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In light of significant risks associated with opioid use, physicians are encouraged to monitor patients to whom they prescribe them.1- 2 Guidelines have endorsed physician-initiated treatment agreements and urine drug testing,3 despite equivocal efficacy.4 Nonmedical use of opioids has increased in conjunction with opioid prescribing and is associated with addiction, overdose, and death. To understand the impact physicians can have on nonmedical use of opioids, studies that examine the sources of these opioids are needed. This study investigates the source of opioids used nonmedically, the features of patients who obtain these opioids from physicians, and the extent to which nonphysician sources are used.
We used data from the National Survey on Drug Use and Health, an annual survey of the civilian, noninstitutionalized population. We restricted our analysis to those 18 years and older and combined survey data from 2006 through 2008.
Respondents who indicated that they had “used [an opioid analgesic] that was not prescribed for you or that you took only for the experience or feeling it caused” in the past month were asked for the source(s) of the opioids. We divided sources into 2 groups: (1) “physician,” which included the responses “single physician” or “2 or more physicians,” and (2) “nonphysician,” which included the responses “free from friends or family,” “purchase from friends or family,” “purchase from a dealer,” “purchase from the Internet,” “prescription forgery,” “theft from friends or family,” “theft from physician offices,” and “theft from a pharmacy.” Respondents were classified into (1) having a physician source, including those who indicated a physician source with or without also indicating a nonphysician source and (2) having only nonphysician sources.
Age, sex, race/ethnicity, income, education, employment, and marital status were included as covariates. Data on lifetime and current (past year) substance use and dependence were obtained via self-report.5 Three binary substance use disorder variables were created: past-year alcohol abuse or dependence; past-year opioid analgesic abuse or dependence; and past-year other substance (stimulants, hallucinogens, heroin, inhalants, marijuana, and/or sedatives) abuse or dependence. The Kessler 6 inventory was used to measure psychological distress.6 Overall health was based on the question, “Would you say your health in general is excellent, very good, good, fair or poor?”
We evaluated multivariable associations between independent variables and the binary dependent variable (having a physician source of opioid analgesics) using logistic regression. We then restricted the sample to those respondents with a physician source of opioids and performed frequencies of nonphysician sources. We used SAS version 9.1 (SAS Institute Inc, Cary, North Carolina) and SUDAAN version 9.0.1 (Research Triangle Institute, Research Triangle Park, North Carolina) to account for the sampling methods and nonresponse, using sample weights that normalized data to annual census distributions.
From 166 453 respondents, 3238 were 18 years or older, reported nonmedical use of opioids, and indicated an opioid source. Of the 3238 respondents, 855 (30.7%, percentage adjusted for sampling strategy) reported having a physician source of opioids.
On multivariable analysis (Table), age 50 years and older (adjusted odds ratio [AOR], 2.5; 95% confidence interval [CI], 1.4-4.5) and past-year opioid analgesic abuse and/or dependence (AOR 2.0; 95% CI, 1.5-2.7) were associated with having a physician source of opioids. Past-year abuse and/or dependence on other substances was associated with having only nonphysician sources (AOR, 0.6; 95% CI, 0.4-0.9).
Among those with a physician source, 465 of 855 (64.0%, percentage adjusted for sampling strategy) had no nonphysician source (eFigure), and of the full study sample, 20% reported physician sources only. Of the respondents with a physician source, 36% also had at least 1 source involving friends or family.
In this large community sample, we found that 31% of respondents with nonmedical use of opioids reported obtaining these medications directly from a physician, and 20% reported obtaining opioid analgesics exclusively from physicians. This suggests that public health efforts to mitigate nonmedical opioid use that occurs outside the sphere of the physician-patient relationship (eg, medication sharing, dealer purchase, theft) may result in substantial benefits. Furthermore, physicians need to be cognizant of the risks not only to patients to whom they prescribe opioids, but also to those with whom the prescription recipient lives or associates. While younger individuals are more likely to nonmedically use opioids,7- 8 our findings reveal that older age is a risk factor for obtaining nonmedically used opioids from a physician. This is partly because older patients visit physicians more frequently9 and are more often seen for pain issues.10 Our data suggest a continued need for physician and public health efforts to curb the increase in nonmedical use of opioids.
Correspondence: Dr Becker, Department of Internal Medicine, Yale University School of Medicine, PO Box 208056, 333 Cedar St, New Haven, CT 06520-8056 (firstname.lastname@example.org).
Author Contributions: Dr Becker had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Becker and Fiellin. Acquisition of data: Becker. Analysis and interpretation of data: Becker, Tobin, and Fiellin. Drafting of the manuscript: Becker and Fiellin. Critical revision of the manuscript for important intellectual content: Becker, Tobin, and Fiellin. Statistical analysis: Becker. Administrative, technical, and material support: Becker. Study supervision: Fiellin.
Financial Disclosure: Dr Fiellin serves on an expert advisory board to monitor for misuse, abuse, and diversion of buprenorphine for Pinney Associates.
Funding/Support: Dr Fiellin's grant support includes RO1 DA020576, RO1 DA019511, and R01 DA025991 from the National Institute on Drug Abuse.
Role of the Sponsor: The National Institute on Drug Abuse had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
Previous Presentation: The study was presented at a plenary session of the Society of General Internal Medicine 33rd Annual Meeting; May 1, 2010; Minneapolis, Minnesota.
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