Prescription Medication Misuse Among Service Members Epidemiology

1. Prescription Medication Misuse Among Service MembersEpidemiology

2. PMM Lecture Goals • Define prescription medication misuse (PMM) • Describe the incidence of PMM between military and civilian matching population subgroups and patterns within subgroups of Service Members • Identify the sources for obtaining misused medications

3. Prescription Medication Misuse Definition • Taking medications for non-intended uses, differently than prescribed, without a prescription or with interacting substances.

4. Drugs frequently misused • Analgesics • Most commonly misused • Oxycodone • Methadone • Hydrocodone (Vicodin®) • Tranquilizers • Diazepam (Valium)® • Stimulants • Dextroamphetamine (Adderall®) • Methylpenidate (Ritalin®) • Sedatives • Eszopiclone (Lunesta®) • Zolpidem (Ambien®)

5. Medications Misused 2008 DoD Health Related Behaviors Survey of Active Duty Service Members, RTI 2008 National Survey on Drug Use and Health, SAMHSA

6. Epidemiology of PMM • Patterns in Service Members compared to the US population • Age matched • Employment matched • Gender matching • Limits to comparisons • Rates for different groups of Service Members • Age specific rate among Service Members • Rates for different ranks of Service Members • Other demographic groupings of Service Members • Increase in incidence over time among Service Members • Sources of misused medications • Proportions of medications misused in both populations

7. Limitations to Service Member to Civilian Comparison • Comparison of two DIFFERENT studies! • Differently worded questions • Trends still revealing • Direct comparisons to rate of marijuana use very telling of scope of problem • Limited conclusions but still the best evidence available

8. Civilian vs. SM PMM Perspective • Potentially higher incidence of PMM in SMs • Service Member vs. civilian rate • 11% vs 2.5% 30 day incidence rate • More common than Marijuana use among SMs • 3% 30 day incidence rate (2008 DoD Health Related Behaviors Survey) • More common among Service Members than Marijuana use among civilians • 5.8% 30 day incidence rate (National Survey on Drug Use and Health, 2008) • Even the limitations of comparing two studies can not explain this contrast away.

9. Civilian vs. Military Incidence of PMMAge Matched Comparison • Civilian Incidence • 2.5% PMM in past 30 days, 4.4% among members of general population age matched with Service Members • Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: National Findings. Rockville: Office of Applied Studies 2009. • 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009 • Incidence in Service Members • 11.1% 30 days incidence of PMM • 18.4% in the past 12 months (23.1% in Army) • 2008 Department of Defense survey of health related behaviors among military personnel, Research Triangle Institute, Research Triangle Park NC 2009

10. Rates Matched for Employment Status(PMM or ISA) • Higher rate of all substance misuse or abuse in Service Members when compared to fully employed civilians • Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD. 2009. • 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. Research Triangle Institute, Research Triangle Park NC. 2009.

11. Service Member vs. Civilian Contrast • By age grouping • Incidence significantly decreases with increasing age in general population, not in Service Members • Oldest Service Members show the greatest deviation from age matched civilian cohort

12. PMM by Age GroupService Members Vs. Civilian

13. PMM Incidence – Gender Comparison Service Members Vs. US Population • US population – males have higher incidence • Males – 4.6% 30 day incidence • Females – 3.2% 30 day incidence • Service Members – females have higher incidence • Males – 11.4% 30 day incidence • Females – 13.2% 30 day incidence

14. Choice of Medications Misused • Roughly equal ratios of % misusers by medication category/ % of total misusers per population between the two groups • Analgesics chosen by most misusers

15. Medications Misused Data from 2008 DoD Health Related Behaviors Survey and 2008 National Survey on Drug Use and Health

