Association between non-medical and prescriptive usage of opioids
Introduction
While the use of opioids in the treatment of pain is recognized as one of the mainstays of pain management, their utilization has always been tempered with concerns about abuse, addiction, and diversion of medicinal supplies into illicit channels of trade (American Academy of Pain Medicine and American Pain Society, 1997; Federation of State Medical Boards of the United States, 1998). The cultivation, manufacture, distribution, and dispensing of opioids are subject to international control, with the intent of assuring access for legitimate medical and scientific purposes while minimizing diversion and abuse (Single Convention on Narcotic Drugs, 1961). The international obligations continue to influence national control programs. There are significant differences among nations both with respect to utilization of abusable pharmaceuticals and the degree of concern over diversion of such drugs to illicit use (Costa e Silva, 2002).
The United States reports one of the highest levels of per capita consumption of opioids for legitimate purposes in the world (United Nations, 2004). The United States also has a high level of public concern with the non-medical use and abuse of prescription and illicit drugs. While this paper addresses non-medical use of prescription opioids in the United States, it is hoped that the experience in the United States may serve to inform policy in many countries which will need to address this issue as international efforts to expand access to treatment continue.
Non-medical use of prescription drugs, drug abuse, and addiction are complex and covert disorders and none of the world's nations can be certain of the exact prevalence of drug abuse within its borders. On a national level, the United States government has tried to address this problem through federally sponsored information sources intended to provide data on the prevalence of non-medical use of pain relievers and other pharmaceuticals subject to abuse and the health consequences of such abuse. These databases include the National Survey on Drug Use and Health (NSDUH), which provides prevalence data based on a population survey, and the Drug Abuse Warning Network (DAWN), which provides information on the extent of drug abuse-related harm, as suggested by emergency department admissions due to non-medical use of prescription and illicit drugs. These surveys consistently suggest a significant increase in both the prevalence and adverse consequences of prescription opioid abuse and diversion in the United States since the early to mid 1990s (SAMHSA, 2002a, SAMHSA, 2002b, SAMHSA, 2003a, SAMHSA, 2003b).
Unlike illicit drugs, there are reliable estimates of the amounts of prescription drugs available for legitimate and illicit uses. Data on prescription sales have been used as a tool for exploring abuse of prescription opioids (Joranson et al., 2000, Zacny et al., 2003, Gilson et al., 2004, Novak et al., 2004). These data have been used in conjunction with data from DAWN as an indicator of non-medical use (Zacny et al., 2003, Novak et al., 2004). This paper builds on this previous work by expanding the concept that abuse of prescription opioids is a predictable consequence of the amount of prescriptive use of any given opioid. It further explores the types of relationships initiated by others (Joranson et al., 2000, Zacny et al., 2003, Gilson et al., 2004, Novak et al., 2004), by testing the fundamental relationships between non-medical use, potency, and level of prescriptive use for opioids in the outpatient treatment of pain.
Section snippets
National data on drug abuse
DAWN is an annual report of a nationally representative, geographically weighted sample of emergency department (ED) visits (“episodes” in DAWN terms) related to intentional non-medical use where the patient's reason for using the substance(s) was dependence, suicide attempt or gesture, or psychic effects (recreational use). These data provide an annual estimate of the medical consequences of drug abuse for the 48 coterminous United States. The data are reported at the level of drug substance
Relationship between DAWN ED mentions and kilogram usage
Previous work provides evidence that for the years 1997 through 2002, there was a positive relationship between the amount of opioid in prescriptive use, expressed in terms of prescriptions, and the DAWN ED mentions for that opioid in any given year (Zacny et al., 2003, Gilson et al., 2004, Novak et al., 2004). To further explore this relationship, the kilogram amounts of the major opioids in prescriptive use in the United States were collected from 1994 to 2002 (Table 1).
Examination of the
Discussion
The remarkably similar rates of DAWN events per morphine equivalent for the various opioids suggest that the morbidity associated with non-medical use is fairly constant for the major prescription opioids. The stability of the rates over time suggest that during this period the “closed” system of narcotic control functioned at about the same level of efficiency, leaking a relatively constant fraction of the prescribed medicines to the illicit market. In the presence of a fixed percentage of
Acknowledgements
This investigation was entirely supported by Purdue Pharma L.P. using data from IMS Health (cited with permission) and Substance Abuse and Mental Health Services Administration.
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