Nonmedical use of prescription drugs in the European Union

Nonmedical prescription drug use (NMPDU) typically encompasses consumption of a medication that is not prescribed to a user or that is consumed in a manner not intended by the prescriber (e.g. taking higher doses, using non-approved routes of administration). It also captures situations in which the medication is obtained illegally (e.g. purchased through a dealer or the Internet) or under false pretenses (e.g. doctor shopping or feigning symptoms). In addition to the source of acquisition and the route of administration, the underlying motivations for use may include using the medication for self-treatment of a physical and/or mental health problem or for tension reduction/relaxation/euphoria [1]. NMPDU is among the leading public health issues in the United States (US) [2–5]. Prescriptions written for central nervous system (CNS) medications in the US has dramatically increased over the past decade, primarily in the therapeutic classes involving opioids, sedatives, and stimulants [6, 7]. Inspection of the number of peer-reviewed publications and media reports focusing on prescription drug abuse, misuse, and diversion over the past several years suggests that NMPDU is more widespread in the US than other nations, including the European Union (EU). This lack of attention is surprising, as the EU has also witnessed a rise in the number of prescriptions across these same therapeutic classes [8]. In tandem, there has also been an increase in emergency room visits and drug treatment admissions for prescription CNS medications in the EU [9–12]. Yet, the EU lacks a systematic method for identifying and monitoring trends in NMPDU over time, so its prevalence and associated user characteristics are largely unknown.

The US has arguably the most sophisticated and diverse drug abuse surveillance systems in the world, ranging from direct estimates of self-reported drug use to administrative data on drug arrests, seizures, and drug treatment admissions [13–20]. In the EU, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the agency charged with coordinating information about specific drugs, and their health and social consequences. The agency was established in 1993, and disseminates reports using data provided from its member nations. Most of its data are from secondary sources, such as arrests, seizures, and drug treatment admissions [21]. While the US has numerous opportunities for funding epidemiological studies on NMPDU, the EU has comparatively fewer sources of funding to support new data collection efforts. On occasion, the EMCDDA is able to acquire primary survey data from dedicated government funding.

Due to the lack of a comprehensive surveillance system and funding for NMPDU studies in the EU, most of what is known comes from studies conducted in the US. A consistent finding in the literature from the US and the EU is that NMPDUs often engage in polydrug use [22, 23]. However, there is also a group of persons who engage in NMPDU but who do not engage in poly-drug use [24–26]. Of importance is that few studies have specifically examined these two groups, including providing estimates of the number of users relative to the total group of persons engaging in NMPDU, as well as their defining characteristics.

NMPDU has received a considerable amount of attention in the US, but anecdotal evidence suggests that other nations are experiencing dramatic increases as well [27]. Drug abuse is becoming more global in nature. With regard to prescription medications, global studies are critical to pharmacovigilance, which is the process of monitoring the individual and population-level health effects after medications have been approved for retail sales. This process has relevance for numerous stakeholders, as NMPDU is a key metric that provides a measure of a medication’s abuse liability and safety profile for clinicians, payers, and policy-makers. Prescription drug abuse is a prominent topic in many Internet chat-rooms, including information about availability, consumption, and side-effects. These discussions are international in focus, as participants come from many different types of nationalities. The international borders that separate the drug trade in each country are also eroding. For example, drug users are even able to make anonymous purchases through online pharmacies [28–30]. There is need to understand whether the high levels of NMPDU observed in the United States are similar in other EU countries. The objectives of this study are to examine the prevalence NMPDU in the EU, including a set of analyses to identify the subgroups at greatest risk and the methods of acquisition.

This study documented the cross-national prevalence of NMPDU and associated characteristics of users in five EU countries. The results reported here provide important comparative estimates for cross-national investigations. For instance, data from the 2013 National Survey on Drug Use and Health (NSDUH), which is among the leading epidemiological sources of drug abuse in the United States, revealed that 20 % of those aged 12 years or older reported any lifetime use of a prescription psychotherapeutic [36]. The lifetime estimates for the EU-Meds Study ranged between 7 and 13 %. Despite methodological differences across studies, the findings suggest that the prevalence estimates in the EU are likely to be lower than the prevalence of nonmedical prescription drug use in the US. There were no data available on the health consequences of NMPD in this study, such as motor vehicle accidents or emergency department visits. Therefore, it is possible that the EU and the US may share similarities in the level of use, but the individual and societal consequences associated with use may differ. Compared to the EU, the US has a higher rate of motor vehicle accidents and unintentional overdoses that can be attributable to prescription medicines [2, 37–39]. The limited data from the EU suggest that much of the burden is attributable to illicit drugs rather than prescription-type medications [40]. Although Europeans may be using these medications on their own or without their physician’s knowledge, the public health consequences may not have reached levels similar to those in the US.

