Abstract
We assessed the nonmedical use of prescription opioids (NMUPO) among adolescents who participate in competitive sports. Using data from Monitoring the Future, we found that adolescent participants in high-injury sports had 50% higher odds of NMUPO than adolescents who did not participate in these types of sports (i.e., nonparticipants and participants in other sports). Detecting certain subpopulations of youths at risk for NMUPO should be a central concern among health care providers.
Nonmedical use of prescription opioids (NMUPO) among adolescents in the United States has increased over the past 15 years.1–3 The 2011 Monitoring the Future data indicated that 15.2% of high school seniors used controlled medications nonmedically in the past 12 months, with acetaminophen and hydrocodone and oxycodone hydrochloride topping the list of specific opioid medications.3 This increasing trend in nonmedical use should be no surprise given that the percentage of adolescents who were prescribed controlled medications at ambulatory medical centers almost doubled between 1994 and 2007, from 6.4% to 11.2%.4
Since 1994, there also has been an increase in interscholastic sports participation among adolescents.5,6 In 2011, about a quarter of all US public high school students—7.5 million in total—participated in interscholastic sports.7 Roughly 2 million high school athletic injuries occur each year,8–10 and about a quarter of emergency department visits by children and adolescents involve sports-related injuries, many of which require some type of intervention to help control pain.11 Because of their increased access to opioid medications through prescriptions or handouts from injured teammates, sports participants could be at higher risk for NMUPO.3,12 We sought to determine whether adolescents who participate in sports are more likely to report NMUPO than those who do not.
METHODS
The data analyzed here were collected as a part of the Monitoring the Future (MTF) study of US secondary school students, which is an annual cross-sectional survey.13 For the purposes of these analyses, we merged MTF data collected from 8th- and 10th-grade students during 2010 and 2011, which allowed us to capture a large sample of adolescents to examine the relationship between sports participation and NMUPO. Merging data for 2010 and 2011 resulted in a total weighted sample of 21 135 adolescents. After participants with missing data were excluded from the analysis, the final weighted sample comprised 13 636 adolescents (MTF reports respondents’ race only as White, Black, or Hispanic, which accounted for 17% of the missing data).
The MTF uses 8 different forms to survey 8th and 10th graders: Forms 1 through 4 for 8th graders and Forms 5 through 8 for 10th graders. For this study, we included only 8th graders who completed Form 1 and 10th graders who completed Form 5 because only those forms provide questions on competitive sports participation.14 The primary question provided to respondents was as follows: “In which competitive sports (if any) did you participate during the LAST 12 MONTHS? Include school, community, and other organized sports. (Mark all that apply).” The competitive sports that respondents could select included (but were not limited to) baseball, basketball, cheerleading, crew, cross country, equestrian, field hockey, football, golf, gymnastics, ice hockey, lacrosse, soccer, swimming, tennis, track and field, volleyball, water polo, and wrestling. For the purposes of the analyses, we constructed an additional global measure of sports participation to capture whether respondents participated in at least 1 sport during the past 12 months.
Only 2 MTF questions asked respondents about the nonmedical use of opioids in Form 1 and Form 5 of the MTF survey. These questions included whether respondents used Vicodin or OxyContin without a doctor’s orders during the past 12 months. We combined responses to these questions to construct the dependent variable for the analysis. We coded respondents who indicated using either one of these medications as reporting NMUPO during the past 12 months. Although this combined measure included questions on the nonmedical use of only 2 prescription opioids (Vicodin and OxyContin), use was similar as indicated in self-reported responses to questions in the combined measure and to the general question in the MTF that asked respondents whether they used any prescribed narcotic during the past 12 months without a doctor’s orders (5.5% vs 5.0%, respectively).
The multistage sampling design used for MTF resulted in clustering of the data, which may cause some overstatement of the statistical significance of results when analyses are conducted that do not account for the complex sampling. Design effects reflecting the cluster sampling were not available from MTF study staff for the subpopulations and the estimates examined in this brief. Therefore, the standard errors may be understated, and we considered only highly significant results to be reliable (adjusted odds ratios based on 99% confidence intervals). We used binary logistic regression to compute adjusted odds ratios to determine whether sports participants had greater odds of NMUPO during the past 12 months. Additionally, we computed adjusted odds ratios to determine which sport each respondent participated in had the highest odds of NMUPO during the past 12 months.
RESULTS
Among the sample of respondents, 5.5% reported NMUPO during the past 12 months. As shown in Table 1, compared with nonparticipants, adolescents who participated in any type of competitive sport had similar odds of reporting NMUPO (adjusted odds ratio [AOR] = 1.17; 99% confidence interval [CI] = 0.93, 1.48). However, as indicated in Table 2, types of sports participation yielded different odds; adolescents who participated in football (AOR = 1.50; 99% CI = 1.12, 1.99) or wrestling (AOR = 1.49; 99% CI = 1.01, 2.19) had nearly a 50% increase in the odds of NMUPO compared with their peers who did not participate in these sports. All other types of sports participation had no impact on NMUPO.
