Youth Perspectives of Prescription Pain Medication in the Opioid Crisis

      Objective

      To characterize current youth perspectives of prescription pain medication.

      Study design

      In total, 1047 youths aged 14-24 years were recruited by targeted social media advertisements to match national demographic benchmarks. Youths were queried by open-ended text message prompts about exposure and access to prescription pain medication, perceived safety of prescribed and nonprescribed medication, and associations with the word “opioid.” Responses were analyzed inductively for emerging themes and frequencies.

      Results

      Among 745 respondents (71.2% response rate), 439 identified as female (59.3%), 561 as white (75.8%), and mean age was 18.3 ± 3.2 years. Previous exposure to prescription pain medication was reported by 377 respondents (52.0%), most commonly related to dentistry (32.8%), surgery (19.2%), and injury (12.0%). Nonmedical sources of access to prescription pain medication were identified by 256 respondents (36.9%) and medical sources other than their doctor by an additional 111 respondents (16.0%). Three additional themes emerged from youth responses: (1) prescribed medication was thought to be safer than nonprescribed medication, based on trust in doctors; (2) risks of addiction and overdose were thought to be greater for nonprescribed medication; (3) respondents had a widely ranging understanding of the word “opioid,” from historical to current events, medical to illicit substances, and personal to public associations.

      Conclusions

      Although youths are aware of the opioid crisis, they perceive less risk of prescription pain medication prescribed by a doctor, than from other sources. Policies should target education to youth in clinical and nonclinical settings, highlighting the risks of addiction and overdose with all opioids.

      Keywords

      Abbreviation:

      SES (Socioeconomic status)
      The death toll from the US opioid crisis continues to rise, including among youth.
      • Gaither J.R.
      • Shabanova V.
      • Leventhal J.M.
      US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016.
      • Seth P.
      • Scholl L.
      • Rudd R.A.
      • Bacon S.
      Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015-2016.
      • Hedegaard H.
      • Warner M.
      • Miniño A.
      Drug overdose deaths in the United States, 1999–2016.
      Opioid-related overdose deaths rose to 12.6 deaths per 100 000 persons among 15-24 year-olds in 2017.
      • Hedegaard H.
      • Warner M.
      • Miniño A.
      Drug overdose deaths in the United States, 1999–2016.
      Data from a single state suggest that prevalence of opioid use disorder had the most dramatic increases among adolescents and young adults in states such as Massachusetts.
      • Barocas J.A.
      • White L.F.
      • Wang J.
      • Walley A.Y.
      • LaRochelle M.R.
      • Bernson D.
      • et al.
      Estimated prevalence of opioid use disorder in Massachusetts, 2011-2015: a capture-recapture analysis.
      Although recent deaths are increasingly from intravenous opioids such as heroin and fentanyl, it is estimated that 80% of youth with intravenous heroin use initiated with prescription opioids.
      • Lankenau S.E.
      • Teti M.
      • Silva K.
      • Jackson Bloom J.
      • Harocopos A.
      • Treese M.
      Initiation into prescription opioid misuse amongst young injection drug users.
      ,
      • Cicero T.J.
      • Ellis M.S.
      • Surratt H.L.
      • Kurtz S.P.
      The changing face of heroin use in the United States: a retrospective analysis of the past 50 years.
      Moreover, prescription opioid use in adolescence confers an increased risk of future opioid misuse.
      • Miech R.
      • Johnston L.
      • O'Malley P.M.
      • Keyes K.M.
      • Heard K.
      Prescription opioids in adolescence and future opioid misuse.
      In response to the opioid crisis, several states have mandated risk education; yet, these policies have failed to effectively address youth.
      • McGinty E.E.
      • Stuart E.A.
      • Caleb Alexander G.
      • Barry C.L.
      • Bicket M.C.
      • Rutkow L.
      Protocol: mixed-methods study to evaluate implementation, enforcement, and outcomes of U.S. state laws intended to curb high-risk opioid prescribing.
      ,
      • Parker A.M.
      • Strunk D.
      • Fiellin D.A.
      State responses to the opioid crisis.
      For example, the state of Michigan mandated education at the time of prescribing on the risks of opioid misuse, addiction, and diversion in July 2018. However, minors presenting for surgical or emergency care (the most common reasons that opioids are prescribed to youth) are exempt from this law.

      Mich Comp Laws 3337303c2017.

