Prescribing of Controlled Medications to Adolescents
and Young Adults in the United States
WHAT’S KNOWN ON THIS SUBJECT: The nonmedical use of
prescription drugs by adolescents and young adults has
surpassed all illicit drugs except marijuana and has become an
increasing public health concern. Adolescents and young adults
are in the most likely age groups to abuse prescription
medications.
WHAT THIS STUDY ADDS: This study’s results demonstrate
increasing rates of prescribing of controlled medications to
adolescents and young adults across multiple settings, including
ambulatory offices and emergency departments.

abstract

+

OBJECTIVE: The nonmedical use of prescription drugs by adolescents
and young adults has surpassed all illicit drugs except marijuana, yet
little is known about prescribing patterns. We examined the prescribing of controlled medications to adolescents aged 15 to 19 and young
adults aged 20 to 29.
METHODS: We used cross-sectional data from the National Ambulatory
Medical Care Survey (N ϭ 4304 physicians) and the National Hospital
Ambulatory Medical Care Survey (N ϭ 2805 clinics; N ϭ 1051 emergency departments) between 2005 and 2007. We also used consecutive
data from 1994 to describe trends.

AUTHORS: Robert J. Fortuna, MD, MPH,a,b,c Brett W.
Robbins, MD,a,b,c Enrico Caiola, MD,a,b Michael Joynt,
MD,a,b and Jill S. Halterman, MD, MPHc
a

Center for Primary Care, bDepartment of Internal Medicine, and
Strong Children’s Research Center, Department of Pediatrics,
University of Rochester School of Medicine and Dentistry,
Rochester, New York
c

KEY WORDS
adolescent, teen, young adult, prescribing, controlled
medication, opioid, sedative, hypnotic, stimulant
ABBREVIATIONS
NSDUH—National Survey on Drug Use and Health
NAMCS—National Ambulatory Medical Care Survey
NHAMCS—National Hospital Ambulatory Medical Care Survey
NCHS—National Center for Health Statistics
All authors made substantial contributions to the conception
and design, interpretation of data, drafting and revising of the
manuscript, and final approval for publication.
www.pediatrics.org/cgi/doi/10.1542/peds.2010-0791
doi:10.1542/peds.2010-0791
Accepted for publication Aug 26, 2010
Address correspondence to Robert J. Fortuna, MD, MPH, Center
for Primary Care, Culver Medical Group, University of Rochester
School of Medicine and Dentistry, 913 Culver Rd, Rochester, NY
14609. E-mail: robert_fortuna@urmc.rochester.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.

RESULTS: A controlled medication was prescribed at 2.3 million visits
by adolescents and 7.8 million visits by young adults in 2007. Between
1994 and 2007, controlled medications were prescribed at an increasing proportion of visits from adolescents (6.4%–11.2%) and young
adults (8.3%–16.1%) (P Ͻ .001 for trend). This increase was seen
among males and females, in ambulatory offices and emergency departments, and for injury-related and non–injury-related visits (all P Ͻ
.001). A controlled medication was prescribed during 9.6% of all adolescent visits and 13.8% of young-adult visits for non–injury-related
indications and at 14.5% of adolescent visits and 27.0% of young-adult
visits for injury-related reasons. Controlled medications were prescribed at a substantial proportion of visits for common conditions,
such as back pain, to both adolescents (23.4%) and young adults
(36.9%).
CONCLUSIONS: Controlled medications are prescribed at a considerable proportion of visits from adolescents and young adults, and prescribing rates have nearly doubled since 1994. This trend and its relationship to misuse of medications warrants further study. Pediatrics
2010;126:1108–1116

1108

FORTUNA et al

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 ARTICLES

The nonmedical use of prescription
medications has increased by 162% in
the past decade and has surpassed all
illicit drugs except marijuana in the
United States.1 Adolescents and young
adults are in the age groups most
likely to abuse prescription medications.1–3 In the National Survey on Drug
Use and Health (NSDUH), 12.6% of adolescents between the ages of 12 and 17
years and 31.4% of young adults reported nonmedical use of prescription
medications at some point in their
lifetime.4
An inherent tension exists between adequately treating individual patient’s
symptoms while remaining cognizant
of the growing nonmedical use of prescription medications. Numerous patient advocacy groups, state medical
boards, and the Joint Commission on
the Accreditation of Hospitals have focused physician efforts on adequately
treating pain,5,6 which has led, in part,
to an increase in national opioid consumption. Between 1997 and 2006, the
sale of oxycodone increased by 732%,
hydrocodone by 244%, and methadone
by 1177%.1 At the same time, sedativehypnotic medications became among
the mostly widely advertised medications to patients, and sales have increased substantially.7,8
Concurrently, there has been an increase in the abuse of prescription
medications.1,3,6 Motivations for misuse of prescription medications are
broad and range from self-treatment
of various conditions (ie, pain, insomnia, difficulty concentrating) to recreational use.9,10 Although the motivations for misuse vary, the use of
prescriptions medications without
physician supervision imposes considerable risk. Similar to illicit street
drugs, the nonmedical use of prescription medications is associated with unintentional overdoses, trauma, and
high-risk behavior.3,11–15 In fact, emergency department visits that involve
PEDIATRICS Volume 126, Number 6, December 2010

