Substance Abuse Treatment Admissions Involving Abuse of Pain Relievers: 1998 and 2008

In Brief
The proportion of all substance abuse treatment admissions aged 12 or older that reported any pain reliever abuse increased more than fourfold between 1998 and 2008, from 2.2 to 9.8 percent Increases in percentages of admissions reporting pain reliever abuse cut across age, gender, race/ethnicity, education, employment, and region Among admissions for which medication-assisted opioid therapy was planned, reports of pain reliever abuse more than tripled, from 6.8 percent in 1998 to 26.5 percent in 2008

When used appropriately under medical supervision, hydrocodone (e.g., Vicodin^®), oxycodone (e.g., OxyContin^®), morphine, and similar prescription pain relievers provide indispensable medical benefit by reducing pain and suffering. However, these medications also have the potential to produce dependence or abuse, particularly when they are taken without a physician’s direction and oversight.¹ Nonmedical use of prescription pain relievers is a matter of increasing public health concern. In 2008, among the population of the United States aged 12 or older, nonmedical use of prescription pain relievers was the second most prevalent type of illicit drug use, after marijuana use. The majority of nonmedical users of prescription pain relievers in the past year (55.9 percent) obtained their pain relievers most recently from a friend or relative for free, and another 8.9 percent bought them from a friend or relative.² Increases in pain reliever abuse may place greater demands on the health care system because of adverse consequences such as overdoses. Additional resources may be needed to treat dependence and abuse involving these medications.

The Treatment Episode Data Set (TEDS) collects data on the primary substance of abuse and up to two additional substances of abuse at the time of admission to substance abuse treatment. Using data from the 1998 and 2008 TEDS, this report compares admissions aged 12 or older that reported primary, secondary, or tertiary abuse of prescription pain relievers (hereafter referred to as "any pain reliever abuse") in these 2 years. Prescription pain relievers refer to drugs such as hydrocodone, oxycodone, morphine, and other drugs with morphine-like effects; heroin and nonprescription methadone are excluded.

The proportion of all substance abuse treatment admissions aged 12 or older that reported any pain reliever abuse increased more than fourfold between 1998 and 2008, from 2.2 to 9.8 percent. This increase occurred among both male and female admissions, and admissions in all age groups, racial/ethnic groups, educational levels, and employment categories (Table 1 and Figure 1). Increases were especially pronounced among admissions aged 18 to 34. For admissions aged 18 to 24, 1.5 percent reported pain reliever abuse in 1998 compared with 13.7 percent in 2008. Similarly, the percentage of admissions aged 25 to 34 that reported pain reliever abuse increased from 2.1 to 13.5 percent.

American Indian admissions were about 6 times more likely to have reported pain reliever abuse in 2008 than in 1998 (8.0 vs. 1.3 percent). Reports of pain reliever abuse among non-Hispanic White admissions also increased from 3.2 percent in 1998 to 14.4 percent in 2008.

Pain reliever abuse increased by about the same amount across adult admissions at all educational levels and across admissions in all employment status categories. Specifically, percentages reporting pain reliever abuse more than tripled for admissions aged 18 or older, regardless of educational level. Similarly, admissions in different employment status categories were all about 4 times as likely in 2008 to have reported pain reliever abuse than their counterparts in 1998 were.

Table 1. Percentages of Substance Abuse Treatment Admissions within Selected Demographic Groups That Reported Any Pain Reliever Abuse: 1998 and 2008
Characteristic	Percent Reporting Any Pain Reliever Abuse, 1998	Percent Reporting Any Pain Reliever Abuse, 2008
Total Admissions	2.2%	9.8%
Gender
Male	1.8%	8.1%
Female	3.5%	13.3%
Race/Ethnicity
White, Non-Hispanic	3.2%	14.4%
Black, Non-Hispanic	0.8%	2.0%
Hispanic	0.8%	3.1%
American Indian	1.3%	8.0%
Asian or Pacific Islander	3.6%	5.2%
Other	2.0%	6.1%
Highest Grade (Aged 18 or Older)
0 to 8	1.9%	9.7%
9 to 11	1.7%	8.3%
12 (or GED)	2.3%	10.2%
More than 12	3.8%	12.1%
Employment Status (Aged 16 or Older)
Employed	2.1%	9.2%
Full Time	2.1%	9.0%
Part Time	2.1%	9.7%
Unemployed	2.7%	11.1%
Not in Labor Force	2.3%	9.2%
Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