      Youth-directed education through mass media campaigns such as the National Youth Anti-Drug Media Campaign or school-based programs such as Drug Abuse Resistance Education (D.A.R.E.) have not effectively reduced substance use among youth.
      • Allara E.
      • Ferri M.
      • Bo A.
      • Gasparrini A.
      • Faggiano F.
      Are mass-media campaigns effective in preventing drug use? A Cochrane systematic review and meta-analysis.
      • Perry C.L.
      • Komro K.A.
      • Veblen-Mortenson S.
      • Bosma L.M.
      • Farbakhsh K.
      • Munson K.A.
      • et al.
      A randomized controlled trial of the middle and junior high school D.A.R.E. and D.A.R.E. Plus programs.
      • Pan W.
      • Bai H.
      A multivariate approach to a meta-analytic review of the effectiveness of the D.A.R.E. program.
      The current youth perceptions of prescription pain medication within the context of the opioid crisis have not been well-described in large scale.
      • Moore S.K.
      • Grabinski M.
      • Bessen S.
      • Borodovsky J.T.
      • Marsch L.A.
      Web-based prescription opioid abuse prevention for adolescents: program development and formative evaluation.
      ,
      • Yedinak J.L.
      • Kinnard E.N.
      • Hadland S.E.
      • Green T.C.
      • Clark M.A.
      • Marshall B.D.
      Social context and perspectives of non-medical prescription opioid use among young adults in Rhode Island: a qualitative study.
      The youth voice is urgently needed to inform policy and risk education to combat the opioid crisis.
      This qualitative study using the MyVoice national text message poll of youth was used to explore the perceptions of prescription pain medication and opioids. The objective was to characterize previous exposure, access, and perceived safety related to prescription pain medication from prescribed and nonprescribed sources. Allowing youth to describe their experience in their own words, we aimed to inform efforts to clarify the language used when educating youth about prescription pain medications and opioids.

      Methods

      MyVoice is a large-scale, longitudinal mixed methods study of youth aged 14-24 years.
      • DeJonckheere M.
      • Nichols L.P.
      • Moniz M.H.
      • Sonneville K.R.
      • Vydiswaran V.G.V.
      • Zhao X.
      • et al.
      MyVoice national text message survey of youth aged 14 to 24 years: study protocol.
      • DeJonckheere M.
      • Fisher A.
      • Chang T.
      How has the presidential election affected young Americans?.
      • Crissman H.P.
      • Czuhajewski C.
      • Moniz M.H.
      • Plegue M.
      • Chang T.
      Youth perspectives regarding the regulating of bathroom use by transgender individuals.
      • Van Sparrentak M.
      • Chang T.
      • Miller A.L.
      • Nichols L.P.
      • Sonneville K.R.
      Youth opinions about guns and gun control in the United States.
      Open-ended text message responses are used to explore and draw meaning from the experience of the individuals.
      • DeJonckheere M.
      • Nichols L.P.
      • Moniz M.H.
      • Sonneville K.R.
      • Vydiswaran V.G.V.
      • Zhao X.
      • et al.
      MyVoice national text message survey of youth aged 14 to 24 years: study protocol.
      • DeJonckheere M.
      • Fisher A.
      • Chang T.
      How has the presidential election affected young Americans?.
      • Crissman H.P.
      • Czuhajewski C.
      • Moniz M.H.
      • Plegue M.
      • Chang T.
      Youth perspectives regarding the regulating of bathroom use by transgender individuals.
      • Van Sparrentak M.
      • Chang T.
      • Miller A.L.
      • Nichols L.P.
      • Sonneville K.R.
      Youth opinions about guns and gun control in the United States.
      • Creswell J.W.
      Research design: qualitative, quantitative, and mixed methods approaches.
      • Zucker N.A.
      • Schmitt C.
      • Nichols L.P.
      • Plegue M.A.
      • Chang T.
      179–Confidentiality in the doctor-patient relationship: perspectives of youth Ages 14–24.
      Text messaging use for qualitative research is effective, easy to implement, and preferable among low-income communities.
      • Chang T.
      • Gossa W.
      • Sharp A.
      • Rowe Z.
      • Kohatsu L.
      • Cobb E.M.
      • et al.
      Text messaging as a community-based survey tool: a pilot study.
      • Sharp A.L.
      • Chang T.
      • Cobb E.
      • Gossa W.
      • Rowe Z.
      • Kohatsu L.
      • et al.
      Exploring real-time patient decision-making for acute care: a pilot study.
      • DeJonckheere M.
      • Nichols L.P.
      • Vydiswaran V.G.V.
      • Zhao X.
      • Collins-Thompson K.
      • Resnicow K.
      • et al.
      Using text messaging, social media, and interviews to understand what pregnant youth think about weight gain during pregnancy.
      Nearly all youth (97%) use text messaging.
      • Porath S.
      Text messaging and teenagers: A review of the literature.
      The convenience and accessibility of text messaging alleviates challenges of traditional qualitative methods (eg, interviews, school-based samples), including time and travel, sampling limited to single schools or communities, time lag, and willingness to disclose sensitive information.
      • Vyas A.N.
      • Landry M.
      • Schnider M.
      • Rojas A.M.
      • Wood S.F.
      Public health interventions: reaching Latino adolescents via short message service and social media.
      • Schnall R.
      • Okoniewski A.
      • Tiase V.
      • Low A.
      • Rodriguez M.
      • Kaplan S.
      Using text messaging to assess adolescents' health information needs: an ecological momentary assessment.
      • Schober M.F.
      • Conrad F.G.
      • Antoun C.
      • Ehlen P.
      • Fail S.
      • Hupp A.L.
      • et al.
      Precision and disclosure in text and voice interviews on smartphones.
      MyVoice participants are recruited through targeted Instagram and Facebook advertisements to match national demographic benchmarks set to weighted samples from the 2016 American Community Survey. Participant consent is obtained for data collection at the time of enrollment, and parental consent is waived by the institutional review board (HUM00119982) for minor participants due to minimal risk.
      Age, sex, race, ethnicity, zip code, and socioeconomic status (SES; defined as low if respondents reported qualifying for free or reduced-price school lunch in middle/high school or medium/high if not) are collected from all participants upon enrollment.
      • Nicholson L.
      • Slater S.
      • Chriqui J.
      • Chaloupka F.
      Validating adolescent socioeconomic status: comparing school free or reduced price lunch with community measures.
      Participants are identified only by nickname and cellular phone number to maintain confidentiality. A weekly text message survey is sent to all participants for which they receive modest incentive ($1) for participation. All question sets were developed through an iterative writing and piloting process involving the academic researchers, methodologists, and youth. Question sets are staggered into 6 monthly waves and closed after 1 week. Text message responses are linked to respondent demographics. Detailed procedures have been previously described.
      • DeJonckheere M.
      • Nichols L.P.
      • Moniz M.H.
      • Sonneville K.R.
      • Vydiswaran V.G.V.
      • Zhao X.
      • et al.
      MyVoice national text message survey of youth aged 14 to 24 years: study protocol.
      • DeJonckheere M.
      • Fisher A.
      • Chang T.
      How has the presidential election affected young Americans?.
      • Crissman H.P.
      • Czuhajewski C.
      • Moniz M.H.
      • Plegue M.
      • Chang T.
      Youth perspectives regarding the regulating of bathroom use by transgender individuals.
      • Van Sparrentak M.
      • Chang T.
      • Miller A.L.
      • Nichols L.P.
      • Sonneville K.R.
      Youth opinions about guns and gun control in the United States.