This epidemiological study also examined different patterns of exposure to prescription medications. One of the pathways to NMPDU is commonly referred to as “iatrogenic addiction” [24]. This pathway leads to nonmedical use after receiving treatment for a legitimate medical condition. Therefore, persons initiated into NMPDU through this pathway are less likely to have a history of poly-drug use. These data show that persons receiving a prescription had a higher likelihood of engaging in NMPDU than persons without a prescription. However, poly-drug users were not at differential risk than persons engaging only in NMPDU. A note of caution is that this study is population-based, and did not link exposure from a specific prescription to long-term outcomes. Instead, the survey asked about the receipt of medications used to treat common conditions, and the subsequent use of prescription medications nonmedically. Given the limitations of observational data, this finding should not be construed as a recommendation against prescribing medications to treat legitimate conditions. Any such recommendation should be based on methodologies that allow for a greater ability to address confounding than an observational design. Future studies are needed to more thoroughly investigate the role of patient access and the likelihood of NMPDU. In the EU, some prescription medications are available directly from a pharmacist. For example, codeine is available from a pharmacist in several EU countries. Additional studies are needed to examine how differences in prescribing are related to the onset and course of NMPDU.

This study also found that social sources (e.g. a family member or friend) were the most prevalent methods of acquisition, which is similar to findings in the US and other international studies [13, 41, 42]. However, the patterns we observe in the self-reported methods of acquisition regarding medications for NMPDU suggest that the Internet is becoming less common for accessing prescription medications for NMPDU in the US [43]. Inciardi and colleagues conducted an analysis of 2006 NSDUH data, showing that among those using the Internet to acquire medications, stimulants were the most common prescription drug purchased on the Internet (4 %), followed by sedatives (1 %), and opioids (0.5 %) [30]. According to a 2009 study conducted by the Pew Research Center, approximately 74 % of adults aged 18 years or older in the US use the Internet [44]. Compared with the US, preliminary evidence indicates that a larger proportion of citizens in the EU use the Internet, and also use it more frequently [45]. The US has been aggressive in regulating Internet pharmacies over the past several years, so it is unclear whether differences in the number of Internet users or aggressive policies may explain any between-country differences between the EU and other countries [46, 47].

Like any community based epidemiologic investigation, there are numerous limitations inherent in the study design. Perhaps the most lingering question about this study is whether the quota sampling methodology may have also increased the between-country differences due to its reliance on proactive recruitment instead of using a preexisting sampling frame. Nonprobability samples have been shown to yield prevalence estimates for illicit drug use that are higher than probability surveys [48]. Therefore, this design used a diverse range of recruitment methodologies (e.g. street intercept, recruitment flyers, print advertisements), including proactive recruitment across diverse ranges of population strata. This design yields less bias in terms of coverage, nonresponse, and measurement than an internet panel study, but in theory introduces more bias than a probability sample. However, probability studies also face challenges because cellular telephones, privacy concerns, and identity threats significantly hamper their ability to recruit subjects [49]. This study conducted numerous validation checks by comparing our results with other known population-based studies of drug abuse in selected EU countries. The data were comparable, increasing confidence in study findings. For example, we subset our data to prevalence data obtained from reports sourced by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). The data were sourced for persons of a similar age range in the same countries [50]. For cannabis, the EU estimate was 43.6 and the EU-Meds survey was 44.5 %, a difference of −0.9 percentage points. We also compared data from individual countries. To illustrate, the differences in amphetamine use, which includes prescription and illicit (e.g., methamphetamine) ranged from −2.8 percentage points to 2.2 percentage points. To illustrate, the estimate for Denmark, ages 15–34 in the 2014 EU Meds study was 7.5 %, but was 10.3 % for a study conducted in Denmark in 2011, reported by the EMCDDA. The survey methods were kept as comparable as possible across the countries, although it is possible that even subtle differences in the survey procedures (e.g. instrument translation, recruitment methods) may have increased the observed differences in the between-country estimates.

With these limitations in mind, projects such as the current study can provide important comparative data for countries across the EU, the US, and beyond. The US is fortunate in that it has numerous systems and funding for drug abuse research that can be used to study substance use across geographic space and time. The EU drug abuse surveillance systems tend to focus less on human population-based studies, thereby making a direct comparison between the population rates in the US and the EU quite challenging. This study used the same base interview schedule that is also used by NSDUH, but modifications were made to accommodate cultural differences in terminology and self-administration. Thus, there are important methodological differences between the two studies that preclude direct comparisons. However, identification of the initial scope and prevalence of NMPDU in the EU is an important first step in building a worldwide system that can be used to monitor trends in substance use, track prominent risk and protective factors, and trace the transmission of information and products across national borders.

CI, confidence interval; EMCDDA, European Monitoring Center for Drug and Drug Abuse; EU, European Union; NMPDU, nonmedical prescription drug use; NSDUH, National Survey on Drug Use and Health; OR, odds ratio; RTI, Research Triangle Institute; UK, United Kingdom; US/USA, United States of America