the nonmedical use of narcotic pain relievers have more than doubled in recent years.15 In addition, the nonmedical use of prescription medications is
associated with other forms of substance and alcohol abuse.11,12
Prescription medications reportedly
are easier to obtain than illicit street
drugs16 and are most commonly obtained from friends and relatives.17
Overall, reports of diversion of prescription medications range from 24%
among adolescents to 35.8% among
college students.18,19 Although adolescents and young adults are in the age
groups most likely to abuse prescription medications,1 few data exist about
the prescribing of controlled medications to adolescents and young adults.
Our goals were to describe the frequency of prescriptions for controlled
medications (opioids, sedative-hypnotics,
stimulants) provided to adolescents
and young adults between 2005 and
2007, determine trends in prescribing,
identify factors associated with prescribing, and describe indications for
prescribing controlled medications to
adolescents and young adults.

METHODS
Data Source
We used cross-sectional data from the
National Ambulatory Medical Care Survey (NAMCS) and the National Hospital
Ambulatory Care Survey (NHAMCS) to
examine the prescribing of controlled
medications to adolescents and young
adults. The NAMCS and NHAMCS are
both conducted yearly by the National
Center for Health Statistics (NCHS) and
the Centers for Disease Control and
Prevention; US Census Bureau employees act as the field agents for data
collection. The surveys use a multistage probability design to select a
stratified systematic sample of visits
to physician practices, outpatient departments, and emergency departments.20,21 The data are weighted to

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produce national estimates of utilization of ambulatory and emergency
medical care in the United States.20,21 A
comprehensive description of the
methods used for sampling, data collection, and weighting are available online at www.cdc.gov/nchs/ahcd.htm.
Study Time Period and Age Groups
Our primary analyses were focused on
the most recent data available from
2005 to 2007. To assess trends in utilization, we used data from 1994 to 2007.
We evaluated adolescents between 15
and 19 years of age and defined young
adults as those between 20 and 29
years of age on the basis of previous
studies.22,23
Classification of Controlled
Medications
We defined a controlled medication as
any scheduled medication regulated
by the Drug Enforcement Agency and
used classifications provided by the
NAMCS and NHAMCS to categorize
controlled medications as pain medications/opioids, sedative-hypnotics,
stimulant medications, or other medications. Between 1994 and 2005, the
NAMCS and NHAMCS classified medications on the basis of the National Drug
Code Directory.20,21,24 Beginning in
2006, the NAMCS and NHAMCS assigned drug codes and classifications
on the basis of Multum’s Lexicon Drug
Database.20,21
Table 1 lists the classification codes
used to define subtypes of controlled
medications. We classified miscellaneous controlled medications including scheduled antitussive medications,
medications containing butalbital (eg,
Fiorinal), sibutramine (Meridia), anabolic steroids, antidiarrheal medications (eg, Lomotil), certain anesthetics, and antimigraine medications as
“other” medications. Nonscheduled
medications, such as Nubain, butor1109

 TABLE 1 Classification of Controlled Medications on the Basis of National Drug Codes and
Multum’s Lexicon Drug Codes
Medication Class

National Drug Code

Multum’s Lexicon Drug Codes

Pain
Sedative-hypnotic
Stimulant

1720, 1721, or 1722
0626, 0627, 0634, 1374, or 1373
0631

060, 063, or 191
201, 203, 068, 069, 070, 178, of 179
071 or 253

phanol, and tramadol, were not included in these analyses.
Reason for Visits
To describe the principle reason for
visits during which a controlled medication was prescribed, we used the
“most important” reason for the visit
as identified by the patient. We
grouped visits into general categories
(eg, injury, back pain, chest pain)
based on the primary reason for visitclassifications codes provided by the
NAMCS/NHAMCS and report the specific codes for each category in Supplemental Table 6. For the majority of visits, only a single reason for the visit
was listed. When applicable, we also
report the 2 most common secondary
reasons for visits in Supplemental
Table 7.
Statistical Analysis
We performed all statistical analyses
by using SAS 9.1 (SAS Institute Inc,
Cary, NC) and SAS-callable SUDAAN (Research Triangle Institute, Research Triangle Park, NC) to appropriately
weight visits and account for the complex sampling design. We used ␹2 test
statistics, accounting for the complex
sampling design, to compare all proportions. We stratified our analyses on
the basis of injury status and defined
an injury-related visit as any visit related to a traumatic injury, poisoning,
or adverse effect of medical treatment
on the basis of established variables in
the NAMCS and NHAMCS.20,21
We compared the characteristics of
patient visits during which a controlled medication was prescribed for
both adolescent and young adults,
stratified according to injury status.
1110

