1. Running Head: RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 1
An Examination of the Socioeconomic Risk Factors
Associated with Prescription Drug Abuse
Kevin Tebrugge, D.O.
Florida A&M University
Author Note
Kevin Tebrugge, D.O., Institute of Public Health, Florida A&M University.
Correspondence concerning this paper can be addressed to Kevin Tebrugge, D.O., 7103
Towner Trace, Tallahassee, FL 32312 kevin1.tebrugge@famu.edu

2. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 2
Abstract
This paper examines seven published articles that report the relationship between the
socioeconomic status of patients and both perceived and actual misuse of prescription drugs.
Emphasis is placed on narcotic misuse. Research on this topic is currently limited. It is suggested
that further investigation be performed. Narcotic misuse is of considerable concern, especially in
the case of utilization for chronic non-malignant pain (CNMP).

3. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 3
An Examination of the Socioeconomic Risk Factors Associated with Prescription Drug Abuse
Introduction
Drug abuse is now estimated to be one of the most costly health problems in the United
States. The overall cost of drug abuse in 2002 was estimated at $ 180.9 billion in 2002,
increasing annually by 5.3% between 1992 and 2002 (Office of National Drug Control Policy,
2004). These costs include increases in criminal justice activity, loss of productivity, and costs
associated health care services (ONDCP, 2004). Factors such as impact on quality of life of the
individual and their family members were not considered in this data. By comparison, and based
on data from the 1990’s, drug abuse ($24.9 billion in 1995), can be compared to heart disease ($
183.1 billion in 1999), cancer ($96.1 billion in 1990) and diabetes 98.2 billion in 1997)
(ONDCP, 2004).
Since 2009, drug poisoning became the leading cause of injury death in the United States,
over- taking motor vehicle accidents (Morbidity and Mortality Weekly Report [MMWR, 2010]).
In attempting to understand the dramatic increase in poisoning fatalities, the CDC analyzed death
certificates from the National Center for Health Statistics and found that the majority listed
drugs, both legal and illegal, as the cause of death. (Paulozzi, Budnitz, and Xi, 2006). Among the
classes of prescription drugs abused, opioids, which are taken for pain relief, were the most
widely misused, far outweighing other classes of other prescription [United States Department of
Health and Human Services (HHS) Substance Abuse and Mental Health Services
Administration, National Survey on Drug Use and Health, 2010].
According to The International Association for the Study of Pain, pain is defined as “An
unpleasant sensory and emotional experience associated with actual or potential tissue damage”

4. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 4
[International Association for the Study of Pain (IASP), 1994]. Chronic nonmalignant pain
(CNMP) is pain unconnected to cancer that continues longer than the usual course of disease or
injury. It may or may not be associated with a pathologic process (Argoff, 2007).
In recent years, particularly in Florida, special attention has been paid to prescription opioid
use for CNMP. In 2010, Florida led the nation in diverted prescription drugs, resulting in seven
Floridians dying every day (Florida’s Prescription Drug Diversion and Abuse Roadmap 2012-
2015). Diversion occurs when a prescription is shared with others or used in a way not intended
by the prescriber.
Major Misuse Behaviors
In some cases, drugs are diverted when the medication is taken by someone other than the
intended patient. The patient can contribute to this form of diversion by sharing their unused pain
medication with family members, for example. Other instances occur when the opioids are stolen
from another person, pharmacy, hospital, or clinic. Medications may also be obtained in
exchange for sex, or purchased from the patient directly [National Institute of Drug Abuse
(NIDA), 2014].
Diversion can also occur when an individual takes medication in a greater quantity or in
manners other than stated by the directions. Usually, opioids are prescribed for oral use.
However, abusers may crush the tablets then snort or inject the powder, or smoke the powder in
order to facilitate entry of the opioid onto the bloodstream and therefore the brain. This tends to
amplify the effect (NIDA, 2014).
Opioids as a class can produce euphoric effects at higher doses, so taking them for the
purpose of getting high is one of the main reasons they are abused (NIDA, 2014).

5. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 5
The association between opioid misuses based on socioeconomic status has not been well
established. The purpose of this paper is to review current literature in an attempt to investigate
such a relationship.
Literary Review
One study that attempted to investigate such a correlation was “Trends in Use of Opioids for
Non-Cancer Pain 2000-2005 Among Mental Health and Substance Abuse Disorders” (TROUP,
2008). This study compared opioid use among a commercially-insured population, and
Medicaid enrollees between the years 2000-2005. The investigators found a higher rate of
opioid use for (CNMP) in the Medicaid group. These results were more pronounced in the
Medicaid enrollees who were prescribed opioids for CNMP and were dual diagnosed with
mental health or substance abuse disorders (Edlund, et al 2010). Spiller and colleagues also
found a consistent association between poverty rate, unemployment rate, and prescription opioid
rates, with prescription opioid drug use increasing as poverty and unemployment rates increased
(Spiller, Lorenz, Bailey& Dart, 2009). Niazi and colleagues evaluated data from 1994-2006 on
narcotic use in Pakistan, and concluded that the main cause of drug abuse was unemployment,
illiteracy, income inequality, and poverty (Niazi, Zaman, & Ikram, 2009).
Race, Age, and Socioeconomics
Primary care providers (PCPs) are commonly required to treat patients with CNMP. There
has been a rise in opioid prescriptions written by PCPs for the treatment of CNMP (Edlund et
al, 2010). This has resulted in an increase in opioid analgesic misuse, with an estimated
prevalence ranging from 9% - 41% in patients treated with opioids for CNMP (Edlund et al,
2010). One patient population often treated by PCPs that have been found to have a higher

6. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 6
prevalence of chronic pain (prevalence 40-60%) as well as mental health and substance abuse
disorders are those with HIV/AIDS (Hewitt, McDonald, Portenoy, 1997).
This population is important to study because mental health and substance abuse disorders
have been found to be significant risk factors for opioid analgesic misuse (Ives, Chelminki, &
Hammett-Stabler, 2006), Also, because they are HIV infected, they are risk for under treatment
of pain (Brietbart, Passik, & McDonald, 1998). In this population, physicians are more likely to
view non-Caucasian patients as having a higher risk of prescription opioid abuse (Burgess and
Crowley 2008). No evidence has been shown to verify this higher risk of misuse (Ives et al,
2006).
Recently, a study was conducted to evaluate PCP’s judgment on opioid abuse in HIV-
infected indigent adults (Vijayaraghavan, Penko, & Guzman, 2010). The authors purposely
selected patients who were indigent and living in poor, urban neighborhoods to reflect a group of
patients who might be thought to be at high risk for abuse. The researchers found that PCPs were
likely to overestimate abuse in young and African -American patients, despite the fact that
neither of these populations in the study were actually found to be at increased risk for misuse
(Vijayaraghavan, 2010).
Conclusions
Drug poisoning is the leading cause of injury death in the United States, and recent studies
have found that prescription opioids are most often the cause (ONDCP, 2004). Much attention
has recently been directed at the treatment of CNMP with opioids. The prevalence of opioid
misuse ranges between 9% - 41% in patients treated for CNMP. The use has increased
disproportionately in those living in poverty and with a history of mental health and substance

7. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 7
abuse disorders (Paulozzi, 2006). Physicians are more likely to perceive younger and non-
Caucasian patients as being at higher risk for opioid abuse; however, this conclusion has not
been supported by the medical literature (Vijayaraghavan, 2010).
Recommendations
This review suggests that clinicians may be relying upon racially based clinical stereotypes
when formulating conclusions about opioid diversion. Efforts need to be focused on recognizing
pain as a public health problem. New models of care are needed that address the root cause of
pain, which do not rely so heavily on the use of opioids.
Additionally, future efforts are needed to train health care providers about stereotypical
attitudes they may possess. This can be accomplished by focusing educational efforts on cultural
competence such that health care professionals can evaluate and communicate effectively with
diverse populations.

8. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 8
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10. RISK FACTORS ASSOCIATED WITH PRESCRIPTION DRUG ABUSE 9
Morbidity and Mortality Weekly Report 59 (2010):957
National Institute on Drug Abuse. Prescription Drugs & Cold Medicines Retrieved from
http://www.drugabuse.gov/drugs-abuse/prescription-drugs-cold-medicines on April 24,
2011
Paulozzi LJ, . Budnitz D, and Y. Xi, “ Increasing Death from Opioid Analgesics in the United
States,” Pharmacoepidemiology and Drug Safety 15 (2006): 618-627
Spiller H1
, Lorenz DJ, Bailey EJ, Dart RC. Epidemiological trends in abuse and misuse of
prescription opioids. J Addict Dis. 2009; 28(2): 130-6
Sullivan, M. D., Edlund, M. J., Fan, M.-Y., DeVries, A., Braden, J. B., & Martin, B. C. (2008).
Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and
Medicaid insurance plans: The TROUP Study. Pain, 138(2), 440–449.
doi:10.1016/j.pain.2008.04.027
Vijayaraghavan M, Penko J, Guzman D. Primary care providers’ judgment of opioid analgesic
misuse in a community-based cohort of HIV-infected indigent adults. J. Gen. Inter. Med.
2011 Apr, 26 (4) 412-418
United States Department of Health and Human Services. Substance Abuse and Mental Health
Services Administration. Center for Behavioral Health Statistics and Quality. National
Survey on Drug Use and Health, 2010. ICPSR32722-v5. Ann Arbor, MI: Inter-university
Consortium for Political and Social Research [distributor], 2014-06-26.
http://doi.org/10.3886/ICPSR32722.v5