       Data Collection

      Between December 2017 and June 2018, 1047 MyVoice participants received the following 5 open-ended text message prompts: (1) “Hi from MyVoice! Have you ever taken a prescription pain medication? Tell us about it.” (2) “When it comes to your health, how safe is it to use prescription pain medication that was NOT prescribed to you? Why?” (3) “When it comes to your health, how safe is it to use a prescription pain medication that WAS prescribed to you? Why?” (4) “Could you get prescription pain medication from somewhere other than your doctor? Where?” (5) “When you hear the word ‘opioid,’ what do you think of?”

       Statistical Analysis

      Participants were considered respondents if they provided at least 1 response. Missing or incoherent responses were excluded on a question-by-question basis (2%-6% per question). Using an inductive and descriptive qualitative approach, an interdisciplinary research team (surgeons, a family physician, a mixed-methods methodologist, and a research informatics expert) reviewed the dataset and developed a coding scheme.
      • Creswell J.W.
      Research design: qualitative, quantitative, and mixed methods approaches.
      Two researchers then performed line-by-line coding on all open-ended responses independently. Coding was regularly compared, clarified, and confirmed. Although coding generally matched, consensus was met for any discrepancies. For instances in which the coding scheme inadequately captured the meaning or sentiment of the quote, additional codes were identified and consensus was met for inclusion. If meaning could not be derived, responses were coded as “unclear.” After coding all interviews, codes were condensed and related to one another to inductively identify emerging themes. To ensure validity and reliability, emerging themes were discussed regularly in meetings with the larger research team to confirm neutrality and triangulated with review of previous literature to address trustworthiness of the study findings.
      • Creswell J.W.
      • Miller D.L.
      Determining validity in qualitative inquiry.
      ,
      • Cohen D.J.
      • Crabtree B.F.
      Evaluative criteria for qualitative research in health care: controversies and recommendations.
      Descriptive statistics were calculated on respondent demographics and themes using Stata, version 15.1 (StataCorp, College Station, Texas).

      Results

      Among 1047 participants, 745 responded (71.2%). The majority of respondents were female (n = 439, 59.3%), and 75.8% were white (n = 561). Mean age was 18.3 ± 3.2 years and median age was 17 years (IQR 5). Low SES was reported among 217 (29.3%) respondents (Table I).
      Table IRespondent demographics
      Respondent characteristics (n = 740)Mean (SD) or n (%) of respondents
      Age, y, Mean (SD)18.3 (3.2)
      Sex
      Categories are mutually exclusive but may not add to 100% due to rounding.
       Female439 (59.3)
       Male258 (34.9)
       Nonbinary15 (2.0)
       Transgender13 (1.8)
       Other or unspecified19 (2.6)
      Race
      Respondents may respond “yes” to more than 1 category.
       White561 (75.8)
       Asian98 (13.2)
       Black or African American85 (11.5)
       American Indian21 (2.8)
       Native Hawaiian or other Pacific Islander1 (0.1)
       Other30 (4.1)
      Ethnicity
      Categories are mutually exclusive but may not add to 100% due to rounding.
       Hispanic/Latino81 (10.9)
       Not Hispanic/Latino663 (89.6)
       Not specified1 (0.1)
      SES
      Categories are mutually exclusive but may not add to 100% due to rounding.
      ,
      Low SES is defined as qualifying for free or reduced-price lunch, whereas medium/high SES is defined as not qualifying for free or reduced-price lunch.
       Low SES217 (29.3)
       Medium/high SES515 (69.6)
       Not specified13 (1.8)
      Region
      Categories are mutually exclusive but may not add to 100% due to rounding.
      ,
      § South, Midwest, West, and Northeast represent major Census Regions within the US as identified by zip code of respondent residence.
       Midwest471 (63.6)
       Northeast62 (8.4)
       South120 (16.2)
       West90 (12.2)
       Unknown2 (0.3)
      Categories are mutually exclusive but may not add to 100% due to rounding.
      Respondents may respond “yes” to more than 1 category.
      Low SES is defined as qualifying for free or reduced-price lunch, whereas medium/high SES is defined as not qualifying for free or reduced-price lunch.
      § South, Midwest, West, and Northeast represent major Census Regions within the US as identified by zip code of respondent residence.
      Qualitative analysis revealed 4 primary themes: (1) “All you have to do is ask around”: Exposure and access to prescription pain medication were common. (2) “Safe, because it was prescribed by a doctor”: Prescribed pain medication was safer than nonprescribed based on an implicit trust in the doctor. (3) “Using pain medications that were not prescribed is unsafe, but even prescribed pain meds have their risks”: All pain medication carried risk, but medication that had not been prescribed was perceived as riskier. (4) “Heroin, cocaine, and poppy seeds”: Respondents had a wide range of understanding of the word “opioid,” from historical to current events, medical to illicit substances, and personal to public associations.

