. Participants were asked to self-report prior medically confirmed diagnoses of blood borne infectious diseases like HIV/AIDS, hepatitis (Hep A, Hep B, Hep C), and sexually transmitted infections like Syphilis. Risk behaviors, such as unprotected sex and needle sharing, were ascertained via standardized survey items drafted from the Composite International Diagnostic Interview. Results: Of the 344 past-year nonmedical prescription opioid users, 72.5% reported at least one lifetime CID. The most common were Hep B (18.8%), Hep A (8.9%), and Hep C (8.4%). Over 5% reported an HIV/AIDS diagnosis. The risk of onset for a CID was between 18 and 35, with 80% of the risk of a first STD in this window. Injection practices were associated with CIDs, and in particular Hep C and Hep A. The characteristics significantly associated with a lifetime CID were having bipolar disorder (O.R.=16.3), an opioid use disorder (O.R.=8.3), and a lifetime mood disorder (O.R.=6.83). Jail/prison and drug treatment were associated with a lower risk of disease risk. Most (95.4%) of the infectious diseases onsets prior to initiation of the NMPOU. Conclusion: This study highlights that common infectious diseases, both STDs and injection-based (e.g., Hep- A,B,C) are very common among NMPOUs, though the risk onset is largely in early adulthood prior to the initiation of NMPOU.