An Epidemiologic Overview of Prescription Drug Misuse

Howard D. ChilcoatTracy Dusablon

Department of Mental HygieneJohns Hopkins University

School of Hygiene and Public Health

Extramedical Use

Used drug when it was not prescribed for you, or that you took only for the experience or feeling that it caused

Classes of drugs

Analgesics (e.g., Codiene) Tranquilizers (e.g., Valium) Sedatives (e.g., Seconal) Stimulants (e.g.,

amphetamines)

Data Sources

National Household Survey on Drug Abuse (NHSDA), 1985 – 1998

(Age 12+, n = 5,000 – 20,000+)

National Comorbidity Study (NCS)Diagnostic criteria for major

psychiatric disorders (DSM-IIIR)(Age 15 – 54, n = 8,098)

Reported Lifetime and Past Year Use of Prescription Drugs,

NHSDA 1998

0123456789

10

Sedatives Tranquilizers Stimulants Analgesics Any Rx Drug

Prescription Drug

Per

cent

Past YearLifetime

Past Year Use of Prescription Drugs by Sex, NHSDA, 1998

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Sedatives Stimulants Tranquilizers Analgesics Any Rx Drug

Prescription Drug

Per

cent

MaleFemale

Reported Use of Analgesics in Past Year (By Sex)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

1985 1988 1990 1991 1992 1993 1995 1996 1997 1998 1999Year

Per

cent

Male

Female

Reported Use of Tranquilizers in Past Year (By Sex)

0.00.51.01.52.02.53.03.54.04.55.0

1985 1988 1990 1991 1992 1993 1995 1996 1997 1998 1999Year

Per

cent Male

Female

Reported Use of Sedatives in Past Year (By Sex)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

1985 1988 1990 1991 1992 1993 1995 1996 1997 1998 1999Year

Per

cent

Male

Female

Reported Use of Stimulants in Past Year (By Sex)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

1985 1988 1990 1991 1992 1993 1995 1996 1997 1998 1999Year

Per

cent

Male

Female

Reported Use of Analgesics in Past Year (Male)

0123456789

1985 1988 1990 1991 1992 1993 1995 1996 1997 1998 1999Year

Per

cent

12-17 18-25

26-34 35+

Reported Use of Analgesics in Past Year (Female)

0

1

2

3

4

5

6

7

8

1985 1988 1990 1991 1992 1993 1995 1996 1997 1998 1999Year

Per

cent

12-17

18-25

26-34

35+

Reported Past Year Use of Prescription Drugs , Ages 60+

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1982 1985 1988 1990 1991 1992 1993 1995 1996 1997 1998Year

Per

cent

Sedatives

Stimulants

Tranquilizers

Analgesics

20 40 60 80Age

0.0

00

.01

0.0

20

.03

0.0

40

.05

Pre

va

len

ce

MalesFemales

Prevalence of Extramedical Analgesic Use in the Past Year

(1998)

20 40 60 80Age

0.0

00

0.0

05

0.0

10

0.0

15

0.0

20

Prevale

nce Males

Females

Prevalence of Extramedical Tranquilizer Use in the Past Year

(1998)

20 40 60 80Age

0.0

00

0.0

02

0.0

04

0.0

06

Pre

va

len

ce Males

Females

Prevalence of Extramedical Sedative Use in the Past Year

(1998)

20 40 60 80Age

0.0

00

0.0

05

0.0

10

0.0

15

0.0

20

Prevale

nce

MalesFemales

Prevalence of Extramedical Stimulants in the Past Year

(1998)