FORTUNA et al

We subsequently developed logistic regression models to evaluate for racial
and regional differences in prescribing while controlling for potential confounders. On the basis of previous literature and clinical significance, we
included age, site of care (outpatient
office or emergency department), gender, race, ethnicity, insurance, region
of the country, and metropolitan status in the model. To account for clinical
and statistical evidence of effect modification according to injury status, we
developed separate logistic regression models for each level of injury status (injury related or non–injury related) for adolescents and young
adults. To account for sickle cell– and
cancer-related pain, we reran key
analyses excluding any visits for sickle
cell or cancer. To enhance our identification of visits related to sickle cell disease, we used both diagnosis and
probable diagnosis ICD 9 codes including 28260, 28262, 28264, 28269, 51730,
28952, 28241, and 28242.
Last, we used logistic regression to assess for trends in the prescribing of
controlled medications between 1994
and 2007 for adolescents and young
adults. We combined the data into
2-year increments to increase sample
size and for ease of interpretation. We
modeled whether a controlled medication was prescribed at a visit (yes/no)
against year, similar to previous studies.25 We reported P values associated
with the trend in prescribing on the
logic scale over the years studied.
To ensure reliability of national estimates, the NCHS has established strict
release standards for data based on
the relative SE of the point estimate

(Ͼ30% considered unreliable) and the
absolute number of visits (Ͻ30 considered unreliable).12,13 All values reported meet the established release
criteria for national estimates, unless
otherwise noted. This study was approved by the University of Rochester
Research Subjects Review Board, and
the protocols used by the NAMCS were
approved by the NCHS institutional review board.19

RESULTS
Between 2005 and 2007, 4304 physicians
participated in the NAMCS (65.1% participation), and 2805 hospital-based outpatient clinics (85.0% participation) and
1051 emergency departments (88.8%
participation) participated in the
NHAMCS. Table 2 lists unweighted and
weighted characteristics of the data
between 2005 and 2007.
Trends
A controlled medication was prescribed at 2.3 million visits by adolescents (aged 15–19 years) and at 7.8
million visits by young adults (aged
20 –29 years) in 1994, and that number
increased to 5.7 million visits by adolescents and 18.6 million visits by
young adults in 2007. Figure 1 shows
the rates of prescribing of controlled
medications between 1994 and 2007.
Over this time period, controlled medications were prescribed at an increasing proportion of adolescent visits (6.4 –11.2%; P Ͻ .001 for trend) (Fig
1A) and young-adult visits (8.3–16.1%;
P Ͻ .001 for trend) (Fig 1B). For young
adults, the trend for opioids was modest before 2001 (Fig 1B; P ϭ .14 for
trend) and increased considerably after 2001 (P Ͻ .001 for trend), which
corresponds with the introduction of
the Joint Commission on the Accreditation of Hospitals initiative to improve
pain control. These increasing rates of
prescribing were seen across multiple
settings and for both injury-related
and non–injury-related visits (Table 3).

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 ARTICLES

TABLE 2 Visits Recorded in the NAMCS and the NHAMCS Between 2005 and 2007
Unweighted Visits, n

Weighted Visits, n (%)

55 189

486.344 million (100)

29 785
25 404

400.546 million (82.4)
85.799 million (17.6)

17 130
38 059

160.776 million (33.1)
325.568 million (66.9)

35 956
19 233

322.755 million (66.4)
163.588 million (33.6)

39 087
13 055
3047

387.719 million (79.7)
74.796 million (15.4)
23.830 million (4.9)

10 140

70.222 million (14.4)

14 683
12 962
17 220
10 324

94.695 million (19.5)
115.270 million (23.7)
185.105 million (38.1)
91.276 million (18.7)

20 359
18 634
10 110
4776

269.926 million (56.7)
108.748 million (22.9)
54.849 million (11.5)
42.543 million (8.9)

Total
Site
Ambulatorya
Emergency departmentb
Age
Adolescent (15–19 y)
Young adult (20–29 y)
Gender
Female
Male
Race
White
Black
Otherc
Ethnicity
Hispanicd
Region
Northeast
Midwest
South
West
Insurance
Private
Public
Uninsured
Othere
a

Ambulatory data are from the NAMCS and the outpatient portion of the NHAMCS.
Emergency department data are from the NHAMCS.
c Includes Asian, Native Hawaiian, American Indian, Alaskan Native, and more than 1 race.
d Hispanic ethnicity, any race.
e Includes worker’s compensation, other forms of payment, and unknown source of expected payment.
b

Prescriptions for multiple controlled
medications similarly increased over
this time period. Between 1994 –1995
and 2006 –2007, more than 1 controlled medication was prescribed at
an increasing proportion of visits by
adolescents (0.4 –1.7%; P Ͻ .001) and
young adults (0.5–3.2%; P Ͻ .001).
Visit Characteristics
Table 4 lists the characteristics of visits during which a controlled medication was prescribed between 2005 and
2007. Overall, a controlled medication
was prescribed to adolescents at 9.6%
of non–injury-related and 14.5% of
injury-related visits. Similarly, a controlled medication was prescribed to
young adults at 13.8% of non–injuryrelated and 27.0% of injury-related visits. Controlled medications were more
commonly prescribed at visits from
young adults compared with adolesPEDIATRICS Volume 126, Number 6, December 2010

cents for both injury-related and non–
injury-related indications (P Ͻ .001 for
both).
Controlled medications were more
commonly prescribed in the emergency department than in ambulatory
offices and in the South and West compared with the Northeast. Controlled
medications were consistently prescribed at higher rates to patients
without insurance compared with
those with private insurance. Modest
gender and racial differences were
found among young adults at non–
injury-related visits.
Indications
Figure 2 lists the primary reason for
visits during which a controlled medication was prescribed to adolescents
and young adults. Musculoskeletal
complaints and back pain (19%) were

