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February 2004, Vol 94, No. 2 | American Journal of Public Health 266-268
© 2004 American Public Health Association

RESEARCH AND PRACTICE

Risk Factors Associated With Problem Use of Prescription Drugs

Linda Simoni-Wastila, PhD and Gail Strickler, MS

Linda Simoni-Wastila is with the Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore. Gail Strickler is with the Schneider Institute for Health Policy, Heller Graduate School, Brandeis University, Waltham, Mass.

Correspondence: Requests for reprints should be sent to Linda Simoni-Wastila, PhD, University of Maryland, School of Pharmacy, Department of Pharmaceutical Health Services Research, 515 W Lombard St, Rm 275, Baltimore, MD 21201 (e-mail: lsimoniw{at}rx.umaryland.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

We estimate the prevalence of and risk factors for the problem use of prescription drugs, overall and by therapeutic class. Applying logistic regression analysis to data from the National Household Survey on Drug Abuse,1 we found that nearly 1.3 million Americans aged 12 years and older experience problem use of prescription drugs signifying physiological dependence or heavy daily use. Those at greatest risk include older adults, females, those in poor/fair health, and daily alcohol drinkers.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Recent data document that 10 million individuals, or 7% of the US population, reported nonmedical use of prescription drugs in 1999.1 Nonmedical prescription drug use, which encompasses drug taking behaviors ranging from noncompliance to recreational use to abuse, does not adequately measure problem use of prescription drugs requiring treatment intervention.2,3 Using data from the National Household Survey on Drug Abuse (NHSDA),1 we estimate the prevalence of problem use of prescription drugs and elicit risk factors for such use.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
The NHSDA, the premier data source on the prevalence of substance use,4–6 is a multistage area probability sample survey of households representative of the noninstitutionalized US population aged 12 years and older. To obtain sufficient sample size, we used NHSDA data from 1991 through 1993 to construct a sample of 4049 respondents reporting any NHSDA-defined4–6 past-year nonmedical prescription drug use.

Nonmedical prescription drug users were designated problem users if they met criteria for dependency/heavy use. Dependency required meeting 2 of 5 criteria: (1) inability to cut down; (2) getting less work done; (3) using substance in past month and being depressed, argumentative, anxious, or upset, feeling isolated, and/or having health problems and/or difficulty thinking clearly; (4) needing larger amounts; or (5) experiencing withdrawal symptoms.7,8 As defined in the NHSDA, heavy use is daily nonmedical use of 1 or more prescription drugs for at least 2 weeks in the past year.4–6

Explanatory variable selection was guided by earlier studies9–11 and literature review12–23 of the medical and nonmedical use of abusable prescription drugs. Covariates incorporated on this basis include race, age, gender, marital status, urbanicity, education, work status, health insurance, income, and general health status. Daily alcohol use and past-year use of illicit drugs controlled for polysubstance use.

Multivariate logistic regression analysis was used to model the probability of problem use of any prescription drug, as well as of narcotic analgesics, minor tranquilizers, stimulants, and sedative-hypnotics. Analyses were conducted with SAS (SAS Institute, Inc, Cary, NC) and SUDAAN (Research Triangle Institute, Research Triangle Park, NC) to adjust for the clustering inherent in the NHSDA.24,25 To account for the stratified sampling design of the NHSDA, prevalence and logistic estimates were weighted to provide nationally representative demographic and use patterns.24,25


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Annually, more than 8.2 million individuals, or 4% of the US population, reported any past-year nonmedical use of prescription drugs (Table 1Go). Of these, 1.3 million individuals (15.5%) were categorized as problem users of prescription drugs. Being female, being in poor/fair health, and drinking alcohol daily are potential risk factors for problem use of any prescription drug, whereas young age (< 25 y) and full-time employment appear to protect against problem use (Table 2Go).


