[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Invited Commentary
Substance Use and Addiction
March 27, 2020

The Role of the Household in Prescription Opioid Safety

Author Affiliations
  • 1Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 2Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
  • 3Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 4Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Netw Open. 2020;3(3):e201108. doi:10.1001/jamanetworkopen.2020.1108

Although the US has seen a decrease in opioid misuse rates among adolescents and young adults since 2015,1 opioid use disorder and overdose remain major public health problems in this high-risk population. Data from the US Substance Abuse and Mental Health Services Administration estimate that in 2018, 5.6% of young adults aged 18 to 25 years and 2.8% of adolescents aged 12 to 17 years misused prescription opioids in the past year.1 The reasons for high substance use rates in this age group are complex but include many factors rooted in neurodevelopment, socioeconomic characteristics, peer groups, and family life.2

For young adults, the family environment is an increasingly recognized factor associated with opioid misuse. Opioid use by family members, many of whom live with, have lived with, or are at least close with adolescents and young adults, has been associated with initiation of opioid therapy, long-term opioid use, and overdose among their opioid-naive adolescent and young adult family members.3-5 There are multiple possible explanations for these associations. First, the physical presence of prescription opioids in the home lowers the barrier for nonprescription use and experimentation by younger family members. Second, shared familial genetics and environmental exposures mean that household members also share risk factors for opioid misuse or addiction. Third, parents’ or other family members’ perceptions and habits surrounding opioids and pain management could influence younger household members as they mature and develop their own perceptions and habits. Regardless of the exact pathway, the spread of opioid use within households may be an important mechanism associated with the use of physician-prescribed opioids within the larger community—geographical, cultural, or otherwise.6 However, to understand the magnitude of risk created by family members’ opioid use, one must disentangle an individual’s personal risk factors for opioid use from the opioid use of their family members.

Ngyuen and colleagues7 unpack the challenging epidemiology of opioid use within families using a retrospective cohort of 72 040 patients aged 11 to 26 years within 45 145 families enrolled in a single commercial health plan from 2006 to 2018. They assessed opioid use by both index patients and their family members who were also enrolled in the health plan for a mean (SD) follow-up period of 4.9 (3.8) person-years. Opioid prescription was very common in this cohort, with 36.5% of index young adults and adolescents (n = 26 284) receiving at least 1 opioid prescription and 65.9% (n = 47 461) having at least 1 family member receive a prescription. The authors found that for these adolescents and young adults, personal receipt of an opioid prescription and a family member’s receipt of an opioid prescription were both risk factors independently associated with opioid overdose, with adjusted hazard ratios of 6.62 (95% CI, 3.39-12.91) and 2.17 (95% CI, 1.24-3.79), respectively. The presence of both risk factors for an individual was associated with a nearly 13-fold increase in the risk of opioid overdose (adjusted hazard ratio, 12.99; 95% CI, 5.08-33.25), whereas higher total dosages given to either index patients or their family members contributed further to an increased risk of overdose. These increased risks persisted for 12 months after personal or family opioid exposure, although they attenuated somewhat over that time.

The concerning findings of Ngyuen et al7 must be interpreted in light of the limitations to the study’s design. The analysis is observational in nature, leaving the possibility that unobserved confounding could still explain an unknown proportion of the estimated associations. There are clear observable confounders that differ between the populations compared in the study, including highly relevant risk factors, such as a history of drug use disorders or psychiatric illness. Therefore, although the authors control for many patient characteristics in their analyses, it is likely that important unobserved differences remain. Also, the study uses data from a single insurer in a single state, potentially limiting its generalizability to other populations.

