The Role of the Household in Prescription Opioid Safety

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.

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.