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the most common principle reason for
visits, followed by injury (12%) and
psychiatric illness/insomnia (11%).
Table 5 lists prescribing rates of controlled medications for specific indications in both the outpatient and emergency department settings. These
indications are the principle reasons
for visits during which a controlled
medication was prescribed. A controlled medication was prescribed at
23.4% of visits by adolescents and
36.9% of visits by young adults in which
back pain was listed as the principle
reason for the visit. Similarly, a controlled medication was prescribed at
13.0% of all visits by adolescents and
at 24.0% of all visits by young adults
for headaches. Controlled medications
were more commonly prescribed at visits by young adults than by adolescents
for most of the indications evaluated.
Visits for a diagnosis related to sickle
cell disease, tumors, masses, or malignancy accounted for 0.2% of all adolescent and 0.7% of all young-adult visits
during which a controlled medication
was prescribed. Exclusion of these visits from the analyses did not change
any key findings.

DISCUSSION
The nonmedical use of prescription
drugs by adolescents and young adults
has surpassed all illicit drugs except
marijuana and has become an increasing public health concern.1,3 The results of this study demonstrate increasing rates of prescribing of
controlled medications to adolescents
and young adults across multiple settings, including ambulatory offices and
emergency departments. Overall, a
controlled medication was prescribed
at ϳ1 of every 6 visits by young adults
and ϳ1 of every 9 visits by adolescents. Although the increased prescribing of controlled medications
does not necessarily foster misuse or
1111

 Percentage of v isits with controlled
medicaƟon prescribed

A

diversion, the current trends warrant
vigilance.

18
All controlled medicaƟons
16

Opioid
SedaƟve-hypnoƟc

14

SƟmulant

12
10
8
6
4
2
0
1994-5

1996-7

1998-9

2000-1

2002-3

2004-5

2006-7

We found that prescriptions for controlled medications, including opioids,
sedative-hypnotics, and stimulants, increased over the study period (1994 –
2007) among adolescents and young
adults, consistent with trends previously observed in other age groups.25,26
This increase in prescribing of controlled medications was observed for
both males and females and across multiple settings (ambulatory offices and
emergency departments) and for injuryrelated and non–injury-related visits.

Year

B

18
All controlled medicaƟons
16

Opioid

Percentage of visits with controlled
medicaƟon prescribed

SedaƟve-hypnoƟc
14

SƟmulant

12
10
8
6
4
2
0
1994-5

1996-7

1998-9

2000-1

2002-3

2004-5

2006-7

Year

FIGURE 1
Percentage of visits during which controlled medications were prescribed to adolescents (A) and
young adults (B) from 1994 to 2007 in the NAMCS and the NHAMCS. For the data shown in A, P Ͻ .001
for trend for all; for the data shown in B, P Ͻ .001 for trend for all controlled medications, opioids, and
sedative-hypnotics, and P ϭ .09 for trend for stimulants.

TABLE 3 Percentage of Visits During Which a Controlled Medication Was Prescribed
Adolescents, Ages 15–19 y

All
Site of care
Ambulatory office
Emergency
department
Injurya
Injury related
Non–injury related
Gender
Female
Male
a

Young Adults, Ages 20–29 y

1994–1996

2005–2007

P

1994–1996

2005–2007

P

6.2

10.6

Ͻ.001

8.3

15.9

Ͻ.001

4.6
13.5

8.1
23.9

Ͻ.001
Ͻ.001

6.2
18.7

11.7
34.3

Ͻ.001
Ͻ.001

8.4
5.2

14.5
9.6

Ͻ.001
Ͻ.001

12.1
7.0

27.0
13.8

Ͻ.001
Ͻ.001

4.9
8.0

9.7
11.9

Ͻ.001
.002

7.3
10.7

14.1
20.1

Ͻ.001
Ͻ.001

Injury includes traumatic injuries, poisonings, or adverse effects of medical treatment.

1112

FORTUNA et al

This rising trend in prescribing of controlled medications was most pronounced for opioids prescribed to
young adults, particularly after 2001,
which corresponds with the Joint Commission on the Accreditation of Hospitals initiative to treat pain as a fifth
vital sign. We found a similar increase,
although less pronounced, in the prescribing of opioids to adolescents.
These increases are possibly attributable, in part, to evolving federal and
state regulations, increased advocacy,
and increased physician comfort with
opioids. Although increased prescribing augments the potential availability
of opioids, it does not necessarily lead
to diversion or abuse. The NSDUH recently reported that the nonmedical
use of prescription opioids continues
to increase among young adults but is
beginning to decline slightly for adolescents.27 Although nonmedical use
among adolescents is beginning to decline, the Drug Abuse Warning Network
recently found that emergency department visits that involve the nonmedical
use of narcotic pain relievers has
more than doubled between 2004 and
2008.15 Overall, potential associations
between population-level prescribing
patterns of opioids and misuse or diversion is complex and warrants further study to further elucidate the
relationship.