       Theme #1: “All You Have to Do Is Ask Around”

      The majority of respondents (n = 377; 52.0%) reported previous exposure to prescription pain medication, most commonly related to acute care prescribing: dentistry (n = 123; 32.8%), surgery (n = 72; 19.2%), and injury (n = 45; 12.0%) (Table II). Although rare (n = 3; 0.8%), some respondents reported recreational use as their only exposure: “I've never been prescribed any pain medication but my brother was once and he never took any so I actually ended up abusing his and took the whole bottle over a couple weeks because it was fun and addictive” (20-year-old white male, Midwest, medium/high SES).
      Table IISummary of MyVoice national text message poll responses
      Poll promptsn (%) of respondents
      Have you ever taken a prescription pain medication? Tell us about it. (n = 730)
       Past use
      Categories are mutually exclusive but may not add to 100% due to rounding.
      Yes377 (52.0)
      No348 (48.0)
      Unsure5 (0.7)
       Reasons for past use
      Respondents may respond “yes” to more than 1 category.
      ,
      Out of respondents with past opioid use.
      (n = 375)
      Dental123 (32.8)
      Surgery72 (19.2)
      Injury or accident45 (12.0)
      Chronic pain42 (11.2)
      Illness16 (4.3)
      Recreation3 (0.8)
      No reason specified110 (29.3)
      Could you get prescription pain medication from somewhere other than your doctor? Where? (n = 694)
      Respondents may respond “yes” to more than 1 category.
       Illicit sources (eg, drug dealer, school contacts, online)188 (27.1)
       Friend or family sources89 (12.8)
       Medical sources (eg, pharmacy, other clinician)111 (16.0)
       No sources or unsure346 (49.9)
      When you hear the word "opioid," what do you think of? (n = 694)
      Respondents may respond “yes” to more than 1 category.
       Current event (eg, “the opioid epidemic in the rust belt”)281 (40.5)
       Prescription pain medication (eg, “drugs prescribed during painful surgeries”)207 (29.8)
       Illicit substance (eg,“hard drugs,” “illegal drugs like heroin”)180 (25.9)
       Historical reference (eg, “poppy flowers,” “The opioid issue in China that resulted in Britain extorting China”)46 (6.6)
       Personal experience (eg, “my friend's sister who overdosed,” “my dad”)4 (0.6)
       Unsure (eg, “I have no idea”)39 (5.6)
      Categories are mutually exclusive but may not add to 100% due to rounding.
      Respondents may respond “yes” to more than 1 category.
      Out of respondents with past opioid use.
      Nonmedical sources from which respondents could obtain prescription pain medication were identified by 36.9% of respondents (n = 256), including “street” sources (drug dealers, other illegal sources, or asking around at school or online) or leftover prescriptions from family or friends. For example, illicit sources were described as: “Stealing or illicitly buying them” (16-year-old white male, Midwest, medium/high SES); “A lot of people at my school sell drugs but let's not talk about that” (15-year-old white male, West, medium/high SES); “All you have to do is ask around. People sell them all of the time” (23-year-old white female, Midwest, low SES). Alternatively, leftover prescriptions of family or friends also were accessible: “From my parent prescription” (14-year-old Multiracial female, Northeast, medium/high SES); “You could easily take some from a friend who was prescribed too many pills” (15-year-old white male, Midwest, medium/high SES).
      An additional 16.0% (n = 111) identified access to prescription pain medication through medical sources other than their doctor. Some respondents referred to commercial entities (“The pharmacy” [22-year-old black or African American female, South, low SES]). Others mentioned alternative prescribers, such as “a dentist” (21-year-old white female, Midwest, medium/high SES) or “veterinarians” (24-year-old white male, Midwest, medium/high SES).

