This study found that approximately 17.6% of U.S. high school seniors report medical use of prescription opioids at least once in their lifetime, while 12.9% of high school seniors report nonmedical use of prescription opioids (NMUPO). Nearly one in every four U.S. high school seniors has had some lifetime exposure to prescription opioids either medically or nonmedically. These prevalence rates are lower than smaller regional-based studies of secondary school students and national studies of adolescents.11,12,17
For example, a study conducted in the Detroit metropolitan area found that 48.9% of high school students reported lifetime medical use of prescription opioids while 20.9% reported lifetime NMUPO.12
Recent evidence indicates that the prevalence of medical and nonmedical use of controlled medications can vary according to geographical location.2,11,12,17
Based on the differences in findings between regional and national studies, it remains critical to monitor medical use and NMUPO at the local, regional, and national levels. These findings serve as a reminder that individual communities should not rely solely on national findings to inform best practices for their local youth. Instead, health professionals and researchers should be encouraged to collect data to learn more about drug use behaviors of local youth and use national findings to benchmark results.
An important contribution of this study was the racial/ethnic differences found with respect to medical use and NMUPO. Although the results of this study indicated that White students were significantly more likely than African-American and Hispanic students to report medical use and NMUPO, previous studies found no such racial/ethnic differences.11,12,17
In this national study, racial/ethnic differences found in NMUPO may be influenced by the racial/ethnic differences in medical availability, especially since between 33% and 40% of high school seniors who reported NMUPO in the past 12 months obtained these medications from their own previous prescription for opioids.8
Furthermore, peers serve as the leading source of diversion for NMUPO among adolescents, which could have contributed to the racial/ethnic differences found in this study.8,10,11
Previous work has documented barriers for receiving prescription opioids among racial minority patients.18-20
For example, pharmacies in minority zip codes (at least 70% minority residents) were 52 times less likely to carry sufficient opioid analgesics than pharmacies in white zip codes (at least 70% white residents) regardless of income.18
Thus, the racial/ethnic differences in medical use and NMUPO observed in this study could be related to the lack of adequate treatment, insufficient availability, diversion, over-prescribing among White populations, and/or under-prescribing among non-White populations.
Although the results of this study found no gender differences in medical use and NMUPO, previous regionally-based studies have found female youth were significantly more likely than male youth to report lifetime medical use and NMUPO.11,12
At least one other national study found no significant gender differences in lifetime NMUPO among individuals 12 to 17 years of age in 2009; 10.0% of girls and 9.3% of boys reported lifetime NMUPO.17
The differences found between national and regional-based studies could be partially attributed to a multitude of variation between studies including but not limited to differences in age of respondents, geographical location, school type (e.g., size and public vs. private), mode of data collection, questionnaire wording, response rate, and consent process.
Another important contribution of this study was that substance use behaviors were more prevalent among individuals who reported any history of NMUPO while those who reported medical use only were not at increased risk for substance use compared to non-users. These findings, along with results from three earlier smaller studies, should provide some reassurance to clinicians that prescription opioids can be safely prescribed to adolescents.11,12,21
A novel finding of this study was that individuals who have a history of NMUPO before they initiate medical use of prescription opioids have elevated rates of substance use behaviors and prescription opioid abuse. There was also compelling evidence that different prescription opioid use histories are associated with different motives for NMUPO. Clearly, prescribers are encouraged to screen patients for potential substance abuse problems, including NMUPO, using a brief screening instrument when assessing the risk for abusing and diverting controlled medications such as prescription opioids. Notably, we found that 80% of nonmedical users with an earlier history of medical use had used prescription opioids from a prescription they had previously. This finding suggests that the quantity of prescription opioids and/or limiting refills should be carefully considered by prescribers and closely monitored to reduce subsequent NMUPO of leftover opioid medication. Prescribers need to be aware that approximately one in eight high school seniors reported NMUPO at least once in their lifetime. Individuals with a legitimate need for opioid analgesics who have a history of NMUPO should not be denied the medication. Instead, careful prescribing, close monitoring and consultation with an addictionologist should be considered for such individuals.
Study strengths and limitations
This study has noteworthy strengths, including a large national sample of high school seniors. Further, this study represents the first attempt to assess the medical use and NMUPO nationally among adolescents. Despite these strengths, there were also limitations that should be considered. First, since the present study consists of secondary analyses, the survey items in the MTF limited what variables could be examined. Furthermore, the MTF study design and measurement differs from other studies and these differences could explain the lower rates of medical use and NMUPO in the MTF relative to other studies.11,12,17
Second, the results cannot be generalized to all adolescents because this sample only included high school seniors and did not include individuals who had dropped out of school or were not present in school on the day of survey administration. Third, the data are subject to potential bias introduced when assessing sensitive behaviors via self-report surveys administered in a school setting. Finally, the cross-sectional nature of the study presented some limitations; longitudinal studies are needed to examine patterns of medical use and NMUPO.
In conclusion, we found that nearly one in every four high school seniors in the U.S. had some lifetime exposure to prescription opioids either medically or nonmedically. Based on the increased risk of substance abuse associated with NMUPO, it appears critical to assess a patient's history of prescription opioid use. One of our findings should be treated very seriously by prescribers of opioids; we found that 80% of nonmedical users with an earlier opioid prescription admitted to using their prescribed opioids nonmedically, presumably because there were pills leftover. Indeed, this study indicates that the quantity of prescription opioids and number of refills prescribed to adolescents should be carefully considered and closely monitored to reduce subsequent nonmedical use of leftover medication.