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 PEDIATRICS Volume 126, Number 6, December 2010

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.04

10.0
7.1

9.3
11.8

6.7
7.6
12.1
10.5

.09

Ͻ.001

Ͻ.001

.35

9.7
10.3
6.6

8.3
10.7
19.4
87.3

.06

Ͻ.001

P

9.0
10.8

8.3
21.0

9.6

Percent
of Visits

1.0
1.2 (0.9–1.6)

1.0
1.1 (0.7–1.6)
1.8 (1.3–2.5)
1.8 (1.3–2.6)

1.0
1.3 (1.0–1.7)
2.1 (1.4–3.3)
0.8 (0.5–1.4)

1.0
0.6 (0.4–0.9)

1.0
0.8 (0.6–1.2)
0.6 (0.3–1.2)

1.0
1.3 (1.1–1.6)

1.0
2.7 (2.2–3.4)

Adjusted Odds Ratio
(95% Confidence
Interval)a

Non–Injury-Related Visit

14.7
13.4

8.0
11.5
18.7
18.5

11.3
16.8
28.0
19.5

14.6
13.6

14.2
16.6
13.0

14.0
14.9

7.2
27.4

14.5

Percentage
of Visits

.67

.001

Ͻ.001

.71

.69

.67

Ͻ.001

P

1.0
0.8 (0.5–1.2)

1.0
1.5 (1.0–2.5)
2.6 (1.5–4.5)
2.6 (1.5–4.6)

1.0
1.3 (0.8–2.0)
1.6 (1.0–2.6)
1.5 (0.8–2.7)

1.0
0.8 (0.5–1.3)

1.0
0.7 (0.5–1.1)
0.7 (0.3–1.6)

1.0
1.1 (0.8–1.7)

1.0
4.5 (2.8–7.4)

Adjusted Odds Ratio
(95% Confidence
Interval)a

Injury-Related Visit

Adolescents, Ages 15–19 y

13.7
14.8

10.4
12.7
15.6
14.8

13.1
14.4
19.2
10.0

14.3
11.3

14.4
12.5
9.5

12.5
17.6

10.7
32.6

13.8

b

.59

.001

Ͻ.001

.02

.009

Ͻ.001

Ͻ.001

P

1.0
1.0 (0.7–1.4)

1.0
1.3 (1.0–1.6)
1.6 (1.3–2.1)
1.7 (1.3–2.2)

1.0
1.1 (0.9–1.3)
1.0 (0.8–1.2)
0.6 (0.4–0.9)

1.0
0.7 (0.6–0.9)

1.0
0.6 (0.5–0.8)
0.6 (0.4–0.9)

1.0
1.4 (1.2–1.6)

1.0
4.2 (3.6–4.9)

Adjusted Odds Ratio
(95% Confidence
Interval)a

27.4
24.5

20.8
23.2
32.2
26.9

21.7
35.3
38.1
20.1

27.2
25.4

26.5
29.8
24.5

28.0
26.2

19.5
37.2

27.0

Percentage
of Visits

Young Adults, Ages 20–29 y
Non–Injury-Related Visit
Percentage
of Visits

Adjusted for all covariates listed.
Other includes Asian, Native Hawaiian/other Pacific Islander, American Indian/Alaska Native, and patients with more than 1 race reported.
c Any race.
d Other insurance includes worker’s compensation, other forms of payment, and unknown source of expected payment.
e Metropolitan indicates a metropolitan sampling area. Rural includes nonmetropolitan sampling areas, including rural areas and micropolitan areas.

a

Total
Site of care
Ambulatory office
Emergency department
Gender
Female
Male
Race
White
Black
Otherb
Ethnicityc
Non-Hispanic
Hispanic
Insurance
Private
Public
Uninsured
Otherd
Region
Northeast
Midwest
South
West
Metropolitane
Metropolitan
Rural

Characteristic

TABLE 4 Characteristics of Patient Visits During Which a Controlled Medication Was Prescribed Between 2005 and 2007

.33

.006

Ͻ.001

.52

.42

.41

Ͻ.001

P

1.0
0.8 (0.6–1.1)

1.0
1.2 (0.9–1.7)
1.9 (1.4–2.6)
1.6 (1.0–2.4)

1.0
1.8 (1.4–2.5)
1.6 (1.2–2.2)
1.0 (0.8–1.4)

1.0
0.9 (0.6–1.2)

1.0
0.9 (0.7–1.1)
0.9 (0.5-1.6)

1.0
0.9 (0.8–1.2)

1.0
2.2 (1.6–2.9)

Adjusted Odds Ratio
(95% Confidence
Interval)a

Injury-Related Visit

ARTICLES

1113

 Preop/postopa
Derm 2%
3%
General illness
3%

consumer marketing likely fueled the
increased prescribing of sedativehypnotics.7,8 Over a similar time period,
sedative misuse among 12th-graders
increased through the 1990s, peaked
in the mid-2000s, and is now slowly declining.2,28 The nonmedical use of
sedative-hypnotic medications among
young adults, however, has continued
to slowly rise.28

Heme/oncb
1%
Other
3%

GU
4%

Back/musculoskeletal
pain
19%

Headache, neurologic
6%

Chest pain/resp
symptoms
7%

Injury
12%

GI
8%

General follow-up
12%

ORLc
9%

Psych/insomnia
11%

FIGURE 2
Primary reason for visits during which an opioid was prescribed to adolescents and young adults from
2005 to 2007 in the NAMCS and the NHAMCS. Descriptions of visit codes, including outpatient and emergency
department settings, are available in Supplemental Table 6. a Preoperative/postoperative (preop/postop)
includes procedures; b includes sickle cell disease; c otolaryngology (ORL) includes tooth, mouth, and ear
pain in addition to other symptoms referable to the ears, nose, and throat. Derm indicates dermatologic;
GU, genitourinary; Resp, respiratory; GI, gastrointestinal; Heme/onc, hematologic/oncologic.