20 40 60 80Age

0.0

00

.010

.020

.030

.040

.050

.06

Pre

va

len

ce

WhitesBlacksHispanics

Prevalence of Extramedical Analgesic Use in the Past

Year

• 0 • 20 • 40 • 60 • 80• Age

•0

.00

•0

.02

•0

.04

•0

.06

•0

.08

•0

.10

•0

.12

•In

cid

ence

• Males• Females

Cumulative Incidence of Analgesic Use

• 20 • 40 • 60• Ag

e

•0

.00

•0

.02

•0

.04

•0

.06

•In

cid

ence

• Males• Females

Cumulative Incidence of Tranquilizer Use

• 20 • 40 • 60• Age

•0.00

•0.01

•0.02

•0.03

•0.04

•In

cid

ence

• Males

• Females

Cumulative Incidence of Sedative Use

• 20 • 40 • 60• Age

•0.00

•0.02

•0.04

•0.06

•In

ciden

ce

• Males• Females

Cumulative Incidence of Stimulant Use

Lifetime Prevalence of Extramedical Analgesic Use

Analgesic Percent

Codeine 2.05

Darvon 0.58

Demerol 0.77

Morphine 0.57

Percodan 0.89

Tylenol w/Codeine 2.74

Lifetime Prevalence of Extramedical Analgesic Use by Sex

SexAnalgesic % Male % Female

Codeine 2.66 1.57Darvon 0.64 0.53Demerol 0.93 0.64Morphine 0.80 0.39Percodan 1.08 0.74Tylenol w/Codeine 2.85 2.65

Lifetime Prevalence of Extramedical Analgesic Use by Age Group

Age Group

Analgesic12-17

%18-25

%26-34

% 35+

%Codeine 1.21 2.98 2.09 1.85Darvon 0.07 0.44 0.71 1.15Demerol 0.46 1.08 0.77 0.74Morphine 0.59 0.70 0.33 0.58Percodan 0.12 1.05 1.34 1.18Tylenol w/Codeine 1.89 3.40 3.42 2.43

Lifetime Prevalence of Extramedical Analgesic Use by Race

Race

AnalgesicWhite

%Black

%Hispani

c%

Other%

Codeine 3.10 1.13 1.10 1.52Darvon 0.86 0.45 0.25 0.34Demerol 1.17 0.40 0.44 0.51Morphine 0.81 0.45 0.31 0.34Percodan 1.49 0.43 0.31 0.51Tylenol w/Codeine 3.71 1.89 1.74 3.13

Lifetime Prevalence of Extramedical Analgesic Use by Family Income

Analgesic

Family Income Category<$20,00

0

%

$20,000 to $49,000

%

$50,000 +

%

Codeine 1.28 2.02 2.15Darvon 0.41 0.53 0.64Demerol 0.67 0.69 0.73Morphine 0.44 0.62 0.53Percodan 0.56 0.75 1.01Tylenol w/Codeine 2.10 2.80 2.67

Prevalence of Extramedical Analgesic Use, Recent Users ( 2 Years or Less)

Analgesic Percent

Codeine 31.48

Darvon 1.94

Demerol 10.90

Morphine 7.75

Percodan 6.05

Tylenol w/Codeine 41.65

Reported Lifetime and Past Year Dependence of Prescription Drugs, NCS

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Sedatives Anlagesics Tranquilizers Stimulants Any Rx Drug

Prescription Drug

Per

cent

Past YearLifetime

Past Year Dependence of Prescription Drugs by Sex, NCS

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Sedatives Analgesics Tranquilizers Stimulants Any Rx Drug

Prescription Drug

Per

cent

MaleFemale

Rx Drug Dependence : Lifetime Comorbidity with Psychiatric

Disorders

Rx Dependence Present (%)

n = 250

Rx Dependence Absent (%) n = 7848

Adjusted OR

(95% CI)

Depression 39.2 16.4 2.2 (1.7 – 3.0) Agoraphobia 19.9 6.1 2.5 (1.5 – 4.2) Simple Phobia 26.9 11.3 1.7 (1.2 – 2.5) Social Phobia 25.2 12.0 1.5 (0.9 – 2.4) Panic Attack 33.0 6.5 4.9 (3.3 – 7.4) Antisoc. Personality Disorder

26.0 2.4 12.4 (8.0 – 9.2)

Lifetime Cocaine Dependence

29.4 2.4 12.6 (7.9 – 20.0)

Cocaine Dependence: Lifetime Comorbidity with Psychiatric

Disorders

Cocaine Dependence Present (%)

n = 264

Cocaine Dependence Absent (%) n = 7834

Adjusted OR

(95% CI)