16. Misusers by Medication Category/ Total Misusers in Each Group

17. Sources of Misused Medications

18. Sources of Misused Medications • 22% obtained through prescription • Friends or relatives were the most common sources • 47% obtained them from a friend or relative for free • 13% purchased • 2/3 purchased from a friend or relative. • Partnership for a Drug-Free America, Partnership Attitude Tracking Study • Schepis T and Krishnan-Sarin S. Sources of Prescriptions for Misuse by Adolescents: Differences in Sex, Ethnicity, and Severity of Misuse in a Population-Based Study. J Am Acad Child Adolesc Psychiatry. 2009; 48: 828-36. • Corroborated by data from National Survey on Drug Use and Health (NSDUH) performed for Substance Abuse and Mental Health Administration (SAMHSA) • 18% of medications misused obtained with a prescription • Majority from friend or relative • No Service Member specific data • 14% of Army received a prescription for an opioid • US Army Suicide Report • Media reports have documented sharing • Personal reports of card games with oxycontin

19. Patterns of PMM Among Service Members • Varied by rank • Varied by service • Varied by deployment history

20. PMM by Military Rank • Rates vary more by military rank (enlisted vs. officer) than by age

21. PMM Differences by Rank • Difference based on educational level seen in the general population of the US may partially contribute to the officer – enlisted differences • PMM among civilian high school grads – 8.6% • PMM among civilian college graduates – 5.7% • 2008 National Survey on Drug Use and Health, SAMHSA • Junior enlisted typically have a high school diploma while most officers have a college degree • Doesn’t explain the entire difference, particularly among senior enlisted who routinely have college degrees or higher

22. PMM by Service • Highest rates in the Army and Marine Corps • Differences achieved statistical significance

23. PMM by Service • Different rates between services not explained by average age, % enlisted, % officers, % with high school education only, % with college degree or higher or combinations

24. PMM – Impact of Deployment • 19.1 % of OIF/OEF deployed endorsed in previous 12 months • 17.0 % for never deployed • Mild increased incidence in every service • 2008 DoD Survey of Health Related Behaviors

25. PMM Overall Trends • Common place, recent surveys suggest it is more common among Service Members • Occurring without a prescription in most cases • More common in enlisted Service Members • Female Service Members have higher incidence • Increased incidence among previously deployed Service Members • Soldiers and Marines have the highest incidence, but all services are affected • Cause of increasing health care costs and lost productivity

26. Patient Scenario – Anthony Salazar - Complaint • A 21 year old male who suffers from pain after an upper extremity injury is in a primary care clinic for the chief complain: “I need more pills” • He appears agitated as he reports constant pain • He would like the following refills: Oxycodone, Gabapentin, Lorazepam, Quetiapine and Fluoxetine • He would also like a prescription for methadone. A fellow WTU member shared this drug with him. Methadone has helped with the pain and sleep

27. Anthony Salazar - History • An IED encounter in Iraq resulted in the loss of his right arm/forearm and a partial bowel resection • He has had an explorative laparotomy, frequent wound washouts (both abdomen and upper extremity) and skin grafting to his arm. His most recent hospitalization was for a medication overdose • The patient finds it difficult to be awake, sleep and interact with anyone • He drinks large quantities of alcohol and smokes 1-2 packs of cigarettes a day

28. Anthony Salazar - Questions • How common is medication misuse among US Service Members? • How likely is he to seek misused medications if you refuse to prescribe them? • What percentage of misuse occurs in the absence of a prescription? • What about his drug overdose history? Do you think this patient is suicidal? • What treatment plan would you consider? Medications, therapy? Detoxification? Complementary medicine?

29. Military Resources • Military Homefront Support • 800-342-9647 • www.militaryonesource.com • Branch Specific Support is also available: • Army Substance Abuse Program (ASAP) • Navy Alcohol and Drub Abuse Prevention (NADAP) • Marine Substance Abuse Combat Center (SACC) • Air Force Alcohol and Drub Abuse Prevention and Treatment (ADAPT)

30. Non-Military Resources • Substance Abuse and Mental Health Services Administration (SAMHSA) www.findtreatment.samhsa.gov • 1-800-662-HELP • National Suicide Prevention Lifeline 800-273-TALK • National Alliance on Mental Illness www.nami.org • Mental Health America www.mentalhealthamerica.net • American Academy of Addiction Psychiatry www.aaap.org • American Academy of Child and Adolescent Psychiatry www.aacap.org • National Drug Abuse Clinical Trials www.drugabuse.gov/CTN/ or www.clinicaltrials.gov • Narcotics Anonymous www.na.org/ • Alcoholics Anonymous www.aa.org

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