Abstract
The ongoing opioid epidemic has been a global concern for years, increasingly due to its heavy toll on young people’s lives and prospects. Few studies have investigated trends in use of the wider range of drugs prescribed to alleviate pain, psychological distress and insomnia in children, adolescents and young adults. Our aim was to study dispensation as a proxy for use of prescription analgesics, anxiolytics and hypnotics across age groups (0–29 years) and sex over the last 15 years in a large, representative general population. The study used data from a nationwide prescription database, which included information on all drugs dispensed from any pharmacy in Norway from 2004 through 2019. Age-specific trends revealed that the prevalence of use among children and adolescents up to age 14 was consistently low, with the exception of a substantial increase in use of melatonin from age 5. From age 15–29, adolescents and young adults used more prescription drugs with increasing age at all time points, especially analgesics and drugs with higher potential for misuse. Time trends also revealed that children from age 5 were increasingly dispensed melatonin over time, while adolescents from age 15 were increasingly dispensed analgesics, including opioids, gabapentinoids and paracetamol. In contrast, use of benzodiazepines and z-hypnotics slightly declined in young adults over time. Although trends were similar for both sexes, females used more prescription drugs than their male peers overall. The upsurge in use of prescription analgesics, anxiolytics and hypnotics among young people is alarming.
Trial registration The study is part of the overarching Killing Pain project. The rationale behind the Killing Pain research was pre-registered through ClinicalTrials.gov on April 7, 2020. Registration number NCT04336605; https://clinicaltrials.gov/ct2/show/record/NCT04336605.
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Introduction
Increasing use of prescription drugs for pain, psychological distress and insomnia among young people is a growing global concern [35]. While pharmacological treatment can provide effective short-term symptom relief, such as in acute and palliative care, potential misuse involves risk in terms of negative health consequences. For clinicians working with young patient populations, there is a fine line between undertreating these often co-occurring conditions and limiting potential misuse. However, despite these concerns the scope and trends of use for the wider range of prescription analgesics, anxiolytics and hypnotics have rarely been studied systematically, especially across the entire developmental trajectory and over extended time periods.
Prescription drugs with higher potential for misuse, such as opioids, gabapentinoids, benzodiazepines and z-hypnotics, are generally not recommended for children and adolescents unless they have a clear indication for treatment, which makes adequate systematic surveillance critical [47]. Potential misuse can lead to dependence, reduced efficacy and increased risk of acute and long-term morbidity and mortality [8, 21, 51]. Importantly, symptoms of cognitive impairment and sedation may also negatively impact social participation and school performance [2].
Recently, the long-term effects of alternative drugs with lower misuse potential have also been questioned. Although safer in terms of potential for misuse, frequent use of analgesics, such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), has been linked to increased risk of medication-overuse headache, cardiovascular risk, gastrointestinal bleeding and renal failure [12, 13, 30]. Furthermore, the consequences of prolonged use of sleep aids, such as melatonin and alimemazine, have not yet been systematically reviewed in children and adolescents [10, 23, 43]. The increase in overweight and sedentary lifestyles may also contribute to increased risk of headaches and musculoskeletal pain [1, 7, 52]. Additionally, some evidence indicates that adolescents and young adults are under more stress when it comes to academic performance and that social media use exacerbate symptoms of depression and anxiety [14, 26]. These types of symptoms are currently also worsening among children and adolescents as a consequence of the ongoing COVID-19 pandemic, which supports the need to take their health complaints seriously [38]. Prescription drugs are in addition viewed as safer, easy to access and associated with less societal stigma compared to illicit drugs among adolescents and young adults who misuse [16]. Second, another potential explanation is that it has become more common to prescribe prescription drugs for health complaints to this group.
Strengths and limitations
The study included the whole Norwegian population and all dispensed drugs from pharmacies across the country. It investigated the entire developmental trajectory, from childhood through to young adulthood, over 15 years. Moreover, it included a wide range of prescription drugs used to treat pain, psychological distress and insomnia. The study also had several limitations. It did not include drugs prescribed through hospitals or institutional settings, nor use of over-the-counter drugs, such as paracetamol, NSAIDs, and (more recently) melatonin, which are readily available without a prescription. Information about why the drugs were prescribed was not available and since the study only included cross-sectional measurements, it was not possible to study individual use over time. Formal statistical tests for time differences were also not feasible since the groups of individuals that were included in consecutive calendar years were not completely independent. It should also be noted that while it is realistic to assume the dispensed drugs were consumed by the recipients, there may have been cases where they were not. Finally, the inferences that can be made from the DDD calculations are limited as DDDs have primarily been developed for adults and are therefore likely less accurate for the actual use in children and young people. DDDs for different products within the same drug group (e.g., opioids) may also vary to some extent and are thus primarily informative for comparisons of overall use of the different drug groups over time [33].
Conclusion and future directions
Young people from the age of 15 are more likely to use prescription analgesics and drugs with higher potential for misuse with increasing age. This age-specific trend has been consistent over the past 15 years, while use of analgesics has steadily been increasing in this age group over time. During the same time period, use of melatonin for insomnia has also become increasingly common in children from age 5. These trends call for public health interventions and a proactive approach across research and clinical practice to better understand the etiological mechanisms driving the increase in prescription drug use.
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Acknowledgements
The authors thank the Norwegian Institute of Public Health (NIPH), the Division of Clinical Neuroscience at Oslo University Hospital, the Norwegian Centre for Violence and Traumatic Stress Studies, the Change Factory and the Norwegian Council for Mental Health, for their collaboration. The Killing Pain project has been funded by the Dam Foundation (project number 2020/FO283043) and the Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS). SOS and MH, both from NIPH, were funded in part by the Norwegian Research Council (Grant number 320360).
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The study has been approved by the Regional Committees for Medical and Health Research Ethics (REC), (reference 2017/2229).
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Stangeland, H., Handal, M., Skurtveit, S.O. et al. Killing pain?: a population-based registry study of the use of prescription analgesics, anxiolytics, and hypnotics among all children, adolescents and young adults in Norway from 2004 to 2019. Eur Child Adolesc Psychiatry 32, 2259–2270 (2023). https://doi.org/10.1007/s00787-022-02066-8
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DOI: https://doi.org/10.1007/s00787-022-02066-8