Gender and nonmedical prescription opioid use and DSM-5 nonmedical prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions – III
Introduction
The past decade has witnessed a startling rise in harms from nonmedical prescription opioid use (NMPOU): drug poisoning death rates attributable to NMPOU have tripled; (Warner et al., 2012), opioid-related emergency room visits increased by 153%; (Substance Abuse and Mental Health Services Administration (SAMHSA), 2013) and drug treatment admission rates for nonheroin opioids increased 236% (SAMHSA, 2014). NMPOU is also associated with many other adverse health consequences including nonmedical prescription opioid use disorder (NMPOUD; Huang et al., 2006), psychiatric comorbidity (Amari et al., 2011, Becker et al., 2008, Compton et al., 2005, Katz et al., 2013, Martins et al., 2009, Martins et al., 2012), cognitive impairment and drug interactions (U.S Department of Health and Human Services, 2011), transitions to injection drug or heroin use with resultant infections (Jones, 2013, Pollini et al., 2011, Muhuri et al., 2013), falls and fractures among older adults (Miller et al., 2011, Rolita et al., 2013) and neonatal opioid withdrawal syndrome (Creanga et al., 2012). Societal costs of NMPOU and NMPOUD are estimated at $53–$72 billion annually (Birnbaum et al., 2011, Coalition Against Insurance Fraud, 2007, Hansen et al., 2011).
Despite important sex differences in sociodemographic and clinical correlates of NMPOU and NMPOUD observed among chronic pain patients (Campbell et al., 2010, Fillingim et al., 2003, Jamison et al., 2010, Manubay et al., 2015) and individuals in substance abuse treatment (Back et al., 2011, Green et al., 2009, McHugh et al., 2013), little is known about sex-specific correlates of NMPOU and NMPOUD in the U.S. general population. This is especially true for NMPOUD since few national surveys have collected the information necessary to derive diagnoses of NMPOUD and the full range of its psychiatric comorbidities. In the 2001–2002 National Institute on Alcohol Abuse and Alcoholism's (NIAAA) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), 12-month and lifetime rates of NMPOU were greater among men (2.1%; 6.1%) than women (1.5%; 3.5%; Huang et al., 2006). Similarly, 12-month and lifetime prevalences of Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV; American Psychiatric Association, 1994) NMPOUD were greater among men (0.5%; 2.0%) than women (0.2%; 0.9%). Substantial comorbidity was observed among NMPOUD and other DSM-IV substance, mood anxiety and personality disorders (Huang et al., 2006).
In the 2013 Substance Abuse and Mental Health Services Administration's National Survey on Drug Use and Health (NSDUH), prevalences of DSM-IV 12-month and lifetime NMPOU were greater among men (4.6% and 15.7%) than women (3.8% and 12.7%; SAMHSA, 2014). The rate of 12-month DSM-IV NMPOUD in 2013 was also greater among men (0.9%) than women (0.6%). Studies using earlier data from the NSDUH found greater rates of NMPOU among men (Back et al., 2010, Tetrault et al., 2007) but no sex differences in rates of 12-month NMPOUD (Back et al., 2010). However, NSDUH does not assess lifetime diagnoses, disability or the full range of psychiatric disorders.
To date, only one national survey has examined sex-specific risk profiles of NMPOU and NMPOUD directly, using data from 2003, which are now over a decade old (Tetrault et al., 2007). Moreover, all previous national estimates of NMPOUD were based on DSM-IV criteria. However, DSM-5 (American Psychiatric Association, 2013) made major changes to the NMPOUD diagnosis, including combining most abuse and dependence criteria into a single diagnosis, adding a craving criterion, and setting a diagnostic threshold of ≥2 criteria (Hasin et al., 2013). Major changes were also made to mood and anxiety disorders, suggesting the need to examine NMPOUD and its psychiatric correlates using DSM-5 criteria.
Because of the seriousness of NMPOU and NMPOUD, the lack of gender-specific information about NMPOU and DSM-5 NMPOUD in the United States from a single, reliable and uniform source represents a critical knowledge gap. We therefore present sex-specific national data on the prevalence, correlates, comorbidity, disability and treatment of NMPOU and DSM-5 NMPOUD from 2012 to 2013 NIAAA NESARC-III (Grant et al., 2014).
Section snippets
Sample
The target population of NESARC-III was the U.S. noninstitutionalized adult civilian population residing in households and selected group quarters. As detailed elsewhere (Grant et al., 2014), probability sampling was used to select respondents. Primary sampling units were counties or groups of contiguous counties, secondary sampling units (SSUs) comprised groups of Census-defined blocks, and tertiary sampling units were households within SSUs. Eligible adults within sampled households were
NMPOU
The prevalences of 12-month NMPOU were greater among men than women (4.4% and 3.9%; adjusted odds ratio (AOR) = 1.2, 95% confidence limit (CI) = 1.04–1.32) (Table 1). Among both sexes, rates of 12-month NMPOU were lower among Asian/Pacific Islanders and in the two youngest age groups and among those with incomes <$20,000.00. Among men, the prevalence of NMPOU was also lower among respondents with annual incomes between $35,000.00 and $69,999.00 and residents of the Northeast. Among women,
Discussion
In 2012–2013, prevalences of 12-month NMPOU were greater among men (4.4%) than women (3.9%), representing about 5.0 and 4.7 million adult Americans. Lifetime rates of NMPOU were also considerably greater among men (13.0%) than women (9.8%) or 26.7 and 14.7 million Americans. In contrast, 12-month (0.9%, 0.9%) and lifetime (2.2%, 1.9%) prevalences of NMPOUD did not differ by sex.
The sex difference observed in NMPOU is consistent with prior surveys (Back et al., 2010, Huang et al., 2006, SAMHSA,
Role of funding source
The NESARC-III was funded and sponsored by the National Institute on Alcohol Abuse and Alcoholism, with supplemented support from the National Institute on Drug Abuse. The sponsors had no involvement in the study design, collection, analysis and interpretation of the data, in the writing of the report and in the decision to submit the article for publication.
Contributors
Dr. Kerridge wrote the first draft of the manuscript and all other authors contributed to subsequent draft revisions. Drs. Kerridge, Saha, Zhang, Jung, Ruan and Smith contributed to the data analyses. All authors participated in the concept, design and collection of study data.
Conflict of interest
No authors claim conflict of interest.
Acknowledgements
This research was supported by the National Institute on Drug Abuse, National Institutes of Health (5F32DA0364431: Dr. Kerridge), the National Institute on Alcohol Abuse and Alcoholism (K05AA014223: Dr. Hasin), the New York State Psychiatric Institute (Dr. Hasin), and the in intramural program, NIAAA, NIH.
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