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  		TABLE 1—— Annualized Population Estimates of Past-Year Nonmedical and Problem Prescription Drug Use
 

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  		TABLE 2—— Probability of Prescription Drug Problem Use Overall and by Therapeutic Class
 
Analysis by therapeutic class revealed that being female, unmarried, and age 35 years and older increase the odds of problem use of narcotic analgesics (Table 2Go). Factors predictive of problem use of tranquilizers include female gender, White race, high school completion, poor/fair health, and daily drinking. For sedative-hypnotics, poor health increased the likelihood of problem use, and income less than $40 000 reduced it. Past-year illicit drug use reduced the odds of problem use of all 3 classes. No variables reached statistical significance in predicting problem use of stimulants.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
Problem use of prescription drugs is not insignificant—nearly 1.3 million US citizens report problem use of prescription drugs each year. In addition to nonmedical use, factors associated with problem use include older age, female gender, poor/fair health status, and daily drinking. Other factors, including marital status, education, employment status, and income, are uniquely associated with individual therapeutic classes. Because many of these factors also predict nonmedical prescription drug use,9,11,15 they may be useful in identifying individuals at risk for problem use. Finally, although other studies have linked nonmedical drug use to illicit drug use,9,11,26–29 our findings suggest that problem use of narcotics, sedative-hypnotics, and minor tranquilizers occurs in the absence of illicit drug taking. This may reflect differences in individuals reporting a primary problem of prescription drug use needing treatment versus polysubstance users who nonmedically use prescription drugs as adjuncts to illicit drug use.

Although recent NHSDA reports document the relative stability of nonmedical drug use over time,1,30 further analysis using current data is needed to corroborate the prevalence of problem use of prescription drugs. Also, these findings are likely conservative estimates due to underreporting associated with the NHSDA and other self-report data.31,32 Finally, definitions of nonmedical use, dependency, heavy use, and problem use, although used elsewhere,7 require further validation and refinement.

Despite these limitations, this study is the first to estimate the prevalence of problem use of prescription drugs potentially requiring treatment and associated risk factors. Further studies are needed to explore alcohol and drug use patterns and risk factors among polysubstance users. Research also is required to provide an improved understanding of the continuum comprising medical exposure, nonmedical use, and problem use of prescription drugs with addiction potential.


   Acknowledgments
 
We gratefully acknowledge the National Institute on Drug Abuse for its generous financial support (R29 DA09886). Grant Ritter, PhD, of the Schneider Institute for Health Policy at Brandeis University provided invaluable statistical and analytic guidance.

Human Participant Protection
The Brandeis University institutional review board exempted this research from human subjects review because it employs public-use secondary data.


   Footnotes
 
Contributors
L. Simoni-Wastila designed the study, developed the analytic plan, supervised the data analysis, and wrote the brief. G. Strickler conducted all programming and contributed to writing the brief.

Peer Reviewed

Accepted for publication February 27, 2003.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Substance Abuse and Mental Health Services Administration. Summary of Findings from the 1999 National Household Survey on Drug Abuse. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; August 2000. DHHS publication (SMA) 00-3466.

2. Gilman GA, Rall TW, Nies AS, Taylor P, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 8th ed. Elmsford, NY: Pergamon Press; 1990.

3. Wesson DR, Smith DE, Ling W, Seymour RB. Sedative-hypnotics and tricyclics. In: Lowinson, JH, Runiz P, Millman LB, Langrod JG, eds. Substance Abuse: A Comprehensive Textbook. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1997.

4. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: Main Findings 1991. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; May 1993. DHHS publication (SMA) 93-1980.

5. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: Main Findings 1992. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; January 1995. DHHS publication (SMA) 94-3012.

6. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: Main Findings 1993. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; June 1995. DHHS publication (SMA) 95-3020.

7. Epstein JF, Gfroerer JC. Estimating substance abuse treatment need from a national household survey. Presented at: 37th International Congress on Alcohol and Drug Dependency; August 18, 1995; La Jolla, Calif.

8. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Washington, DC: American Psychiatric Association; 1987.

9. Simoni-Wastila L, Strickler G, Ritter G. Gender and other factors associated with the non-medical use of abusable prescription drugs. Subst Use Misuse. In press.

