ANDRA WILKINSON, HANNAH WINSLOW
The majority of people who misuse drugs start before their 18th birthday. Furthermore, the risk of addiction increases when drug use starts in adolescence, making this period a key prevention window. Leftover prescription pills, either from one’s own prescription or those of family or friends, are the dominant source of opioid pain relievers for adolescents who misuse them. By the end of high school, approximately 13 percent of teens will have misused opioid pain relievers (i.e., used them without prescription, in a manner not prescribed, or to get high). Strategies that address adolescent misuse of prescription opioid pain relievers represent a critical component of any successful effort to address the opioid crisis.
A national study of 12th graders found that, among those with no prior history of drug use and strong disapproval of illegal drug use, a prescription for opioids in high school was associated with a threefold increased risk of later opioid misuse. Opioid pain reliever misuse can substantially increase the risk of initiating heroin use. As such, decreasing excessive opioid prescribing and lowering the number of leftover pills are important strategies for preventing opioid pain reliever misuse—and, potentially, later heroin or fentanyl (a more powerful and lethal synthetic opioid) use among youth.
Adolescent outreach and education is necessary but not sufficient for prevention. To prevent adolescent misuse, many states have implemented policies designed to limit unnecessary prescribing. Recent legislative efforts have included the following strategies:
- Limiting the number of doses given in an initial prescription for acute pain. As the number of days covered by an opioid prescription increases,so do the chances of misuse (although further research is needed). As of early April 2018, 19 states had some limit on opioid prescribing.
- Assisting physicians with monitoring the number of prescriptions given to an individual. Prescription drug monitoring programs (PDMPs) are electronic databases that allow clinicians to know whether patients have already received opioids from another provider. While 49 states have some type of prescription drug monitoring law, only 36 states require clinicians to consult the PDMP before prescribing. A study of mandatory PDMP use among dentists (the top prescribers of opioids to adolescents) found that prescribing amounts fell by 78 percent in three months once PDMP consultation became a requirement.
- Properly regulating pain clinics to keep bad actors from flooding the market. In the absence of regulation, pain clinics can turn into “pill mills,” which give opioid prescriptions to patients without medical histories or physical exams. For example, one clinic prescribed almost 3 million opioid doses to only 3,000 patients, flooding the community with excess pills prone to misuse. State regulations can make improper prescribing less likely, but, as of June 2018, only 12 states had laws regulating pain clinics.
Despite their effectiveness at reducing misuse, policies targeting the supply of prescription opioids have met varying degrees of resistance. In recent years, opioid prescribing has dropped. Teen prescription opioid and heroin use is now at a historic low, fueling concerns that these new policies may not be necessary, and that poorly implemented policies can—and are—harming terminal patients and those with chronic pain. Furthermore, increased regulation of prescription opioids generally correlates with upticks in heroin use. Ohio, the state with the second-highest opioid overdose death rate, has in recent years passed legislation that includes all three of the previously mentioned policy approaches. In subsequent years, the state saw opioid prescribing fall 20 percent, while its overall overdose death rate continued to rise as the proportion of deaths due to heroin and fentanyl increased.
However, the relationship observed between decreasing supplies of prescription opioids and increases in heroin use is complex, and research shows that the overall increase in heroin use began long before efforts to decrease opioid prescribing. For this reason, lawmakers should consider ways to expand treatment while taking careful steps to limit supply, as confirmed by a recent predictive model. Although prescribing has dropped overall, it still varies considerably across states; for example, certain states have prescribing rates more than twice as high as their neighbors. Some researchers also assert that state policies are important for continued declines in prescription opioid use among youth.
Policies regulating access to prescription opioids are certainly not a cure-all, but they do provide an opportunity for policymakers to intervene before youth addiction begins. As prescription pain relievers continue to be one of the most common drugs of choice for first-time users in adolescence, state policy initiatives to reduce excessive prescribing may be a powerful tool for lawmakers. However, to ensure that prescription opioid regulation corresponds with decreases in overdose deaths, policies limiting supply must not harm chronic pain patients and must go hand-in-hand with expanded and comprehensive addiction treatment.