Opioid abuse and depression in adolescents: Results from the National Survey on Drug Use and Health

doi:10.1016/j.drugalcdep.2015.04.010

Drug and Alcohol Dependence

Volume 152, 1 July 2015, Pages 131-138

https://doi.org/10.1016/j.drugalcdep.2015.04.010 Get rights and content

Highlights

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We investigated the relationship between depression and opioid abuse in adolescents.
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Major depression is strongly associated with opioid abuse in adolescents.
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When comorbid, major depression usually precedes opioid abuse.
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Programs to decrease opioid abuse should consider the prominent role of depression.

Abstract

Objective

To investigate the association of major depressive episode (MDE) with nonmedical prescription opioid use (NMPOU) and opioid abuse/dependence among adolescents aged 12 to 17.

Methods

We analyzed 5 years of data from the National Survey on Drug Use and Health (NSDUH). We used logistic regressions to study the relationship between MDE and NMPOU among all adolescents, as well as the relationship of MDE with opioid abuse/dependence among adolescents with NMPOU. Other covariates included: sociodemographics, alcohol abuse/dependence, nonopioid drug abuse/dependence, delinquency, school performance, religious services attendance, and family support/supervision.

Results

In the sample of all adolescents, 6% reported past year NMPOU, and 8% reported past year MDE. When NMPOU and MDE were comorbid, MDE usually preceded the NMPOU. In the sample of adolescents with NMPOU, 15% reported past year opioid abuse/dependence, and 20% reported past year MDE. In adjusted logistic regression, MDE was associated with both NMPOU (OR = 1.51, p < 0.001) among all adolescents and opioid abuse/dependence (OR = 2.18, p < 0.001) among adolescents with NMPOU.

Conclusion

MDE occurs commonly in adolescents and is associated with NMPOU and opioid abuse/dependence. In terms of population attributable risk, which is a function of both the prevalence and the strength of the association, MDE is an important risk factor for NMPOU among adolescents and opioid abuse/dependence among adolescents with NMPOU. Preventive and clinical programs to decrease NMPOU and opioid abuse/dependence among adolescents should consider the prominent role of depression.

Introduction

Prescription opioid misuse and abuse is a significant public health concern (Executive Office of the President of the United States, 2011). Further, opioids are the most common cause of accidental drug overdose in the United States (Compton and Volkow, 2006, EOPUS, 2011, Paulozzi et al., 2006, Paulozzi and Xi, 2008), constituting an epidemic per the Centers for Disease Control and Prevention (2011). Adolescents are not immune from these problems (Banta-Green, 2012). Between 1999 and 2006, the annual death rate for fatal overdoses of opioids for individuals aged 15 to 24 rose 440%, from 0.7 per 100,000 to 3.8 per 100,000 (Warner et al., 2009), and adolescents are the age group in which the opioid overdose death rate increased most rapidly. According to data from the 2011 Monitoring the Future survey, 8.7% of 12th graders reported past year illicit use of prescription opioids, especially Vicodin, Percocet, and OxyContin (Johnston et al., 2012). Among adolescents, the National Survey on Drug Use and Health indicates that misuse of opioids is second only to misuse of marijuana in prevalence, and the number of past year initiates of opioid misuse is second only to the number who initiated marijuana use (Substance Abuse and Mental Health Services Administration, 2012c).

Research from adults suggests the importance of depression as a risk factor for opioid abuse and dependence (Edlund et al., 2010, Edlund et al., 2007, Schepis and Hakes, 2011). In terms of population-attributable risk, which is a function of both the strength of the relationship and the frequency of the risk factor, depression may be the most important risk factor for opioid abuse/dependence in adults. The self-medication hypothesis is one prominent explanation for the empirically observed high rates of co-occurring depression and substance abuse, such as with opioids (Khantzian, 1997). This theory posits that individuals use psychoactive substances such as opioids to “self-medicate” painful or disturbing psychological symptoms.

Much of the research on opioid abuse/dependence and depression among adolescents is from the National Survey on Drug Use and Health (NSDUH). NSDUH is conducted annually, with approximately 20,000 adolescents aged 12 to 17, is nationally representative, and contains measures of opioid abuse/dependence (American Psychiatric Association, 2000) and nonmedical prescription opioid use (NMPOU), a less severe form of opioid misuse. It also contains a measure of DSM-IV major depressive episode (MDE; American Psychiatric Association, 2000). According to 2012 NSDUH data, 13% of adolescents with MDE reported NMPOU in the past year versus 6% of those without MDE (SAMHSA, 2012d). In an analysis of misuse of any prescription medication (not just opioids) among adolescents using 2008 NSDUH data, major depression was associated with misuse of prescription drugs (OR = 2.60; Havens et al., 2011), but the relationship for NMPOU was not investigated. Wu and colleagues found that there was generally, but not always, an association between depression and opioid abuse/dependence in adolescents (Wu et al., 2008b). Schepis and Krishnan-Sarin (2008), using data on adolescents from the 2008 NSDUH, found MDE to be associated with NMPOU in unadjusted models but did not report data on the relationship for adjusted models. In Vaughn's latent class analysis of adolescents with NMPOU, lifetime depression was not significantly associated with the latent class of nonmedical opioid use (Vaughn et al., 2012).