Figure 1. Percentages of Substance Abuse Treatment Admissions within Specific Age Groups That Reported Any Pain Reliever Abuse: 1998 and 2008

Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

Figure 1 Table. Percentages of Substance Abuse Treatment Admissions within Specific Age Groups That Reported Any Pain Reliever Abuse: 1998 and 2008
Age Groups	1998	2008
Total Admissions	2.2%	9.8%
12 to 17 Years	0.6%	5.2%
18 to 24 Years	1.5%	13.7%
25 to 34 Years	2.1%	13.5%
35 to 44 Years	2.9%	7.6%
45 to 54 Years	3.1%	6.4%
55 to 64 Years	1.9%	6.1%
65 Years or Older	2.0%	3.9%
Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

Percentages of admissions for pain reliever abuse approximately quadrupled in all regions except the West, which had a smaller increase. Between 1998 and 2008, the proportions increased from 2.2 to 11.2 percent in the Northeast, from 2.1 to 8.2 percent in the Midwest, and from 3.0 to 13.9 percent in the South. For admissions in the West, 1.9 percent reported pain reliever abuse in 1998 compared with 6.1 percent in 2008.

Reports of pain reliever abuse increased both for admissions with no prior treatment episodes and for those that had been in treatment at least once before (Table 2). Among admissions with no prior treatment episodes, the proportion that reported pain reliever abuse increased more than fivefold, from 1.7 percent in 1998 to 8.8 percent in 2008. Admissions in 2008 that reported one or more prior treatment episodes were nearly 4 times more likely than their counterparts in 1998 to have reported pain reliever abuse (11.0 vs. 2.8 percent).

Similarly, the percentage of admissions for pain reliever abuse increased for all sources of referral to substance abuse treatment (Table 2). Among individual or self-referrals and referrals from alcohol or drug abuse care providers or other health care providers, about 3 percent in 1998 reported pain reliever abuse compared with more than 12 percent of admissions from these referral sources in 2008.

Table 2. Percentages of Substance Abuse Treatment Admissions within Selected Treatment Groups That Reported Any Pain Reliever Abuse: 1998 and 2008
	Percent Reporting Any Pain Reliever Abuse, 1998	Percent Reporting Any Pain Reliever Abuse, 2008
Prior Treatment Admissions
None	1.7%	8.8%
One or More	2.8%	11.0%
Referral Source
Individual/Self	3.1%	14.0%
Criminal Justice	1.1%	5.5%
Alcohol/Drug Abuse Care Provider	2.8%	13.5%
Other Health Care Provider	3.3%	12.5%
School (Educational)	0.6%	3.6%
Employer/Employee Assistance Program	2.1%	8.9%
Other Community Referral	1.9%	7.7%
Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

Medications currently used to treat addiction to prescription pain relievers or opiates such as heroin include methadone and buprenorphine.³ Buprenorphine has been approved in the United States for treatment of opiate addiction since 2002. In 1998, 6.8 percent of admissions with planned medication-assisted opioid therapy (i.e., methadone but not buprenorphine) reported pain reliever abuse (Figure 2). After the approval of buprenorphine in 2002 for medication-assisted opioid therapy, the proportion of admissions with planned medication-assisted opioid therapy in 2008 more than tripled to 26.5 percent.