TABLE 5 Percentage of Visits for Specific Indication During Which a Controlled Medication Was
Prescribed Between 2005 and 2007 in the NAMCS and NHAMCS
Primary Reason for Visita
Headache
Any
Opioid
Back pain
Any
Opioid
Musculoskeletal
Any
Opioid
Injury
Any
Opioid
Psychiatricb
Any
Sedative-hypnotic
Stimulant
Abdominal painc
Any
Opioid

Adolescent, Ages 15–19 y

Young Adult, Ages 20–29 y

P

13.0
12.7

24.0
16.4

.01
.33

23.4
21.5

36.9
33.4

.008
.01

12.9
11.3

26.2
24.8

Ͻ.001
Ͻ.001

16.6
15.0

26.3
24.3

Ͻ.001
Ͻ.001

31.2
8.9
22.7

32.1
21.0
7.1

.84
Ͻ.001
Ͻ.001

15.9
13.0

28.2
26.8

Ͻ.001
Ͻ.001

a

Descriptions of visit codes are listed in Supplemental Table 6; includes outpatient and emergency department settings.
Psychiatric includes depression, anxiety, and symptoms referable to psychological and mental disorders; excludes primary insomnia.
c Excludes appendicitis or hernia.
b

Sedative-hypnotic medications also
were prescribed at an increasing rate
to both adolescents and young adults.
1114

FORTUNA et al

Increasing awareness of insomnia and
anxiety, the availability of new pharmaceuticals, and widespread direct-to-

We found that stimulant medications
were prescribed to adolescents at an
increasing rate over the study period,
similar to previously observed
trends.29–31 Over a similar time period
between 2002 and 2008, however, the
misuse of methylphenidate (Ritalin)
and other prescription-like stimulant
medications decreased among adolescents and young adults.2,3,28 Despite the
decline in reported misuse, a recent
study29 revealed an increase in poisoncenter calls related to intentional misuse of stimulant medications, possibly
related to increasing intensity of misuse. In addition, reports of lifetime
rates of diversion of stimulant medications have ranged from 16% to 29%,32
which emphasizes the need to adequately address potential diversion.
Overall, prescribing of controlled medications varied according to several
factors. Controlled medications were
more commonly prescribed to young
adults than adolescents for both
injury-related and non–injury-related
indications, possibly related to prescribing differences between pediatric
and adult-focused providers or differences in presenting complaints. Similarly, rates of misuse of prescription
medications are highest among young
adults.3
Prescribing patterns also varied according to geographic region. Controlled medications were prescribed
at higher rates in the South and West
compared with the Northeast in the
United States, possibly because of regional practice differences and state

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 ARTICLES

regulations that vary considerably.26,33
Regional variations in misuse of prescription medications have also been
reported. The NSDUH34 reported the
highest rates of misuse in the South
and West among people aged 12 years
and older. However, the Monitoring the
Future Survey2 revealed less regional
variability in misuse among 12thgraders, and an NSDUH follow-up analysis of substate regions revealed substantial heterogeneity of nonmedical
prescription use within substate regions.35 Potential associations between regional prescribing patterns
and rates of misuse are complex and
difficult to observe when using broad
geographic regions.
We found that controlled medications,
most commonly opioids, were prescribed at a considerable proportion
of encounters for common indications.
A controlled medication was prescribed at nearly one-quarter of adolescent visits and 37% of visits by
young adults with back pain listed as
the primary reason for the visit. Similarly, a controlled medication was prescribed at 13% of adolescent visits and
nearly one-quarter of visits by young
adults for headaches.
Controlled medications are an important treatment modality for a variety of
conditions, and, in some instances,
symptoms are inadequately con-

trolled.5,36 Physicians, therefore, must
balance the fundamental need to adequately treat conditions that require
controlled medications while remaining cognizant of the potential misuse
and diversion of these medications. Although clinical guidelines are available to support treatment of pain and
other conditions,37,38 physicians often
feel ill equipped.39 In addition, many of
them do not routinely ask about prescription drug abuse and frequently
do not obtain records from previous
physicians before prescribing controlled medications.17,40 In the setting
of a hurried and often fragmented
health care delivery system, increased
awareness, improved education, and
enhanced communication are needed.
This study has several limitations.
Most notably, we were unable to distinguish whether a prescription for a controlled medication was ultimately used
for legitimate medical indications or
diverted for nonmedical use. Second,
we were unable to determine how
many pills or refills were given with
each prescription. Third, the NAMCS
and NHAMCS provide encounter-level
rather than individual-level data,
which precludes any longitudinal analysis. Last, we reported the primary
reason for visits during which a controlled medication was prescribed, recorded as the “most important”
patient-identified reason for the visit.

