Assessment of Prescription Opioid Medical Use and Misuse Among Parents and Their Adolescent Offspring in the US

Key Points Question What are the patterns of association between parental and adolescent medical prescription opioid use and misuse in the US? Findings In this nationally representative cross-sectional study of 15 200 parent-adolescent dyads from the National Survey on Drug Use and Health, controlling for other factors, parental medical prescription opioid use within the past year was associated with adolescent medical prescription opioid use and misuse, whereas parental misuse was not. Meaning These findings suggest that reducing opioid prescribing by physicians and educating families about medication use practices that restrict the availability of prescription opioids to adolescents in the home could be important targets for reducing adolescent prescription opioid misuse.


Introduction
Parental smoking and alcohol and marijuana use are associated with increased use of the same drug by offspring, [1][2][3][4] as is prescription opioid misuse. 5However, limited information is known to date about the specific associations between parental and adolescent self-reported medical prescription opioid use, in addition to misuse, especially at the national level.We previously examined parentadolescent prescription opioid misuse from 2004 to 2012 in the National Survey on Drug Use and Health (NSDUH), when medical use was not assessed. 5Existing studies have examined the associations between opioids prescribed to family members and other household members in administrative commercial insurance claims.][8][9][10] The family member's relationship to the study populations is not specified except for mothers in one study 9 and parents in another. 7These studies do not inform on the specific role of parental prescription opioid medical use and misuse in adolescent misuse or on parental and adolescent characteristics that could also account for youth misuse.They highlight, however, the crucial role of opioid prescribing to family members in opioid use or overdose by another family member.As emphasized by Seamans et al, 6(p103) "Opioids are often prescribed in doses exceeding clinical guidelines for patients with non-cancer related pain, and in large quantities, resulting in surpluses of opioids stored in household medicine cabinets.Unused medications create opportunities for nonprescribed use and drug sharing among friends and family members, who may perceive these medications to be low risk given their storage at home."Almost 50% of adolescents who misuse prescription opioids report getting them from friends or relatives. 11derstanding the parental origins of adolescent prescription opioid medical use and misuse has important public health implications, because adolescent prescription opioid use is associated with increased morbidity and mortality.Youths who use prescription opioids are more likely to be diagnosed with an opioid use disorder at 25 years of age 12 and to experience substance-related morbidity, pharmacotherapy for alcohol use disorder, conviction for a substance-related crime, 13 suicide, 14 overdose, and death. 8,10,15,16 our knowledge, no study to date has examined the associations of medical prescription opioid use and misuse between parents and adolescents in the US.To address this gap, we examined these associations in nationally representative samples of parent-adolescent dyads, considering other characteristics of parents and adolescents that could account for the observed associations in prescription opioid use.We addressed 2 questions: (1) What are the associations between parental and adolescent prescription opioid medical use and misuse?and (2) What other parental and adolescent factors are associated with adolescent prescription opioid medical use and misuse?We hypothesized that parental medical prescription opioid use would be associated with adolescent medical prescription opioid use and misuse, whereas parental prescription opioid misuse would be associated only with adolescent prescription opioid misuse.We also hypothesized that negative quality of the parent-adolescent relationship and adolescent depression and delinquency would be associated with adolescent prescription opioid misuse.

JAMA Network Open | Substance Use and Addiction
Prescription Opioid Medical Use and Misuse Among Parents and Their Adolescent Offspring

Participants and Procedures
Data are from the 2015-2017 NSDUH annual, nationally representative cross-sectional surveys of the US population 12 years and older. 17 In selected households, the NSDUH selects 2 persons to be interviewed based on a pairsampling algorithm. 18,19We identified analytical samples of 15 200 parent-child dyads with an adolescent aged 12 to 17 years (9400 mothers and 5800 fathers), weighted to be nationally representative of adolescents living with their mother or father. 4Selection and weighting procedures are described in eMethods 1 in the Supplement.