Depression 31.9 16.6 1.9 (1.4 – 2.6) Agoraphobia 11.1 6.4 1.5 (0.8 – 2.7) Simple Phobia 21.0 11.5 1.5 (1.0 – 2.4) Social Phobia 24.7 12.0 1.7 (1.1 – 2.6) Panic Attack 13.5 7.1 1.7 (1.1 – 2.5) Antisoc. Personality Disorder

26.0 2.3 8.6 (4.9 – 14.9)

Extramedical Analgesic Dependence : Lifetime Comorbidity with Psychiatric

Disorders

Analgesic Dependence Present (%)

n = 68

Analgesic Dependence Absent (%) n = 8030

Adjusted OR

(95% CI)

Depression 43.8 16.9 2.63 (1.36 – 5.08) Agoraphobia 17.9 6.4 2.25 (0.82 – 6.13) Simple Phobia 30.0 11.7 2.13 (1.07 – 4.22) Social Phobia 28.3 12.3 1.82 (0.71 – 4.67) Panic Attack 29.5 7.1 3.88 (1.88 – 8.01) Antisoc. Personality Disorder

36.8 2.9 15.14 (6.99 – 32.79)

Lifetime Cocaine Dependence

39.7 3.0 16.53 (8.82 – 30.97)

20 30 40 50Age

0.0

00

0.0

02

0.0

04

0.0

06

0.0

08

0.0

10

0.0

12

Inc

ide

nc

e

Analgesic Dependence - Entire Sample

Males

Females

20 30 40 50Age

0.0

00

.02

0.0

40

.06

0.0

80

.10

0.1

2

Inc

ide

nc

e

Analgesic Dependence - Users only

MalesFemales

Cumulative Probability of Analgesic Dependence

Odds Ratios & 95% CI for Analgesic Dependence, Given Use

Separate model for each psychiatric

disorder

Model containing Conduct Disorder and

Depression

OR* 95% CI OR* 95% CI

Female 1.20 .66 – 2.16 1.49 .80 – 2.79

Conduct Disorder 3.11 1.68 – 5.75 3.02 1.63 – 5.62

Antisocial Personality 5.10 2.64 – 9.83

Depression 1.56 .87 – 2.82 1.45 .80 – 2.64

* Adjusted for age, race, education

Testing Causal Pathways between PTSD and Substance

Use Disorders

Howard D. ChilcoatNaomi Breslau

Archives of General Psychiatry1998

Traumatic Event

PTSD

Drug A/D

Drug A/D

Potential Pathways

PTSD

Rx Drug A/D

Potential Pathways

Relative Risk = 16.9

Prevalence of Drug A/D by lifetime history of PTSD

No PTSD PTSD

Any Drug A/D 11.9% 29.1%

Marijuana A/D 9.1% 14.5%

Cocaine A/D 3.9% 8.6%

Prescribed A/D 0.6% 9.4%

Relative hazards (95% CI) of specified drug use disorder by prior exposure to

traumatic events and PTSD

Traumatic event,no PTSD PTSD

Any drug A/D 1.3 (0.8 - 2.0) 4.5 (2.6 - 7.6)

Marijuana A/D 1.6 (0.9 - 2.6) 1.8 (0.6 - 4.9)

Cocaine A/D 0.8 (0.4 - 1.8) 1.6 (0.6 - 4.7)

PrescribedDrug A/D

1.2 (0.3 - 6.2) 16.9 (4.5 - 63.6)

All estimates adjusted for sex, race, and educationReference category = never exposed to traumatic event

Findings

Prevalence (past year) of use of Rx drugs is comparable to that of cocaine – analgesics most commonly misused

Ages 18 – 25 years highest period of risk for use and onset of Rx drugs and analgesics

Girls 12-17 years old might be particularly vulnerable

Relative to other drugs, sex differences are small, emerge after age 20 years

Whites and higher income more likely to use Rx drugs (analgesics) than other race/ethinicities

Findings (cont’d)

• High level of comorbidity with other psychiatric disorders

• Strong relationship with antisocial personality disorder, cocaine dependence

• Lifetime prevalence of Rx drug dependence similar to that for cocaine

Future Research Directions

Epidemiology of Rx drug misuse remains relatively unexplored

Focus on Rx drug use by girls and young women

Rx misuse in the elderly Causal relationships between RX

drug misuse and other psychiatric disorders