The findings of this study7 are not surprising, but they add new details to the existing literature pointing to the household milieu as a focus area for assessing the clinical risk of opioid prescribing. Although nonopioid and nonpharmacologic forms of pain management should be pursued for all patients, this study reinforces that adolescents and young adults are at an especially high risk for complications from opioid exposure. Clinicians considering the need to prescribe opioids for young adults, adolescents, or their family members may want to ask about the presence of opioids or other controlled substances at home. It may also be more important than widely appreciated to provide counseling on safe medication storage and the potential for misuse when prescribing opioids. When prescribing, it is easy to forget that once these drugs enter the home, they have the potential to be used by any member of the household.8

The role of the family and household in the ongoing opioid epidemic remains an open area of research, and many questions remain. For example, it would be helpful to define the magnitude of this issue on a national scale. How many families have both high prescription opioid use and children and young adults in the household? What are the exact mechanisms for increased risk of overdose associated with family members’ prescribing? Do other controlled substances, such as benzodiazepines or stimulants, pose comparable risks? Should the presence of adolescents in a household influence how physicians prescribe to their family members? Further research that can more firmly assess causal relationships must be explored as well.

Finally, this study by Ngyuen and colleagues7 emphasizes the need for policy interventions aimed at curbing the opioid epidemic to be informed by underlying risk factors associated with opioid-related morbidity and mortality, including the household milieu. Interventions such as limiting prescription opioid dose or duration and mandating the use of prescription drug monitoring programs have contributed to declining opioid prescribing. However, these interventions are focused solely on limiting prescribing in the physician’s office for individuals. Despite their worsening reputation, opioids will still be prescribed to patients who need them, and that use will be subsequently normalized for family members. Household-level interventions are, thus, a possible next step to manage the risks associated with opioids in the home. Research to inform best practices for use of these high-risk drugs, such as for securing or disposing of the medication to prevent misuse or theft, is lacking. A deeper understanding of the household’s role in prescription opioid misuse provided by studies like this one by Ngyuen and colleagues7 will help build the evidence base necessary to design interventions and clinical guidelines that ensure the safe use of prescribed opioids in the home.

Back to top
Article Information

Published: March 27, 2020. doi:10.1001/jamanetworkopen.2020.1108

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Worsham CM et al. JAMA Network Open.

Corresponding Author: Michael Barnett, MD, MS, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 411, Boston, MA 02115 (mbarnett@hsph.harvard.edu).

Conflict of Interest Disclosures: Dr Barnett reported receiving personal fees from Greylock McKinnon Associates outside the submitted work and is retained as an expert witness for litigation against opioid manufacturers. No other conflicts were reported.

References
1.
Substance Abuse and Mental Health Services Administration.  Key Substance Use and Mental Health Indicators in the United States: Results From the 2018 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality; 2019.
2.
Committee on the Prevention of Mental Disorders and Substance Abuse Among Children and Young Adults.  Preventing Mental, Emotional, and Behavioral Disorders Among Young People. National Academies Press; 2009.
3.
Seamans  MJ, Carey  TS, Westreich  DJ,  et al.  Association of household opioid availability and prescription opioid initiation among household members.  JAMA Intern Med. 2018;178(1):102-109. doi:10.1001/jamainternmed.2017.7280PubMedGoogle ScholarCrossref
4.
Harbaugh  CM, Lee  JS, Chua  K-P,  et al.  Association between long-term opioid use in family members and persistent opioid use after surgery among adolescents and young adults.  JAMA Surg. 2019;154(4):e185838. doi:10.1001/jamasurg.2018.5838PubMedGoogle Scholar
5.
Khan  NF, Bateman  BT, Landon  JE, Gagne  JJ.  Association of opioid overdose with opioid prescriptions to family members.  JAMA Intern Med. 2019;179(9):1186-1192. doi:10.1001/jamainternmed.2019.1064PubMedGoogle ScholarCrossref
6.
Vaan  Md, Stuart  T.  Does intra-household contagion cause an increase in prescription opioid use?  Am Sociol Rev. 2019;84(4):577-608. doi:10.1177/0003122419857797Google ScholarCrossref
7.
Nguyen  AP, Glanz  JM, Narwaney  KJ, Binswanger  IA.  Association of opioids prescribed to family members with opioid overdose among adolescents and young adults.  JAMA Netw Open. 2020;3(3):e201018. doi:10.1001/jamanetworkopen.2020.1018Google Scholar
8.
Barnett  ML, Hicks  TR, Jena  AB.  Prescription patterns of family members after discontinued opioid or benzodiazepine therapy of users.  JAMA Intern Med. 2019;179(9):1290-1292. doi:10.1001/jamainternmed.2019.1047PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×