Measures Prescription Opioid Medical Use and Misuse
Data were collected from January 6, 2015, to December 20, 2017.Parent and adolescent past 12-month prescription opioid misuse and medical use was defined as per the NSDUH based on 2 questions.A screener asked about the use of 37 (in 2015) or 36 (in 2016 and 2017) prescription opioids in the past 12 months, grouped into 12 classes (eTable 1 in the Supplement).Respondents were then asked about having misused each selected prescription opioid as "using the drug in any way not directed by a doctor, including without a prescription of one's own; in greater amounts, more often, or longer than prescribed; any other way."A positive answer for any drug defined the respondent as a misuser; medical use was having used exclusively without any misuse in the past year.Medical use and misuse were defined as mutually exclusive categories, although misusers of one drug could have also used another without misuse.The prescription opioid use variable was coded 0 for no prescription opioid use, 1 for medical prescription opioid use only, and 2 for prescription opioid misuse.

Mothers
d See eTable 1 in the Supplement for the specific prescription opioid pain relievers asked about.
e Scores range from 0 to 6, with higher scores indicating higher levels of the variable.See eMethods 2 in the Supplement for the specific definitions.
f Scores range from 1 to 4, with higher scores indicating higher levels of the variable.See eMethods 2 in the Supplement for the specific definitions.
g Scores range from 1 to 5, with higher scores indicating higher levels of the variable.See eMethods 2 in the Supplement for the specific definitions.
h Includes smoking, alcohol, and marijuana.
i Scores range from 0 to 3 for parents and 0 to 6 for adolescents, with higher scores indicating higher levels of the variable.See eMethods 2 in the Supplement for the specific definitions.
The NSDUH does not report rates of concurrent prescription opioid misuse and medical use.
Some crude estimates can be made from the answers to 2 questions: one about the overall way of misusing opioids and another about the source of the last prescription opioid misuse, in which the first 2 alternatives are a physician's prescription (eTable 2 in the Supplement).We estimated that, in the 2015-2017 public data among adults living with children younger than 18 years, 59.7% of misusers misused their own prescriptions, and 66.0% misused without a prescription.Among adolescents living with a mother or father, the percentages were 48.6% and 73.0%, respectively (eTable 2 in the Supplement).

Associations Between Parent and Adolescent Prescription Opioid Medical Use and Misuse
There were significant and positive bivariate associations between past

