Prescription Medication Misuse Among Service Members Epidemiology

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  • Prescription Medication Misuse Among Service Members Epidemiology
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  • 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
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  • Prescription Medication Misuse Definition Taking medications for non-intended uses, differently than prescribed, without a prescription or with interacting substances.
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  • Drugs frequently misused Analgesics Most commonly misused Oxycodone Methadone Hydrocodone (Vicodin ) Tranquilizers Diazepam (Valium) Stimulants Dextroamphetamine (Adderall ) Methylpenidate (Ritalin ) Sedatives Eszopiclone (Lunesta ) Zolpidem (Ambien )
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  • Medications Misused 2008 DoD Health Related Behaviors Survey of Active Duty Service Members, RTI 2008 National Survey on Drug Use and Health, SAMHSA
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  • 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
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  • 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
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  • 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.
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  • Civilian vs. Military Incidence of PMM Age 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
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  • 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.
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  • 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
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  • PMM by Age Group Service Members Vs. Civilian
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  • 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
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  • 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
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  • Medications Misused Data from 2008 DoD Health Related Behaviors Survey and 2008 National Survey on Drug Use and Health
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  • Misusers by Medication Category/ Total Misusers in Each Group
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  • Sources of Misused Medications
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  • 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
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  • Patterns of PMM Among Service Members Varied by rank Varied by service Varied by deployment history
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  • PMM by Military Rank Rates vary more by military rank (enlisted vs. officer) than by age
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  • 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 Doesnt explain the entire difference, particularly among senior enlisted who routinely have college degrees or higher
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  • PMM by Service Highest rates in the Army and Marine Corps Differences achieved statistical significance
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  • 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
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  • 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
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  • 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
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  • 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
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  • 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
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  • 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?
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  • 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)
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  • Non-Military Resources Su