TABLE 1—
Past-Year Nonmedical Use of Prescription Opioids Among 8th and 10th Graders in the United States: Monitoring the Future, 2011
| Variable | AOR (99% CI) |
| Year of survey | |
| 2010 (Ref) | 1.00 |
| 2011 | 0.77 (0.63, 0.95) |
| Geographic region of respondent | |
| North East (Ref) | 1.00 |
| North Central | 1.15 (0.84, 1.58) |
| South | 0.79 (0.58, 1.09) |
| West | 1.39 (1.00, 1.94) |
| Urbanicity | |
| Lives in a city (Ref) | 1.00 |
| Lives on farm or in country | 1.29 (1.02, 1.64) |
| Family type | |
| 2-parent family (Ref) | 1.00 |
| Single-parent family | 1.24 (0.98, 1.56) |
| Mother’s education | |
| < high school degree (Ref) | 1.00 |
| High school degree only | 0.80 (0.58, 1.11) |
| Some college | 0.84 (0.60, 1.19) |
| ≥ college degree | 0.71 (0.52, 0.98) |
| Respondent’s gender | |
| Male (Ref) | 1.00 |
| Female | 1.29 (1.05, 1.59) |
| School year | |
| 8th grade (Ref) | 1.00 |
| 10th grade | 2.37 (1.89, 2.97) |
| Race/ethnicity | |
| White (Ref) | 1.00 |
| Non-White | 0.43 (0.33, 0.55) |
| Self-reported grades in schoola | 0.82 (0.78, 0.86) |
| School suspension | |
| Has never been suspended from school (Ref) | 1.00 |
| Has been suspended from school | 3.69 (2.94, 4.62) |
| Sports participation | |
| Does not participate in sports (Ref) | 1.00 |
| Participates in sports | 1.17 (0.93, 1.48) |
Note. AOR = adjusted odds ratio; CI = confidence interval. AORs control for year of survey, region and geographic location of respondent, family characteristics, and student characteristics simultaneously. Missing cases were excluded from the analysis, leaving a final sample size of 13 751 adolescents. Cox and Snell R2 = 0.054.
Self-reported grades is a continuous measure (0 = D, 1 = C–, 2 = C, 3 = C+, 4 = B–, 5 = B, 6 = B+, 7 = A–, 8 = A).
TABLE 2—
Past-Year Nonmedical Use of Prescription Opioids Among 8th and 10th Graders in the United States, by Sports Participation: Monitoring the Future, 2011
| Sporta | AOR (99% CI) |
| Baseball | 1.20 (0.93, 1.55) |
| Basketball | 0.81 (0.62, 1.05) |
| Cheerleading | 1.37 (0.92, 2.04) |
| Crew | 0.72 (0.25, 2.09) |
| Cross country | 0.45 (0.20, 1.00) |
| Equestrian | 1.50 (0.66, 3.43) |
| Field hockey | 1.30 (0.60, 2.82) |
| Football | 1.50 (1.12, 1.99) |
| Golf | 1.38 (0.88, 2.16) |
| Gymnastics | 1.34 (0.79, 2.28) |
| Ice hockey | 0.88 (0.44, 1.78) |
| Lacrosse | 1.03 (0.56, 1.89) |
| Soccer | 1.04 (0.77, 1.39) |
| Swimming | 0.91 (0.61, 1.34) |
| Tennis | 0.85 (0.53, 1.37) |
| Track and field | 1.05 (0.77, 1.44) |
| Volleyball | 1.09 (0.79, 1.51) |
| Water polo | 1.28 (0.48, 3.40) |
| Wrestling | 1.49 (1.01, 2.19) |
Note. AOR = adjusted odds ratio; CI = confidence interval. AORs control for year of survey, region and geographic location of respondent, family characteristics, and student characteristics simultaneously. AORs and CIs for control variables are not shown. Missing cases were excluded from the analysis, leaving a final sample size of 13 751 adolescents. Cox and Snell R2 = 0.057.
Each sport is a separate binary variable (i.e., 1 indicates that they participate in a given sport and 0 indicates that they do not participate in a given sport) and are all included in the logistic regression model with the control variables simultaneously. Inclusion of all 19 sports into the model simultaneously controls for number and type of sports that respondents participate in.
DISCUSSION
The results of this cross-sectional study suggest that high-injury sports like football and wrestling may increase the risk of NMUPO. We speculate that the greater odds may be related to the fact that football players and wrestlers have the highest severe injury rate among high school athletes15; alternatively, the greater odds may be associated with an increased opportunity to get opioids from a teammate who is diverting opioid medication to peers.3,12 The association between NMUPO and participation in high-injury sports is a potent finding, especially in the United States. Currently, there are 1 million high school students who participate in interscholastic football in this country.7 Because contact sports like football are popular extracurricular activities that many students (both boys and girls) participate in, future research is needed to examine the complex relationship between participation in high-injury sports and prescription use and misuse within this subpopulation of youths.
Finally, although our study revealed that participants in high-injury sports had a greater risk of NMUPO, there were several limitations that should be mentioned. First, our dependent measure of NMUPO was constrained by including only 2 popular opioid medications that could be used nonmedically. The MTF forms provided to 8th and 10th graders that asked questions about different types of sports participation did not include general questions about the nonmedical or medical use of opioids. Unfortunately, our conclusions can be based only on the nonmedical use of these 2 popular opioid medications. Second, we analyzed only 1 type of prescription opioid misuse. Including other types of prescription opioid misuse, such as medical misuse (e.g., taking too much of one’s own medication), would have strengthened this report.16,17 Regrettably, measures in the MTF fail to distinguish between people who misuse their own medication and those who nonmedically use someone else’s prescription opioids. Despite these limitations, our study makes a unique contribution in detecting an at-risk population of adolescents who may be particularly susceptible to prescription opioid abuse.
Acknowledgments
The development of this brief was supported by the National Institute on Drug Abuse, National Institutes of Health (grants R01DA024678, R01DA031160, and T32DA007267).
We thank the Substance Abuse and Mental Health Data Archive for providing access to these data and the anonymous reviewers for their helpful comments on a previous version of this brief.
Note. The contents of this brief are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health.
Human Participant Protection
The University of Michigan institutional review board approved the current study.
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