Characteristics of Parents Who Use Opioids Medically vs Those Who Misuse Prescription Opioids
We compared the substance use, mental health, and sociodemographic characteristics of parental prescription opioid misusers with exclusive medical users and nonusers.Prescription opioid misusers, and to a lesser extent exclusive medical users, used drugs other than prescription opioids
g Includes cocaine, heroin, and hallucinogens.
h Scores range from 0 to 6, with higher scores indicating higher levels of the variable.See eMethods 2 in the Supplement for the specific definitions.
i Scores range from 0 to 3, with higher scores indicating higher levels of the variable.See eMethods 2 in the Supplement for the specific definitions.
included the effect of parental use of other drugs, in particular marijuana.The offspring of parent prescription opioid misusers were disproportionately exposed to parental polysubstance misuse.
Thus, parental use of other drugs could partially account for the bivariate association between parent and adolescent prescription opioid misuse.It should be noted that, in years 2004 to 2012, we found an association between parental and adolescent lifetime prescription opioid misuse (aOR, 1.30 [95% CI, 1.09-1.56]). 5A focus on lifetime rather than past 12-month misuse and other methodological and historical differences between the 2 studies may account for differences in findings.
After controlling for parental use of other drugs and other covariates, parental marijuana use remained associated with adolescent prescription opioid misuse.By contrast, a recent study 4 reported no multivariate association of parental marijuana use with adolescent opioid misuse in the NSDUH.The discrepancy in findings may be accounted for by the inclusion of heroin in the definition of adolescent opioid misuse in that study but not the present one.The association of parental marijuana use with adolescent prescription opioid misuse may reflect direct effects of parental marijuana use on adolescent prescription opioid use and the higher use of marijuana and other drugs by adolescent prescription opioid misusers compared with medical users. 20Because the 12-month measures of drug use in the NSDUH provide no information on the timing of use of these drugs in association with prescription opioid use, they were not included in the models.
The present findings highlight the important association between parental prescription opioid medical use and offspring medical use and misuse.Processes that were not measured may also be relevant.Heritability may account for familial concordance on health conditions, particularly chronic pain, and psychiatric and substance use disorders comorbid with medical prescription opioid use and misuse. 6,7,39Family health practices, including attitudes and norms regarding medication use, especially prescription opioid use, and access to the same clinicians, may also play a role. 6,7The findings also illustrate the unintended consequences of prescribing practices in the US.Prescribing prescription opioids to adults, and in particular parents, is associated with increased risk of misuse by offspring.A hopeful trend is the decreasing percentages of unique individuals prescribed opioids in the US since 2015 40,41 and the implementation of prescription drug monitoring programs. 42e association of parental medical prescription opioid use with adolescent prescription opioid misuse suggests that role modeling and availability of parents' opioid medications in the household are significant familial risk factors for prescription opioid misuse among young people, although adolescents also misuse their own prescription opioid medications and prescription opioids from nonfamilial sources.Among adolescent misusers, 25.9% obtained their last misused prescription opioid from 1 or more physicians; 58.4%, from friends or relatives; and 15.7%, from other sources, including stealing from a physician's office, buying from a drug dealer, or some other way. 11,24,26Thus, adolescents' own opioid prescriptions as well as prescription opioids from other sources, including parents, contribute to availability.Adolescent prescription opioid misusers and, to a lesser extent, medical users experienced elevated rates of psychosocial risk.Adolescents with mental health comorbidities are more likely to be prescribed an opioid, to use opioids long term, and to misuse, 20,21,27,29,31 underscoring the need to monitor closely the functioning of adolescents who are prescribed opioids.
In this historical period of increasing legalization of recreational adult marijuana use in the US, the finding of increased prescription opioid misuse by the offspring of marijuana-using parents may portend an unintended negative consequence of drug policies.4][45][46] Legalization may lead to increased adolescent marijuana use through parental marijuana use 47 given the association between parent and offspring marijuana use. 3,4Legalization may also be associated with increased offspring prescription opioid misuse.Indeed, among adults, marijuana use is associated with incipient prescription opioid misuse and disorder 48 and, as we have reported, precedes the onset of prescription opioid misuse. 49The observed association of parental marijuana use and offspring prescription opioid misuse reproduces patterns at the intergenerational level observed among adults.

JAMA Network Open | Substance Use and Addiction
Prescription Opioid Medical Use and Misuse Among Parents and Their Adolescent Offspring The target civilian noninstitutionalized population represents more than 98% of the US population.Persons living in noninstitutional group quarters (homeless shelters, rooming houses, or college dormitories) and civilians living on military bases are included; individuals on active military duty, in jail, in drug treatment programs, and in hospitals and homeless persons not in shelters are excluded.Approximately 67 500 persons are interviewed in person annually.Substance use and sensitive behaviors are ascertained through audio computer-assisted self-interviewing.Completion rates are 50% to 55%.The New York State Psychiatric Institute-Columbia University Department of Psychiatry institutional review board approved the study, which implemented secondary data analysis of restricted-use NSDUH data at a Federal Statistical Research Data Center.Because of coronavirus disease 2019-related circumstances, we could not access the restricted data to implement new analyses in response to reviewers' questions.Instead, we implemented analyses on the public-use 2015-2017 data on respondents who would approximate parents and adolescent offspring in the analytical sample, namely, adults 30 years and older living with children younger than 18 years and youths aged 12 to 17 years living with a mother or father.The NSDUH obtained written informed consent from adult respondents 18 years and older and from parents/guardians for respondents aged 12 to 17 years.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline (eMethods 2 in the Supplement indicates the percentages missing and how missing data were addressed in the model estimation).