Figure 2. Percentages of Substance Abuse Treatment Admissions for Whom Medication-assisted Opioid Therapy Was/Was Not Planned That Reported Any Pain Reliever Abuse: 1998 and 2008

Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

Figure 2 Table. Percentages of Substance Abuse Treatment Admissions for Whom Medication-assisted Opioid Therapy Was/Was Not Planned That Reported Any Pain Reliever Abuse: 1998 and 2008
Medication-assisted Opioid Therapy	1998	2008
Planned Medication-assisted Opioid Therapy	6.8%	26.5%
No Planned Medication-assisted Opioid Therapy	1.9%	8.6%
Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

In addition, substance use disorders in adults are often associated with psychiatric disorders such as serious mental illness or major depressive episode.⁴ Among admissions with an identified co-occurring psychiatric disorder, 3.4 percent reported pain reliever abuse in 1998 compared with 14.4 percent in 2008 (Figure 3).⁵

Figure 3. Percentages of Substance Abuse Treatment Admissions for Whom a Co-occurring Psychiatric Disorder Was/Was Not Identified That Reported Any Pain Reliever Abuse: 1998 and 2008

Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

Figure 3 Table. Percentages of Substance Abuse Treatment Admissions for Whom a Co-occurring Psychiatric Disorder Was/Was Not Identified That Reported Any Pain Reliever Abuse: 1998 and 2008
Co-occurring Psychiatric Disorder	1998	2008
Co-occurring Psychiatric Disorder	3.4%	14.4%
No Co-occurring Psychiatric Disorder	2.2%	8.3%
Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008.

Increases in the percentage of admissions reporting prescription pain reliever abuse in the United States underscore the public health importance of the misuse of pain relievers in several respects. First, the increases from 1998 to 2008 were widespread, cutting across admissions by age, gender, race/ethnicity, education, employment, and region. Therefore, successful efforts to prevent pain reliever misuse and to treat addiction to pain relievers need to cover a wide range of populations and need to be tailored appropriately to these different populations. Second, the increase in admissions aged 18 to 34 has important implications for families and the labor force, because these are formative years for family growth and career choices. Early identification of pain reliever abuse, outreach to abusers, and provision of appropriate and effective treatment services, including relapse prevention, will be important for helping abusers of prescription pain relievers—and especially those in younger age groups— make long-term productive contributions to society. Finally, education is needed to counter any misconceptions that abusers of prescription pain relievers have about the risks involved in abusing these drugs. Physicians may wish to provide additional education to patients about the potential for abuse and diversion of these medications and emphasize correct dosages, safe storage and proper disposal.

¹ National Institute on Drug Abuse. (2009, July). NIDA InfoFacts: Prescription and over-the-counter medications. Retrieved on February 25, 2010, from http://www.drugabuse.gov/infofacts/PainMed.html

² Office of Applied Studies. (2009). Results from the 2008 National Survey on Drug Use and Health: National findings (NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD: Substance Abuse and Mental Health Services Administration.
³ National Institute on Drug Abuse. (2009, July). NIDA InfoFacts: Prescription and over-the-counter medications. Retrieved on February 25, 2010, from http://www.drugabuse.gov/infofacts/PainMed.html

⁴ Office of Applied Studies. (2009). Results from the 2008 National Survey on Drug Use and Health: National findings (NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD: Substance Abuse and Mental Health Services Administration.
⁵ Psychiatric problem in addition to alcohol or drug problem is a Supplemental Data Set item. The 18 States and jurisdictions in which it was reported for at least 75 percent of all admissions in 1998 and 2008—CA, CO, DE, FL, ID, IA, KS, KY, LA, ME, MD, MO, MS, ND, OK, RI, SC, and TN—accounted for 32.5 percent of all substance abuse treatment admissions aged 12 or older in 1998 and 32.3 percent of admissions in 2008.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (July 15, 2010). The TEDS Report: Substance Abuse Treatment Admissions Involving Abuse of Pain Relievers: 1998 and 2008. Rockville, MD.