Because several conditions may be addressed at any 1 visit, the primary reason for a visit may not necessarily be
the indication for the controlled medication. Secondary reasons, however,
were listed for fewer than half of the
visits during which a controlled medication was prescribed and were
mostly all supportive of the primary indication (Supplemental Table 7).

CONCLUSIONS
Controlled medications are prescribed at a considerable proportion
of all visits by adolescents and young
adults, and rates have nearly doubled
since 1994. Although the increased
prescribing of controlled medications
does not necessarily foster abuse or
diversion, these increasing trends do
warrant vigilance. Potential associations between prescribing patterns
and misuse or diversion are complex
and merit further study. In the setting
of rising prescribing trends, increased
awareness and improved strategies
are needed to ensure adequate treatment for patients and mitigate the potential for nonmedical use of controlled medications.

ACKNOWLEDGMENT
Dr Fortuna received support from the
Center for Primary Care, University of
Rochester.

REFERENCES
1. Manchikanti L, Singh A. Therapeutic opioids:
a ten-year perspective on the complexities
and complications of the escalating use,
abuse, and nonmedical use of opioids. Pain
Physician. 2008;11(2 suppl):S63–S88

National Findings. Rockville, MD: Substance
Abuse and Mental Health Services
Administration; 2009. Office of Applied Studies, NSDUH Series H-36, HHS publication
SMA 09-4434

2. Johnston LD, O’Malley PM, Bachman JG,
Schulenberg JE. Monitoring the Future
National Survey Results on Drug Use,
1975–2008: Volume I, Secondary School
Students. Bethesda, MD: National Institute on Drug Abuse; 2009. NIH publication
09-7402

4. Substance Abuse and Mental Health Services Administration. Results From the 2007
National Survey on Drug Use and Health:
National Findings. Rockville, MD: Substance
Abuse and Mental Health Services
Administration; 2008. Office of Applied Studies, NSDUH Series H-34, DHHS publication
SMA 08-4343

3. Substance Abuse and Mental Health Services Administration. Results From the 2008
National Survey on Drug Use and Health:

PEDIATRICS Volume 126, Number 6, December 2010

5. Phillips DM. JCAHO pain management standards are unveiled: Joint Commission on

Downloaded from by guest on September 20, 2016

Accreditation of Healthcare Organizations.
JAMA. 2000;284(4):428 – 429
6. Kuehn BM. Opioid prescriptions soar: increase in legitimate use as well as abuse.
JAMA. 2007;297(3):249 –251
7. Kessler DA, Levy DA. Direct-to-consumer
advertising: is it too late to manage the
risks? Ann Fam Med. 2007;5(1):4 –5
8. Catlin A, Cowan C, Hartman M, Heffler S; National Health Expenditure Accounts Team.
National health spending in 2006: a year of
change for prescription drugs [published
correction appears in Health Aff (Millwood). 2008;27(2):593]. Health Aff (Millwood). 2008;27(1):14 –29

1115

 9. Boyd CJ, McCabe SE, Cranford JA, Young A.
Adolescents’ motivations to abuse prescription medications. Pediatrics. 2006;
118(6):2472–2480
10. McCabe SE, Boyd CJ, Teter CJ. Subtypes of
nonmedical prescription drug misuse. Drug
Alcohol Depend. 2009;102(1–3):63–70
11. McCabe SE, Cranford JA, West BT. Trends in
prescription drug abuse and dependence,
co-occurrence with other substance use
disorders, and treatment utilization: results
from two national surveys. Addict Behav.
2008;33(10):1297–1305
12. Garnier LM, Arria AM, Caldeira KM, Vincent
KB, O’Grady KE, Wish ED. Nonmedical prescription analgesic use and concurrent alcohol consumption among college students. Am J Drug Alcohol Abuse. 2009;35(5):
334 –338
13. Sung HE, Richter L, Vaughan R, Johnson PB,
Thom B. Nonmedical use of prescription opioids among teenagers in the United States:
trends and correlates. J Adolesc Health.
2005;37(1):44 –51
14. Hall AJ, Logan JE, Toblin RL, et al. Patterns of
abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300(22):
2613–2620
15. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The DAWN report: trends in emergency
department visits involving nonmedical use
of narcotic pain relievers. Available at:
www.oas.samhsa.gov/2k10/dawn016/
opioided.htm. Accessed June 18, 2010
16. Friedman RA. The changing face of teenage
drug abuse: the trend toward prescription
drugs. N Engl J Med. 2006;354(14):
1448 –1450
17. Manchikanti L. National drug control policy
and prescription drug abuse: facts and fallacies. Pain Physician. 2007;10(3):399 – 424
18. Boyd CJ, McCabe SE, Cranford JA, Young A.
Prescription drug abuse and diversion
among adolescents in a southeast Michigan
school district. Arch Pediatr Adolesc Med.
2007;161(3):276 –281
19. Garnier LM, Arria AM, Caldeira KM, Vincent
KB, O’Grady KE, Wish ED. Sharing and selling
of prescription medications in a college student sample. J Clin Psychiatry. 2010;71(3):
262–269
20. National Center for Health Statistics. NCHS
public-use data files and documentation:
National Ambulatory Medical Care Survey

