Clues to the Opioid Crisis in Monitoring the Future but Still Looking for Solutions

Monitoring the Future, a nationally representative cross-sectional survey of high school students, has collected data from high school seniors for >40 years.¹ In this issue of Pediatrics, McCabe et al ² report findings on changes over time in medical and nonmedical use of prescribed opiates among high school seniors. ² This research is important because nonmedical use of prescribed opiates (NUPO) is believed to be a major cause of morbidity and mortality associated with opiates. ³

The consistency of the Monitoring the Future survey provides a high-level view of opiate use across the country from 1975 to 2015. Although helpful, this perspective can obscure critically important changes in local areas or within specific populations.

As might be expected, the study found that NUPO correlated with opioid prescriptions at yearly evaluations over the 40 years. The study also found that although women received more prescription opiates, the incidence of NUPO did not vary by sex. Overall, white adolescents received more prescription opioids than black adolescents and were more likely to report NUPO. However, it is important to recognize the strong relationship between opioid prescription and NUPO, regardless of race. These findings support the policy recommendations to prescribe opioids only when patients have strong indications for opioids and no better treatment options are available.

McCabe et al found a recent decrease in the medical use of prescription opioids and NUPO. This decrease is consistent with findings from the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System from 2009 to 2015.⁴ We view it as an important finding, but there are significant small area variations that would not appear in a national study. The epidemic of opioid use disproportionately affects some urban and more rural areas. NUPO in general has become more common in rural areas. West Virginia, a predominantly rural state, has the highest rate of opioid overdose fatality in the country at 41.5 deaths per 100 000 in 2015. ³ The state also has the second highest rate of opioid prescriptions per capita.

The study by McCabe et al has the same limitations as all large self-report surveys, including the potential for biased reporting. Additionally, high school seniors with NUPO and other serious and multiple problem behaviors are less likely to be attending school on the survey date or even to be enrolled in 12th grade. Despite these limitations, these data are valuable. Americans consume 80% of the world’s prescription opioids, and inappropriate use takes a high toll on society.⁵ We are heartened to see a recent decrease, but we see it as a measured improvement. We understand that the appropriate use of opioids to manage pain can be helpful for our patients, but we must continue to search for solutions to the current crisis. Possible interventions include better education of our patients and families when we prescribe these drugs, better drug regulation, development of new affordable approaches to pain management that have lower potential for abuse, and accessible and affordable treatment programs for those already afflicted.

ABBREVIATION

NUPO

nonmedical use of prescription opioids