This study builds upon past work by using NSDUH data to investigate three key issues not previously addressed in the literature. First, among adolescents with both NMPOU and MDE, we investigated the frequency with which the onset of NMPOU precedes the onset of MDE, and the frequency with which the onset of MDE precedes the onset of NMPOU. Although not definitive, temporal progression can give insight into causality. Consistent with the self-medication hypothesis (Khantzian, 1997), we hypothesized that MDE preceding NMPOU would be more common than NMPOU preceding MDE. Second, we used logistic regression to study the determinants of NMPOU among all adolescents and to study the determinants of opioid abuse/dependence among adolescents with NMPOU. These steps represent the development of abuse/dependence—going from no use to NMPOU (experimentation and recreational use) and, among those with NMPOU, from NMPOU to abuse/dependence (addiction). As an extension of the self-medication hypothesis, we posited that the effects of depression would be stronger for the second step than for the first. That is, some adolescents with depression and NMPOU find that opioids help their depression (at least temporarily) and increase their opioid use, progressing to addiction. Finally, we investigated possible moderators of the relationship of MDE with NMPOU and opioid abuse/dependence. We posited that among depressed adolescents, there are “buffering factors” that decrease the magnitude of the association of the relationship of MDE with NMPOU and opioid abuse/dependence. In particular, we hypothesized that the magnitude of the association of MDE with NMPOU and opioid abuse/dependence would be smaller among adolescents with greater parental support, compared with those with less parental support and smaller among those who attend church more frequently, compared with those who attend church less frequently.

Section snippets

Sample

We used cross-sectional data from NSDUH, which the Substance Abuse and Mental Health Services Administration (SAMHSA) conducts annually and is the primary source of information on illicit drug, alcohol, and tobacco use in the United States. Consistent with SAMHSA policy, all sample sizes in the following text and tables have been rounded to the nearest hundred to protect confidentially of respondents.

To increase the statistical power, we combined 2008–2012 NSDUH data. We investigated factors

Any NMPOU

Among all adolescents, 6.1% reported NMPOU in the past year, and 8.3% had past year MDE (Table 1). Among those with both lifetime MDE and lifetime NMPOU, 47% had the onset of MDE before the onset of NMPOU, 27.2% had the onset of NMPOU before the onset of MDE, and 25.8% had the onset in the same year (results not shown). In an adjusted logistic regression, MDE was significantly associated with NMPOU (OR = 1.51, 95% CI = 1.37–1.67; Table 2). Adolescents with a greater likelihood of NMPOU included

Discussion

Past year MDE was common among adolescents (8%), and among adolescents with NMPOU (20%). MDE was significantly associated with both NMPOU among the total sample of adolescents, and opioid abuse/dependence among those with NMPOU. As hypothesized, among individuals with comorbid depression and NMPOU, depression usually preceded the NMPOU. This suggests the importance of MDE in terms of population attributable risk for NMPOU and opioid abuse/dependence, which is a function both of prevalence and

Role of funding source

The National Survey on Drug Use and Health (NSDUH) is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality (CBHSQ). This study was funded under Contract No. 283-2010-00003C, Project No. 0212800, which was supported by funding from the National Institute of Mental Health (NIMH). The study utilized data previously collected by SAMHSA. Co-authors on the paper were from SAMHSA (Dr. Lipari) and NIMH (Dr. Colpe), and

Contributors

Mark J. Edlund. Study design, supervision of statistical analyses, analysis and interpretation of data, writing of initial draft and revisions of manuscript.

Valerie L. Forman-Hoffman. Study design, supervision of statistical analyses, analysis and interpretation of data, writing of manuscript.

Cherie R. Winder. Statistical programming, analysis and interpretation of data, writing of manuscript.

David C. Heller Statistical programming, analysis and interpretation of data, writing of manuscript.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgments

We thank SAMHSA and NIMH, who provided funding for this study. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Substance Abuse and Mental Health Services Administration. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institute of Mental Health.

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Opioid abuse and depression in adolescents: Results from the National Survey on Drug Use and Health

Highlights

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Sample

Any NMPOU

Discussion

Role of funding source

Contributors

Conflict of interest

Acknowledgments

Drug Alcohol Depend.

Drug Alcohol Depend.

Pain

Drug Alcohol Depend.

J. Am. Acad. Child Adolesc. Psychiatry

J. Adolesc. Health

Addict. Behav.

Drug Alcohol Depend.

J. Am. Acad. Child Adolesc. Psychiatry

J. Adolesc. Health

Diagnostic and Statistical Manual of Mental Disorders, Text Revision

Adolescent abuse of pharmaceutical opioids raises questions about prescribing and prevention

Arch. Pediatr. Adolesc. Med.

Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008

MMWR

The weighted sequential hot deck imputation procedure

Proceedings of the 1980 American Statistical Association, Survey Research Methods Section

Adolescents' assessments of the helpfulness of treatment for major depression: results from a national survey

Psych. Serv.

Epidemic: Responding to America's Prescription Drug Abuse Crisis

Nonmedical prescription drug use and delinquency: an analysis with a national sample

J. Drug Issues

Social learning theory and nonmedical prescription drug use among adolescents

Sociol. Spectr.

Nonmedical prescription drug use among adolescents: the influence of bonds to family and school

Youth Soc.