       Theme #2: “Safe, Because It Was Prescribed by a Doctor”

      The majority of respondents believed prescription pain medication that was prescribed to them to be safe; however, the perceived degree of safety varied (Figure). Prescribed prescription pain medication was felt to be safe in all situations by 236 respondents (33.6%), whereas 346 considered it safe only under certain conditions, such as if instructions were followed (49.3%). In contrast, only a minority of respondents perceived medication that had NOT been prescribed as always (n = 33; 4.6%) or conditionally safe (n = 81; 11.3%).
      Figure thumbnail gr1
      FigurePerceived safety of prescription pain medication use. Respondents were asked how safe they considered prescribed (N = 702) and nonprescribed pain medication (N = 717). Responses were coded as safe, conditionally safe, unsafe, or unsure. The proportion of respondents identifying each category of access or perceived safety are shown on the y-axis.
      Perception of safety was often based in trust that the doctor knew what was best for the patient: “Your doctor obviously prescribed it to you because they knew you would safely benefit from it” (17-year-old Asian female, Northeast, medium/high SES); “The doctor knows what you need and knows it will help you” (16-year-old Hispanic female, South, low SES). Respondents rationalized the safety of prescribed medication because it had been tailored to their specific needs: “It was prescribed for you and it's the correct dosage amount considering it's for your health and body” (17-year-old Hispanic female, South, low SES). Other respondents stated safety was contingent on how it was taken: “I think it is safe as long as it is used in the way the doctor prescribed” (17-year-old Asian/white female, West, low SES).
      There was also a belief that if medication was prescribed for a medical reason, risks of addiction and overdose were lower: “If they are prescribed then that means that they are necessary and portioned so that it is harder to get addicted” (16-year-old white female, Midwest, low SES); “I think it's less addictive when it's counteracted by pain” (15-year-old white male, Northeast, medium/high SES); “Doctors purposefully prescribe non-addictive amounts” (21-year-old white female, Midwest, medium/high SES).

       Theme #3: “Using Pain Medications That Were Not Prescribed is Unsafe, But Even Prescribed Pain Meds Have Their Risks”

      Overall, 555 (77.4%) respondents considered nonprescribed prescription pain medication to be unsafe, compared with only 81 respondents (11.5%) who considered prescribed medication to be unsafe. Respondents cited fear of unknown dosage, ingredients, or side effects of the medication: “You don't know the dosage or how the drug will affect you or how it might interact with other medication you're taking” (15-year-old black or African American female, Northeast, medium/high SES). Respondents also referred to risk of overdose or addiction conferred by unknown dosage: “It's not safe, I know a lot of people who do it anyways. You could easily overdose and die if taken without instructions” (14-year-old white male, South, low SES). Without healthcare provider oversight or a medical indication such as pain, there was also a fear of addiction: “I'm scared of overdosing or becoming addicted” (22-year-old Asian female, Midwest, medium/high SES).
      If pain medication had been prescribed, respondents considered it unsafe if it was used in a way other than prescribed: “It may have expired, and over time our bodies change, which means your health needs change, which also means your medication should change too along with all of that. You be doing just as much damage taking your own old meds, as you would do taking someone else's” (14-year-old African American female, Midwest, medium/high SES). There was also concern about the dangers of prescribed pain medication given the current opioid crisis: “I think caution should still be used given the opioid epidemic that has hit the US due to overprescription of pain meds” (unknown age white female, West, medium/high SES).

       Theme #4: “Heroin, Cocaine, and Poppy Seeds”

      Respondents associated the word “opioid” with a wide range of meanings distributed along three spectrums: events (historic to current), substances (medical to illicit), and relationships (self to everyone else). An additional 39 respondents (5.6%) were unsure of the meaning of the word opioid or had never heard of it.
      Overall, respondents were highly aware of the national opioid crisis in current events; 281 respondents (40.5%) associated “opioid” with the current opioid crisis, high rates of overdose and/or addiction, and overprescribing of prescription opioids: “I think of the prescription pain medication that is often prescribed that many people then end up addicted to and that people can overdose on. I think we need to reevaluate which drugs we're prescribing and which ones we're outlawing based their addictive properties and harmfulness” (15-year-old white female, Midwest, medium/high SES). In contrast, 46 respondents (6.6%) associated “opioid” with historic events such as the Opium wars involving China and the British Empire in the mid-19th century (“Chinese opium wars” [16-year-old white male, South, medium/high SES]) or historic methods for deriving opioids from poppy flowers (“um maybe like a flower? but I'm assuming it's a drug since you brought it up” [19-year-old Asian female, Midwest, medium/high SES]).
      “Opioid” was frequently associated with a drug, but this spanned from pain medications (207 respondents, 29.8%) to illicit substances (180 respondents, 25.9%). Among the 29.8% referring to pain medication, “opioid” was often associated with the term “painkiller” or “pain medication.” Less commonly, specific prescription opioid drug names were mentioned such as Vicodin or OxyContin (49 respondents, 7.0%). Among the 25.9% referring to illicit substances, the word “opioid” was most commonly associated with heroin (94 respondents, 13.5%) and infrequently associated with fentanyl (6 respondents, 0.9%).
      Lastly, some respondents mentioned personal experiences. Some respondents associated “opioid” with family members (“my dad” [16-year-old white transgender male, Midwest, medium/high SES]) or friends (“My friend's sister who overdosed” [21-year-old white female, Midwest, medium/high SES]). Personal experiences with opioids also were noted in responses to the previous questions about prescription pain medication: “I used pain pill prescriptions to aid in my back pain from the age of 12-18. I became extremely addicted to them. I would say not safe at all. Especially with little doctor management involved. I kept getting refills and my doctors weren't concerned about me needing a new prescription” (18-year-old black or African American female, South, low SES). Respondents who had personal experiences with opioids often perceived great risk from prescribed pain medications: “In the case of my wisdom teeth being removed I didn't fill one of the prescriptions because it was the same stuff my uncle got hooked on before he started heroin” (22-year-old white female, Midwest, medium/high SES, Midwest); “My mother is a drug addict and my father is an alcoholic so I have a very addictive personality” (16-year-old white male, Midwest, medium/high SES).