1116

FORTUNA et al

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

(NAMCS)—1996, 1997, 1998, 1999, 2000,
2001, 2002, 2003, 2004, 2005, 2006. Available
at: ftp://ftp.cdc.gov/pub/health_statistics/
nchs/datasets/namcs. Accessed August 13,
2010
National Center for Health Statistics. NCHS
public-use data files and documentation:
National Hospital Ambulatory Medical Care
Survey (NHAMCS)—1996, 1997, 1998, 1999,
2000, 2001, 2002, 2003, 2004, 2005, 2006.
Available at: ftp://ftp.cdc.gov/pub/health_
statistics/nchs/dataset_documentation/
nhamcs. Accessed August 13, 2010
Fortuna RJ, Robbins BW, Mani N, Halterman
JS. Dependence on emergency care among
young adults in the United States. J Gen Intern Med. 2010;25(7):663– 669
Fortuna RJ, Robbins BW, Halterman JS. Ambulatory care among young adults in the
United States. Ann Intern Med. 2009;151(6):
379 –385
US Food and Drug Administration. National
drug code directory. Available at: www.fda.
gov/drugs/informationondrugs/ucm142438.
htm. Accessed June 22, 2010
Pletcher MJ, Kertesz SG, Kohn MA, Gonzales
R. Trends in opioid prescribing by race/
ethnicity for patients seeking care in US
emergency departments. JAMA. 2008;
299(1):70 –78
Olsen Y, Daumit GL, Ford DE. Opioid prescriptions by U.S. primary care physicians from
1992 to 2001. J Pain. 2006;7(4):225–235
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH report: trends in nonmedical use of prescription pain relievers: 2002
to 2007. Available at: www.oas.samhsa.gov/
2k9/painrelievers/nonmedicaltrends.pdf.
Accessed August 13, 2010
Johnston LD, O’Malley PM, Bachman JG,
Schulenberg JE. Monitoring the Future National Survey Results on Drug Use,
1975–2008: Volume II, College Students and
Adults Ages 19 –50. Bethesda, MD: National
Institute on Drug Abuse; 2009. NIH publication 09-7403
Setlik J, Bond GR, Ho M. Adolescent prescription ADHD medication abuse is rising
along with prescriptions for these medications. Pediatrics. 2009;124(3):875– 880
Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics. 1996;98(6 pt
1):1084 –1088

31. Thomas CP, Conrad P, Casler R, Goodman E.
Trends in the use of psychotropic medications among adolescents, 1994 to 2001. Psychiatr Serv. 2006;57(1):63– 69
32. Wilens TE, Adler LA, Adams J, et al. Misuse
and diversion of stimulants prescribed for
ADHD: a systematic review of the literature.
J Am Acad Child Adolesc Psychiatry. 2008;
47(1):21–31
33. Pain & Policy Studies Group. Achieving Balance in Federal and State Policy: A Guide to
Evaluation. 5th ed. Madison, WI: University
of Wisconsin, Paul P. Carbone Comprehensive Cancer Center; 2008
34. Colliver JD, Kroutil LA, Dai L, Gfroerer JC.
Misuse of Prescription Drugs: Data From
the 2002, 2003, and 2004 National Surveys
on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services
Administration, Office of Applied Studies;
2006. DHHS publication SMA 06-4192, Analytic Series A-28
35. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH report: nonmedical use of
pain relievers in substate regions: 2004 to
2006. Available at: http://oas.samhsa.gov/
2k8/pain/substate.htm. Accessed August
13, 2010
36. Gordon DB, Dahl JL, Miaskowski C, et al.
American Pain Society recommendations
for improving the quality of acute and cancer pain management. Arch Intern Med.
2005;165(14):1574 –1580
37. Trescot AM, Helm S, Hansen H, et al. Opioids
in the management of chronic non-cancer
pain: an update of American Society of the
Interventional Pain Physicians’ (ASIPP)
guidelines. Pain Physician. 2008;11(2
suppl):S5–S62
38. Institute for Clinical Systems Improvement.
Assessment and Management of Acute
Pain. Bloomington, MN: Institute for Clinical
Systems Improvement; 2008:1–58
39. Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community
clinic populations. J Gen Intern Med. 2006;
21(6):652– 655
40. Bollinger LC, Bush C, Califano JA, et al. Under
the Counter: The Diversion and Abuse of
Controlled Prescription Drugs in the U.S.
New York, NY: National Center on Addiction
and Substance Abuse at Columbia
University; 2005

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 Prescribing of Controlled Medications to Adolescents and Young Adults in the
United States
Robert J. Fortuna, Brett W. Robbins, Enrico Caiola, Michael Joynt and Jill S.
Halterman
Pediatrics 2010;126;1108; originally published online November 29, 2010;
DOI: 10.1542/peds.2010-0791
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Prescribing of Controlled Medications to Adolescents and Young Adults in the
United States
Robert J. Fortuna, Brett W. Robbins, Enrico Caiola, Michael Joynt and Jill S.
Halterman
Pediatrics 2010;126;1108; originally published online November 29, 2010;
DOI: 10.1542/peds.2010-0791

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/126/6/1108.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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