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11. Simoni-Wastila LJ. The use of abusable prescription drugs: the role of gender. J Womens Health Gend Based Med. 2000;9:289–297.[Web of Science][Medline]

12. Graham K, Wilsnack SC. The relationship between alcohol problems and use of tranquilizing drugs: longitudinal patterns among American women. Addict Behav. 2000;25:13–28.[Web of Science][Medline]

13. Kandel DB, Yamaguchi K. Developmental patterns of use of legal, illegal, and medically prescribed psychotropic drugs from adolescence to young adulthood. In: Jones CL, Battjes RJ, eds. Etiology of Drug Abuse: Implications for Prevention. NIDA Research Monograph 56. Bethesda, Md: US Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse; 1985. DHHS publication (ADM) 85–135.

14. Clayton RR, Voss HL, Robbins C, Skinner WF. Gender differences in drug use: an epidemiological perspective. In: Ray BA, Braude MC, eds. Women and Drugs: A New Era for Research. NIDA Research Monograph 65. Bethesda, Md: US Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse; 1986. DHHS publication (ADM) 86–1447.

15. Substance Abuse and Mental Health Services Administration. Substance Abuse Among Women in the United States. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; September 1997. Analytic series A-3.

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20. Wells KB, Kamberg C, Brook R, Camp P, Rogers W. Health status, sociodemographic factors, and the use of prescribed psychotropic drugs. Med Care. 1985;23:1295–1306.[Web of Science][Medline]

21. Cooperstock R, Parnell P. Research on psychotropic drug use. A review of findings and methods. Soc Sci Med. 1982;16:1179–1196.

22. Reid J. Under the Rug: Substance Abuse and the Mature Woman. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University; June 1998.

23. Verbrugge LM. Gender and health: an update on hypotheses and evidence. J Health Soc Behav. 1985;26:156–182.[Web of Science][Medline]

24. Shah BV, Folsom RE, LaVange LM, Wheeless SC, Boyle KE, Williams RL. Statistical Methods and Mathematical Algorithms Used in SUDAAN. Research Triangle Park, NC: Research Triangle Institute; 1995.

25. Winship C, Radbill L. Sampling weights and regression analysis. Sociol Methods Res. 1994;23:230–257.[Abstract]

26. Kessler RC, Crum RM, Warner LA, Nelson CB, Shulenberg J, Anthony JC. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Study. Arch Gen Psychiatr. 1997;54:313–321.[Abstract/Free Full Text]

27. Iguchi MY, Handelsman L, Bickel WK, Griffiths RR. Benzodiazepine and sedative use/abuse by methadone maintenance clients. Drug Alcohol Depend. 1993;32:257–266.[Web of Science][Medline]

28. Barnas C, Rossman M, Roessler H, Riemer Y, Fleischhacker WW. Benzodiazepines and other psychotropic drugs abused by patients in a methadone maintenance program: familiarity and preference. Clin Neuropharmacol. 1992;15(suppl 1, pt A):110A–111A.

29. Wesson DR, Smith DE. Prescription drug abuse. Patient, physician, and cultural responsibilities. West J Med. 1990;152:613–616.[Web of Science][Medline]

30. Substance Abuse and Mental Health Services Administration. Preliminary Results from the 1996 National Household Survey on Drug Abuse. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; July 1997. DHHS publication (SMA) 97–3149.

31. Harrison ER, Haaga J, Richards T. Self-reported drug use data: what do they reveal? Am J Drug Alcohol Abuse. 1993;19:423–441.[Web of Science][Medline]

32. Turner C, Lessler J, Devore J. The effects of mode of administration and wording on reporting of drug use. In: Turner CF, Lessler JT, Gfroerer JC, eds. Survey Measurement of Drug Use: Methodological Studies. Rockville, Md: US Department of Health and Human Services, Alcohol, Drug Abuse, and Mental Health Administration; 1992:177–217. DHHS publication (ADM) 92–1929.




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This Article
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