      Discussion

      This study revealed that 1 in 2 youth reported previous prescription pain medication use, and 1 in 3 youth reported access to prescription pain medication through a non-healthcare source. Youth considered prescription pain medication that was prescribed to them to be safer than prescription pain medication that was not prescribed to them. Specifically, youth trusted that prescribed pain medication was tailored to their needs and had lower risks of overdose and addiction compared with non-prescribed medications. These misperceptions may contribute to the continued rise in opioid misuse and overdose among youth.
      Our findings align with previous work, suggesting that youth may not connect messaging about the opioid crisis to their own prescription pain medications. For example, we found that youth tended to associate the word “opioid” with the national opioid crisis or illicit substances such as heroin, rather than pain medication typically prescribed in the healthcare setting. Similarly, a previous study found that youth were more likely to report nonmedical use of “Vicodin” as opposed to nonmedical use of “opioids” in the same survey, suggesting that youth do not know what “opioid” means.
      • Palamar J.J.
      • Shearston J.A.
      • Cleland C.M.
      Discordant reporting of nonmedical opioid use in a nationally representative sample of US high school seniors.
      In previous work, young adults who used opioids nonmedically also considered prescription opioids to be safer than illicit drugs such as heroin or cocaine.
      • Daniulaityte R.
      • Falck R.
      • Carlson R.G.
      “I'm not afraid of those ones just ‘cause they've been prescribed”: perceptions of risk among illicit users of pharmaceutical opioids.
      ,
      • Lord S.
      • Brevard J.
      • Budman S.
      Connecting to young adults: an online social network survey of beliefs and attitudes associated with prescription opioid misuse among college students.
      There are several limitations. First, this study is limited in generalizability and may miss youth who do not participate in either Instagram or Facebook. However, Instagram and Facebook were used by 72% and 51% of youth aged 13-17 years in 2018, respectively, and MyVoice recruitment continuously adapts to meet the American Community Survey standards based on current participation.
      • Anderson M.
      • Jiang J.
      Teens, Social media & technology 2018.
      Moreover, the purpose of this platform is to examine the depth of participant experiences in the youth's own voice, rather than generalize to all populations.
      • DeJonckheere M.
      • Nichols L.P.
      • Moniz M.H.
      • Sonneville K.R.
      • Vydiswaran V.G.V.
      • Zhao X.
      • et al.
      MyVoice national text message survey of youth aged 14 to 24 years: study protocol.
      Second, some survey questions referred to prescription pain medication rather than opioids specifically. We were intentionally youth-friendly in our terminology with the concern that youth may not understand the word “opioid.” Despite this, many youths referred to addiction, overdose, or specific opioid medications by name, suggesting that they equated “prescription pain medication” with “opioid.” Third, although text message-based responses provide more limited responses than focus groups or semistructured interviews might, this methodology allows a cross-sectional and timely platform for the contemporary youth voice. Fourth, although MyVoice is intentionally anonymous, social desirability bias may impact youth response. For example, 0.3% of youth reported prescription pain medication use for recreational purposes, a lower estimate than previous studies, whereas 29.3% did not specify motivation.
      • Johnston L.D.
      • O'Malley P.M.
      • Miech R.A.
      • Bachman J.G.
      • Schulenberg J.E.
      Monitoring the Future national survey results on drug use: 1975-2016.
      ,
      • Young A.
      • McCabe S.E.
      • Cranford J.A.
      • Ross-Durow P.
      • Boyd C.J.
      Nonmedical use of prescription opioids among adolescents: subtypes based on motivation for use.
      Despite these limitations, these themes persist within the context of previous literature, emphasizing the urgency with which misperceptions regarding the safety of opioid use must be addressed.
      Youth identified trust in clinicians as a leverage point in the delivery of opioid education. More than one-third of youth (36.9%) who misused prescription opioids obtained them from their own leftover prescriptions.
      • McCabe S.E.
      • West B.T.
      • Boyd C.J.
      Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study.
      When prescribing, clinicians must highlight the parallel risks among all opioids, prescribed and illicit. The most common sources of opioids are from family or friends whether given for free (55.0%), bought (37.9%), or taken without asking (22.2%); these were also likely prescribed by a clinician.
      • McCabe S.E.
      • West B.T.
      • Boyd C.J.
      Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study.
      In addition, recent state policies mandating opioid education at the time of prescribing carry exceptions for minors, potentially limiting the effectiveness of such policies in this age group. Clinicians prescribing opioids to patients of any age should discuss the risks of sharing medications, the importance of locked storage, and prompt disposal of unused medication. Regardless of prescribing, clinicians should confidentially ask all youth about opioid use to create the space for open conversation and intervention. Education targeted at clinicians may first be needed to raise awareness about youths' misperceptions of opioid safety and sources of nonmedical access.
      Educational interventions to raise public awareness in communities and schools are also needed but have historically demonstrated little effect.
      • Parker A.M.
      • Strunk D.
      • Fiellin D.A.
      State responses to the opioid crisis.
      ,
      • Allara E.
      • Ferri M.
      • Bo A.
      • Gasparrini A.
      • Faggiano F.
      Are mass-media campaigns effective in preventing drug use? A Cochrane systematic review and meta-analysis.
      • Perry C.L.
      • Komro K.A.
      • Veblen-Mortenson S.
      • Bosma L.M.
      • Farbakhsh K.
      • Munson K.A.
      • et al.
      A randomized controlled trial of the middle and junior high school D.A.R.E. and D.A.R.E. Plus programs.
      • Pan W.
      • Bai H.
      A multivariate approach to a meta-analytic review of the effectiveness of the D.A.R.E. program.
      Stakeholders should neither assume that all youth are receiving relevant messages about the opioid crisis, nor that youth will be activated by adult-directed messaging. Potential opportunities to improve effectiveness of community- or school-based education may be through use of modern platforms such as social media.
      • Moore S.K.
      • Grabinski M.
      • Bessen S.
      • Borodovsky J.T.
      • Marsch L.A.
      Web-based prescription opioid abuse prevention for adolescents: program development and formative evaluation.
      Messages should use language that helps youth understand that there are similar risks between the prescribed medication used for pain, illicit pills used for recreation without medical supervision, and intravenous heroin and fentanyl that are driving the deaths of family and friends.

