Sean Esteban McCabe, PhD: The Burden of Prescription Drug Misuse in the US

The University of Michigan School of Nursing DASH Center director discusses the impact and reach of adult prescription drug misuse.

Nearly half of all adults from a 26,000-plus participant survey reported at least 1 instance of prescription drug misuse (PDM) between the ages of 18-50, according to findings from a new longitudinal study.

In new research published to JAMA Network Open this week, investigators from the Center for the Study of Drugs, Alcohol, Smoking and Health (DASH) at University of Michigan School of Nursing reported a high prevalence of PDM among nationally representative adult survey participants, as well as significant risk of substance use disorder among those with a history of PDM.

In an interview with HCPLive regarding the findings, study author and DASH Director Sean Esteban McCabe, PhD, discussed the history of research leading to this PDM assessment, the diversity of caregiver stakeholders involved in prescription drug misuse care, the effect of COVID-19 on drug abuse and misuse, and solutions to mitigate the rate of PDM.

HCPLive: What was our prior understanding of the risk factors associated with prescription drug misuse? Is there sustained merit/evidence to the belief that experimental drug use is often a “gateway” to PDM?

McCabe: Early onset alcohol and other drug use has been shown to be a consistent risk factor for prescription drug misuse. We also know that polysubstance use is extremely high among those who report prescription drug misuse (often higher than 90%). Screening can help detect individuals who are at increased risk for prescription drug misuse that can be used before prescribing these medications to individuals. Our team and others are using risk factors to find new ways to improve screening and the medication monitoring process.

The team of authors from your institution is fairly diverse in their professional backgrounds. What’s the importance of multi-faceted expert representation and perspective when considering the effects of drug abuse/misuse on users?

McCabe: Our team of authors are all affiliated with the DASH Center and come from diverse professional backgrounds including nursing, psychology, psychiatry, social work, sociology, and public health. More importantly, the DASH Center is made up of members with lived experience involving substance misuse and substance use disorder that helps inform our research. The multidisciplinary team guided by this lived experience has resulted in some of the best team science I’ve seen in my career.

There are multiple pathways into and out of substance misuse and often individual professional backgrounds are limited by their disciplinary lens to fully understand the complexity of substance misuse. For example, the developmental psychologist on our team stresses the developmental changes that take place when adolescents leave their parent’s home and assume responsibility for their own medication management during young adulthood. The people with lived experience share their experience of how these changes impacted how they obtained prescription medications. The psychiatrists discuss the disorders treated by these medications, prescribing guidelines, and the common course and severity of illness. The public health expert assesses the health benefits and risks associated with various interventions while the nurses and social workers explain associated comorbidities and what is realistic to expect in terms of families and resources in the community.

As a result of our team science approach, our team is able to address critical research questions that are highly relevant. For example, one common misperception is that prescription stimulant misuse during adolescence or young adulthood does not have long-term consequences. Some high school and college students engage in this behavior to improve concentration or help study. This study offers evidence that shows prescription stimulant misuse during late adolescence or young adulthood is associated with significant increased risk of substance use disorder symptoms later in life. These findings are important to change misperceptions.

What from your team’s findings most surprised you?

McCabe: We expected the prevalence of prescription drug misuse to be higher than prior studies because we were following the same individuals from ages 17-18 to age 50. We were somewhat surprised that nearly one-half of individuals reported prescription drug misuse between ages 18 and 50 is significant because it serves as a major wake-up call to take a closer look at our country’s relationship with these medications.

What mitigation practices can be best implemented to reduce the likelihood of patients failing to report/discuss their prescription drug misuse? What care team members are best involved?

McCabe: Health professionals are always looking for ways to identify individuals who will develop problems and those who will not. As I noted earlier, our team and others are using risk factors to find new ways to improve screening and the medication monitoring process. Care team members are often uncomfortable having these crucial and non-judgmental conversations. There are times when patients are filling out the intake form in a medical office or speaking with care team members and they want to tell them about their drug use, but it is easier to check the “no” boxes.

The first important question our care team should ask ourselves is, ‘What are we doing to encourage these individuals—who often fly under the radar of the current screening and monitoring process—to be more comfortable disclosing their drug use? ‘

The second question our care team members need to ask is, ‘What services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred following screening?’Screening is recommended when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.

One final take-home point of this study was our finding that most adults who reported prescription drug misuse shared households with their children. With over 20 million adults with substance use disorders in the United States, we must shift more attention towards the kids in these households. Our research team has consistently found that most children in the United States who have controlled substances in their own home have unsupervised access to these medications. When controlled substances are prescribed to patients, health professionals and families must take into account who else is in the household and how safety will be maintained. My own household has a lockbox for controlled substances, and I encourage others to do the same.

How does the ongoing pandemic likely affect the burden of PDM in the US?

McCabe: In the early stages, the pandemic was the perfect storm for relapse, overdose, and substance-related problems. The pandemic changed how many people who use drugs obtained drugs, and also how people got help if they developed serious problems. Increasingly, fentanyl is being added to a wide range of drugs, including fake prescription drugs, and this has increased the risk for overdose. The pandemic also increased stress for many people in recovery, due to job loss or working full-time from home with no child care, decreased responsibilities, disrupted sleep routines and decreased face-to-face social support. There is an expression in the recovery community: “Stay in the middle of the recovery herd, where you’re less likely to be picked off.” Initially, the pandemic made it harder for some people to stay in the middle of their recovery herd.

Over time, the pandemic has forced people who are recovering from substance use disorder to pivot and find new tools to recover. Substance use treatment is still being offered for those in need of treatment, as is halfway housing, but the reduction in face-to-face social support has made it more challenging for people to get connected to the help that they need. Prior to COVID, only one in four people struggling with addiction sought treatment for their substance use disorder. Finding help and support during COVID has become more challenging for the highest-risk people such as the homeless, parolees and those leaving substance use treatment.

One advantage to COVID is that it forced health professionals to adapt and provide more telehealth assessment, counseling and treatment. Some organizations already provided this service but many others have had to pivot to offer these services due to COVID. This has opened new opportunities that were not available prior to COVID. The online recovery community has grown tremendously during COVID and will continue to be an important resource for people who need virtual options for support meetings such as people who get COVID or high-risk people who cannot attend face-to-face support meetings due to health or other reasons.

I can envision more opportunities for precision medicine and opportunities to tailor substance use treatment with all the resources that will be available via telehealth to match the right treatment delivered by the right person at the right time. This is also applicable to long-term recovery. For example, I am aware of one recovery group that has been meeting online during the entire pandemic and health professionals refer their patients to the meeting during their hospitalization, so they have a supportive recovery community before they are discharged. This would not have been possible prior to COVID. We must learn from COVID to improve our batting average for getting people help they need, because our batting average was not good enough to keep us on any team roster before COVID.

Finally, prescription drug misuse and substance use disorders impact the entire family, and there are resources available to family members and children who need support. Sometimes people live with loved ones who refuse to get help for their prescription drug misuse. There are programs designed to help people in these situations take care of themselves whether their loved one stops using or not. There are online support groups, and health professionals are finding new ways to support families during the pandemic.