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In 1990, an estimated 3 million people in the US used psychotherapeutic
agents for nonmedical purposes. Inappropriate use of prescription
medication, or its use for purposes other than intended by a prescribing
physician, can have significant physical, psychological, and social
consequences. In particular, Health Canada has targeted prescription
drug misuse among First Nations people—those persons with special
rights that date back to the signing of the number treaties in Canada—as
a serious health problem (1). Despite the significant morbidity
associated with inappropriate use of prescription medicine, there
is little information on drug-use patterns among Aboriginal populations
(that is, First Nations or status Indians, nonstatus Indians, Metis,
and Inuit) (2).
Existing literature on prescription medication research has several
limitations. Anderson and McEwan (2) analyzed a pharmacy claims
database for the status Aboriginal population entitled to a medication
subsidy. They found that 1.2% of this population excessively used
acetaminophen with codeine, and up to 7.2% excessively used benzodiazepines.
Excessive use was defined as greater than the maximum dosage stated
by the Saskatchewan Joint Committee on Drug Use (3). The Aboriginal
population also filled more prescriptions for acetaminophen with
codeine and benzodiazepines than did the Canadian general population,
but fewer than income-assisted clients in British Columbia. Although
this study identifies a group that is at potentially high risk for
inappropriate use of prescription medication—those with medication
subsidization—it has limitations. For example, excessive use
does not necessarily reflect inappropriate use: some medical conditions
associated with chronic pain may legitimately require greater amounts
of analgesia. On the other hand, pharmacy claims may underestimate
inappropriate use of prescription medication, because medication
can be obtained apart from a prescription.
In populations with addictions, 28% of a non-Aboriginal population
seeking addiction treatment with the Alberta Alcohol and Drug Abuse
Commission (AADAC) used prescription medication in the past year
(unpublished data, 1998). However, AADAC data do not differentiate
between appropriate and inappropriate use. Within the AADAC population,
male subjects (66%) and those aged 31 to 50 years (58%) were more
likely to use prescription medication. AADAC services are similar
to those services offered by Native Addiction Services (NAS), where
we obtained our study sample; both populations originate from the
same geographical area. Therefore, a comparison with our study findings
is possible. No prescription medication studies of an Aboriginal
population with addiction were identified.
Several variables of interest other than age and sex may be associated
with inappropriate use. As mentioned, Aboriginal status may facilitate
inappropriate use arising from medication subsidies. As well, living
on- or off-reserve may be important. For example, living on-reserve
may facilitate social support and culturally appropriate services,
but at the same time it may entail lack of opportunities for employment
and education. Both lack of social support and lower income and
education level have been found to be associated with addictive
disorders (4).
This study aimed to determine the patterns of prescription medication
use in a high-risk population: Aboriginal persons seeking addiction
treatment. Specifically, we used a cross- sectional survey to investigate
the prevalence of inappropriate use of stimulants, sedatives or
relaxants, opioids or analgesics, and other prescription medications.
This descriptive study also aimed to further characterize prescription
drug use by identifying the source of the prescription medication
and the frequency of its inappropriate use.
Methods
From May 15 to December 15, 2000, during their initial assessment,
we gave a self-administered questionnaire to 209 new clients of
the Native Addiction Services (NAS) in Calgary, Alberta. We excluded
clients from the analysis if they identified themselves as non-Aboriginal.
Non-Aboriginal clients were not used as a comparison group because
they generally constitute too small a proportion of those who attend
NAS.
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The survey was created de novo and then pretested for cultural
sensitivity, face validity, and comprehension by an Aboriginal focus
group of 20 clients who accessed addiction treatment and 10 addiction-treatment
service staff. The survey collected baseline demographic information,
the reason for seeking treatment, and the frequency of medication
use within the past year; as noted above, stimulants, sedatives
or relaxants, opioids or analgesics, and other prescription medications
were measured. These are the particular medication classes most
commonly used inappropriately (5–7). To determine whether prescription
medications were inappropriately used, patients were asked to indicate
whether in the past year they had taken any of the listed medications
longer, in larger amounts, or for other purposes than intended by
a prescribing physician(s). Those who reported inappropriate use
were then asked to indicate the source of their drug, with the following
options: prescribed by a physician, prescribed by several physicians,
given by a family member, taken without permission from a family
member, given by a friend or a stranger, taken without permission
from a friend or a stranger, bought on the street, or obtained from
another source not listed.
Self-identified Aboriginal participants accessed treatment at NAS
in Calgary for a period of 6 months. We obtained informed consent,
participation was voluntary, and the survey was self-administered
at the initial assessment. Clients deposited the completed survey
into a secured box accessed only by the researchers. Surveys were
anonymous, and NAS staff were not informed of survey information.
Client treatment was not affected by study participation, which
is critical for open reporting of this sensitive issue. The study
received approval from the Conjoint Health Research Ethics Board
at the University of Calgary. NAS does not collect client demographic
information, and thus nonresponder information was not available.
We used STATA 7.0 statistical software to calculate the prevalence
of appropriate and inappropriate use, odds ratios (ORs), confidence
intervals (CIs), and 2-sided Fisher’s exact test with a P-value
of 0.05 for statistical significance. Aboriginal clients who did
not use prescription medication served as the comparison group.
Results
There were 149 completed surveys; 5 respondents were excluded because
they self-reported non-Aboriginal descent, giving a final response
rate of 69%. Most respondents were aged 31 to 50 years (56%), and
48% were women. Almost all respondents lived off reserves, and 83%
classified themselves as status Indian. Alcohol abuse and illicit
drug use was the most common reason for seeking treatment at NAS.
Table
1 contains demographic information for all respondents, categorized
by pattern of prescription medication use.
Among the respondents, 44% (n = 64) indicated that they
did not use prescription medications; 8% (n = 11) reported
appropriate use; and 48% (n = 69) reported inappropriate
use (see Figure
1). Among those who reported inappropriate use, 58% (n
= 40) used stimulants; 74% (n = 51) used sedatives or relaxants;
62% (n = 43) used opioids or analgesics; and 22% (n
= 15) used other medications (see Figure
2). No participant specified the “other” prescription
medication. Polypharmacy was common: 36% (n = 25) used only
1 medication class, 26% (n = 18) used 2 medication classes,
20% (n = 14) used 3 medication classes, and 17% (n
= 12) used 4 medication classes. Among those who used medication
appropriately, 18% (n = 2) used stimulants; 27% (n
= 3) used sedatives or relaxants; and 45% (n = 5) used opioids
or analgesics. Table
2 includes frequency of self-reported appropriate and inappropriate
drug use. Among those who used inappropriately, 47% (n =
51) used “greater than 10 times” in the last year. As
seen in Table
3, medications used inappropriately were obtained from a friend
or a stranger (52%), or bought on the street (45%), or prescribed
by a physician (41%).
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