      Data Statement

      Data sharing statement available at www.jpeds.com.

      Supplementary Data

      References

        • Gaither J.R.
        • Shabanova V.
        • Leventhal J.M.
        US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016.
        JAMA Netw Open. 2018; 1: e186558
        • Seth P.
        • Scholl L.
        • Rudd R.A.
        • Bacon S.
        Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015-2016.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 349-358
        • Hedegaard H.
        • Warner M.
        • Miniño A.
        Drug overdose deaths in the United States, 1999–2016.
        National Center for Health Statistics, Hyattsville, MD2017
        • Barocas J.A.
        • White L.F.
        • Wang J.
        • Walley A.Y.
        • LaRochelle M.R.
        • Bernson D.
        • et al.
        Estimated prevalence of opioid use disorder in Massachusetts, 2011-2015: a capture-recapture analysis.
        Am J Public Health. 2018; 108: 1675-1681
        • Lankenau S.E.
        • Teti M.
        • Silva K.
        • Jackson Bloom J.
        • Harocopos A.
        • Treese M.
        Initiation into prescription opioid misuse amongst young injection drug users.
        Int J Drug Policy. 2012; 23: 37-44
        • Cicero T.J.
        • Ellis M.S.
        • Surratt H.L.
        • Kurtz S.P.
        The changing face of heroin use in the United States: a retrospective analysis of the past 50 years.
        JAMA Psychiatry. 2014; 71: 821-826
        • Miech R.
        • Johnston L.
        • O'Malley P.M.
        • Keyes K.M.
        • Heard K.
        Prescription opioids in adolescence and future opioid misuse.
        Pediatrics. 2015; 136: e1169-e1177
        • McGinty E.E.
        • Stuart E.A.
        • Caleb Alexander G.
        • Barry C.L.
        • Bicket M.C.
        • Rutkow L.
        Protocol: mixed-methods study to evaluate implementation, enforcement, and outcomes of U.S. state laws intended to curb high-risk opioid prescribing.
        Implement Sci. 2018; 13: 37
        • Parker A.M.
        • Strunk D.
        • Fiellin D.A.
        State responses to the opioid crisis.
        J Law Med Ethics. 2018; 46: 367-381
      1. Mich Comp Laws 3337303c2017.