JAMA Network Open | Substance Use and Addiction Prescription
Opioid Medical Use and Misuse Among Parents and Their Adolescent Offspring
medically compared with 14.3% (95% CI, 10.9%-18.4%)when a parent misused prescription opioids and 14.3% (95% CI, 13.2%-15.5%)whenaparent had not used prescription opioids.Compared with when parents had not used any prescription opioids, the unadjusted odds ratio (OR) of adolescents' medical use was 1.40 (95% CI, 1.20-1.64)whenparentsused only medically and 1.03 (95% CI, a Data are from the 2015-2017 National Survey on Drug Use and Health (n = 15 200).The weighted percentages for each level of the categorical variables are based on sample sizes (unweighted numbers) of greater than 100.bDifferences were significant by groups for medical use (P < .05)using2-sidedt tests.cDifferenceswere significant by race/ethnicity groups for medical use (P < .05)using2-sided t tests.White was different compared with all other race/ethnicity groups; African American was different compared with all other race/ethnicity groups.dDifferences were significant by race/ethnicity groups for misuse (P < .05)using 2-sided t tests.White was different compared with African American.African American was different compared with Hispanic.e Includes Asian, Native American/Alaska Native, g Differences were significant by age groups for misuse (P < .05)using 2-sided t tests.Age 12 was different compared with age groups 14, 15, 16, and 17.Age 13 was different compared with age groups 15, 16, and 17.Age 14 was different compared with age groups 16 and 17. 0Additional Correlates

of Adolescent Prescription Opioid Medical Use and Misuse
(Table3).With control for all risk factors and parental use of drugs other than prescription opioids, parental medical stimulant use remained uniquely associated with adolescent medical prescription opioid use (aOR, 1.40; 95% CI, 1.02-1.91)andparentalmarijuana use with adolescent prescription opioid misuse (aOR, 1.84; 95% CI, 1.13-2.99).Although adolescent perceived quality of parenting was associated with higher rates of adolescent medical prescription opioid use (OR for low level of monitoring, 1.13 [95% CI, 1.05-1.21];ORfor low level of support, 1.12 [95% CI, 1.04-1.19];and OR for high level of parent-adolescent conflict, 1.17 [95% CI, 1.09-1.26])and, especially, misuse at the bivariate level (OR for low level of monitoring, 1.42 [95% CI, 1.26-1.60];OR for low level of support, 1.37 [95% CI, 1.20-1.55];and OR for high level of parent-adolescent conflict, 1.59 [95% CI, 1.39-1.82]),after controlling for other factors, only parent-adolescent conflict retained a unique association with adolescent prescription opioid misuse (aOR, 1.26; 95% CI, 1.05-1.52).Bivariate associations of parental and adolescent health conditions with adolescent medical prescription opioid use did not persist in the multivariable models.In these models, adolescents who engaged in delinquent behavior and perceived that most of their schoolmates used drugs were more likely to use prescription opioids medically and to misuse than other adolescents, with stronger associations for misuse than medical use (delinquency aORs,

Table 3 .
Parent and Adolescent Factors Associated With Adolescent Past 12-Month Medical Prescription Opioid Use and Misuse

Table 3 .
Parent and Adolescent Factors Associated With Adolescent Past 12-Month Medical Prescription Opioid Use and Misuse (continued)DiscussionParental use of prescription opioids in the US is extremely high and an important source of prescription opioid exposure for children.In this large national sample of parent-adolescent dyads surveyed from 2015 to 2017, 1 in 3 parents and 1 in 6 adolescents used a prescription opioid in the past 12 months: 31.5% of parents used only medically and 4.1% misused, whereas 15.7% of adolescents used only medically and 3.2% misused.
b Includes cocaine, heroin, and hallucinogens.cCalculated using standardized scores.dIncludes Asian, Native American/Alaska Native, e Includes cigarettes, alcohol, and marijuana.

Table 4 .
Characteristics of Parents by Past 12-Month Medical Prescription Opioid Use and Misuse b Based on multinomial logistic regression of each characteristic on parental prescription opioid use.c d Differences were significant compared with the group with misuse (P < .05)using2-sided t tests.eDifferences were significant compared with the group with medical use only (P < .05)using 2-sided t tests.