        • Allara E.
        • Ferri M.
        • Bo A.
        • Gasparrini A.
        • Faggiano F.
        Are mass-media campaigns effective in preventing drug use? A Cochrane systematic review and meta-analysis.
        BMJ Open. 2015; 5: e007449
        • Perry C.L.
        • Komro K.A.
        • Veblen-Mortenson S.
        • Bosma L.M.
        • Farbakhsh K.
        • Munson K.A.
        • et al.
        A randomized controlled trial of the middle and junior high school D.A.R.E. and D.A.R.E. Plus programs.
        Arch Pediatr Adolesc Med. 2003; 157: 178-184
        • Pan W.
        • Bai H.
        A multivariate approach to a meta-analytic review of the effectiveness of the D.A.R.E. program.
        Int J Environ Res Public Health. 2009; 6: 267-277
        • Moore S.K.
        • Grabinski M.
        • Bessen S.
        • Borodovsky J.T.
        • Marsch L.A.
        Web-based prescription opioid abuse prevention for adolescents: program development and formative evaluation.
        JMIR Form Res. 2019; 3: e12389
        • Yedinak J.L.
        • Kinnard E.N.
        • Hadland S.E.
        • Green T.C.
        • Clark M.A.
        • Marshall B.D.
        Social context and perspectives of non-medical prescription opioid use among young adults in Rhode Island: a qualitative study.
        Am J Addict. 2016; 25: 659-665
        • DeJonckheere M.
        • Nichols L.P.
        • Moniz M.H.
        • Sonneville K.R.
        • Vydiswaran V.G.V.
        • Zhao X.
        • et al.
        MyVoice national text message survey of youth aged 14 to 24 years: study protocol.
        JMIR Res Protoc. 2017; 6: e247
        • DeJonckheere M.
        • Fisher A.
        • Chang T.
        How has the presidential election affected young Americans?.
        Child Adolesc Psychiatry Ment Health. 2018; 12: 8
        • Crissman H.P.
        • Czuhajewski C.
        • Moniz M.H.
        • Plegue M.
        • Chang T.
        Youth perspectives regarding the regulating of bathroom use by transgender individuals.
        J Homosex. 2019; 4: 1-16
        • Van Sparrentak M.
        • Chang T.
        • Miller A.L.
        • Nichols L.P.
        • Sonneville K.R.
        Youth opinions about guns and gun control in the United States.
        JAMA Pediatr. 2018; 172: 884-886
        • Creswell J.W.
        Research design: qualitative, quantitative, and mixed methods approaches.
        SAGE Publications, Thousand Oaks (CA)2014
        • Zucker N.A.
        • Schmitt C.
        • Nichols L.P.
        • Plegue M.A.
        • Chang T.
        179–Confidentiality in the doctor-patient relationship: perspectives of youth Ages 14–24.
        J Adolesc Health. 2018; 62: S92
        • Chang T.
        • Gossa W.
        • Sharp A.
        • Rowe Z.
        • Kohatsu L.
        • Cobb E.M.
        • et al.
        Text messaging as a community-based survey tool: a pilot study.
        BMC Public Health. 2014; 14: 936
        • Sharp A.L.
        • Chang T.
        • Cobb E.
        • Gossa W.
        • Rowe Z.
        • Kohatsu L.
        • et al.
        Exploring real-time patient decision-making for acute care: a pilot study.
        West J Emerg Med. 2014; 15: 675-681
        • DeJonckheere M.
        • Nichols L.P.
        • Vydiswaran V.G.V.
        • Zhao X.
        • Collins-Thompson K.
        • Resnicow K.
        • et al.
        Using text messaging, social media, and interviews to understand what pregnant youth think about weight gain during pregnancy.
        JMIR Form Res. 2019; 3: e11397
        • Porath S.
        Text messaging and teenagers: A review of the literature.
        J Res Center Educ Technol. 2011; 7: 86-99
        • Vyas A.N.
        • Landry M.
        • Schnider M.
        • Rojas A.M.
        • Wood S.F.
        Public health interventions: reaching Latino adolescents via short message service and social media.
        J Med Internet Res. 2012; 14: e99
        • Schnall R.
        • Okoniewski A.
        • Tiase V.
        • Low A.
        • Rodriguez M.
        • Kaplan S.
        Using text messaging to assess adolescents' health information needs: an ecological momentary assessment.
        J Med Internet Res. 2013; 15: e54
        • Schober M.F.
        • Conrad F.G.
        • Antoun C.
        • Ehlen P.
        • Fail S.
        • Hupp A.L.
        • et al.
        Precision and disclosure in text and voice interviews on smartphones.
        PLoS One. 2015; 10: e0128337
        • Nicholson L.
        • Slater S.
        • Chriqui J.
        • Chaloupka F.
        Validating adolescent socioeconomic status: comparing school free or reduced price lunch with community measures.
        Spat Demogr. 2014; 2: 55-65
        • Creswell J.W.
        • Miller D.L.
        Determining validity in qualitative inquiry.
        Theory Pract. 2000; 39: 124-130
        • Cohen D.J.
        • Crabtree B.F.
        Evaluative criteria for qualitative research in health care: controversies and recommendations.
        Ann Fam Med. 2008; 6: 331-339
        • Palamar J.J.
        • Shearston J.A.
        • Cleland C.M.
        Discordant reporting of nonmedical opioid use in a nationally representative sample of US high school seniors.
        Am J Drug Alcohol Abuse. 2016; 42: 530-538
        • Daniulaityte R.
        • Falck R.
        • Carlson R.G.
        “I'm not afraid of those ones just ‘cause they've been prescribed”: perceptions of risk among illicit users of pharmaceutical opioids.
        Int J Drug Policy. 2012; 23: 374-384
        • Lord S.
        • Brevard J.
        • Budman S.
        Connecting to young adults: an online social network survey of beliefs and attitudes associated with prescription opioid misuse among college students.
        Subst Use Misuse. 2011; 46: 66-76
        • Anderson M.
        • Jiang J.
        Teens, Social media & technology 2018.
        • Johnston L.D.
        • O'Malley P.M.
        • Miech R.A.
        • Bachman J.G.
        • Schulenberg J.E.
        Monitoring the Future national survey results on drug use: 1975-2016.
        Institute for Social Research, The University of Michigan, Ann Arbor2017
        • Young A.
        • McCabe S.E.
        • Cranford J.A.
        • Ross-Durow P.
        • Boyd C.J.
        Nonmedical use of prescription opioids among adolescents: subtypes based on motivation for use.
        J Addict Dis. 2012; 31: 332-341
        • McCabe S.E.
        • West B.T.
        • Boyd C.J.
        Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study.
        J Adolesc Health. 2013; 52: 480-485
      2. Draft recommendation statement: illicit drug use, including nonmedical use of prescription drugs: screening.
        (Accessed December 27, 2019)