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Prescription Drug Use and Misuse in the United States:

Results from the 2015 National Survey on Drug Use and Health Authors SAMHSA: Arthur Hughes, Matthew R. Williams, Rachel N. Lipari, and Jonaki Bose; RTI International: Elizabeth A. P. Copello and Larry A. Kroutil

Abstract Background. Misuse of prescription psychotherapeutic drugs is second only to marijuana as the nation's most prevalent illicit drug use issue. In 2015, the National Survey on Drug Use and Health (NSDUH) questionnaire was redesigned regarding the data collection regarding four categories of prescription psychotherapeutic drugs: pain relievers, tranquilizers, stimulants, and sedatives. For the first time, NSDUH respondents were asked to report about any past year use of prescription drugs, which includes the use of one's own prescription medication as directed by a doctor, as well as misuse. In addition, misuse was redefined in 2015 as use in any way not directed by a doctor, including use without a prescription of one's own; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. Methods. This report presents 2015 NSDUH findings for people aged 12 or older regarding the past year use or misuse of prescription psychotherapeutic drugs and related topics. Estimates for selected outcomes are presented by age, gender, race, Hispanic origin, and county type. Statistically significant differences are noted within selected subgroups. Results. In 2015, an estimated 119.0 million Americans aged 12 or older used prescription psychotherapeutic drugs in the past year, representing 44.5 percent of the population. About 97.5 million people used pain relievers (36.4 percent), 39.3 million used tranquilizers (14.7 percent), 17.2 million used stimulants (6.4 percent), and 18.6 million used sedatives (6.9 percent). In 2015, 18.9 million people aged 12 or older (7.1 percent) misused prescription psychotherapeutic drugs in the past year. This number included 12.5 million people who misused pain relievers in the past year (4.7 percent), 6.1 million who misused tranquilizers (2.3 percent), 5.3 million who misused stimulants (2.0 percent), and 1.5 million who misused sedatives (0.6 percent). However, most people (84.1 percent) who used prescription drugs in the past year did not misuse them. Past year users of other substances were more likely than people aged 12 or older to have misused prescription drugs. For example, 72.1 percent of past year heroin users and 5.9 percent of past year alcohol users misused pain relievers in the past year. Adults aged 18 or older who did not have mental illness in the past year were less likely than adults with mental illness to have misused prescription drugs in the past year. In 2015, 2.1 million people aged 12 or older were recent initiates for pain reliever misuse (i.e., misused for the first time in the past year), 1.4 million were recent initiates for tranquilizer misuse, 1.3 million were recent initiates for stimulant misuse, and 425,000 were recent initiates for sedative misuse. On average, recent initiates aged 12 to 49 initiated the misuse of prescription drugs in their early to late 20s. About 1.0 percent of people aged 12 or older (2.7 million) had a prescription drug use disorder in the past year, including 2.0 million people with a pain reliever use disorder, 688,000 with a tranquilizer use disorder, 426,000 with a stimulant use disorder, and 154,000 with a sedative use disorder. In 2015, as part of their most recent substance use treatment, 822,000 people received treatment for the misuse of pain relievers, 293,000 people received treatment for tranquilizer misuse, 139,000 received treatment for stimulant misuse, and 116,000 received treatment for sedative misuse. Among people aged 12 or older who misused prescription pain relievers in the past year, the most commonly reported reason for their last misuse was to relieve physical pain (62.6 percent). Among past year misusers of tranquilizers, the most commonly reported reasons were to relax or relieve tension (44.9 percent) or to help with sleep (20.4 percent). Commonly reported reasons for misuse among stimulant misusers were to help be alert or stay awake, help concentrate, or help study (26.8, 26.5, and 22.5 percent, respectively). Among past year sedative misusers, the most common reason was to help with sleep (71.7 percent). Even if people misused prescription drugs for conditions for which these drugs are typically prescribed (e.g., for pain relief or to help with sleep), use without one's own prescription or use more often or at a higher dosage than prescribed nevertheless constitutes misuse. Among people aged 12 or older who misused pain relievers in the past year, the most common source for the last pain reliever that was misused was from a friend or relative (53.7 percent), and about one third misused a prescription from one doctor. About 1 in 20 people who misused pain relievers bought the last pain reliever they misused from a drug dealer or stranger. Conclusions. Compared with prior NSDUH data collection efforts, collecting more detailed information on the use and misuse of a comprehensive set of prescription drugs was determined to be more useful for policy and research purposes. The 2015 estimates provide a more nuanced understanding of prescription drug misuse in the United States.

Introduction Misuse of prescription psychotherapeutic drugs is second only to marijuana as the nation's most prevalent illicit drug use issue.1 Highlighting this critical issue with the most current and accurate information on the nature and extent of prescription drug misuse will help policymakers understand and refine substance use prevention and treatment strategies. The National Survey on Drug Use and Health (NSDUH) collects data on four main categories of prescription psychotherapeutic drugs: pain relievers, tranquilizers, stimulants, and sedatives. Although comparability of substance use measures across time is one of the strengths of NSDUH, prescription drug measures must be updated periodically as new drugs are introduced, new formulations of existing drugs are approved by the U.S. Food and Drug Administration (FDA), drugs are discontinued, controls for prescribing practices are revised, and drugs are switched from prescription to over-the-counter status. In 2015, the NSDUH questionnaire underwent a partial redesign that included changes to the prescription drug questions. Several key enhancements to the NSDUH prescription drug questions are described below and are discussed further in the section titled "New Directions in Measuring Prescription Drug Use and Misuse in the 2015 NSDUH" and in Appendix A. New questions were added for any use of specific prescription drugs.

use of specific prescription drugs. The reference period for questions about the misuse of specific prescription drugs changed from the lifetime to the past year period (i.e., the 12 months prior to the interview date).

New questions were added for the reasons why people misused.

A new section of the interview was created for methamphetamine use, such that methamphetamine is no longer included in estimates for prescription stimulants.

A new prescription drug questionnaire format was implemented. Because of the changes to the prescription drug questions (see Appendix A for more details), the 2015 prescription drug data constitute a new baseline for tracking trends in the use and misuse of prescription drugs over time. This report contains the first release of findings from the 2015 NSDUH for the use and misuse of prescription drugs in the past year among the civilian, noninstitutionalized population of the United States aged 12 or older. Comprehensive 2015 NSDUH detailed tables that show additional prescription drug estimates are available separately at https://www.samhsa.gov/data/.2

Change in Terminology from "Nonmedical Use" to "Misuse" Prior to 2015, NSDUH used the term "nonmedical use" of prescription drugs, which was defined as use of prescription drugs that were not prescribed for an individual or were taken only for the experience or feeling that the drugs caused. However, there were challenges and issues associated with the measurement of this concept.3 One concern, for example, was that the phrase "for the experience or feeling it caused" may erroneously capture reports of legitimate use based on the intended effects of the drug, such as pain relief.4 A further concern was whether the term "nonmedical use" appropriately describes use of prescription drugs that individuals took to treat a condition for which the medications are typically prescribed (e.g., nonprescription use of opioid pain relievers to relieve physical pain) but were prescribed for someone else.5 In addition, the definition did not specifically include the criterion of overuse of prescribed medication, which is particularly important for prescription pain relievers. To address these shortcomings, the 2015 prescription drug questions were revised to ask survey respondents about the use of prescription drugs "in any way that a doctor did not direct you to use them," including (1) use without a prescription of the respondent's own; (2) use in greater amounts, more often, or longer than the respondent was told to take them; or (3) use in any other way a doctor did not direct the respondent to use them. Along with changes to the definition of misuse, NSDUH reports and tables no longer use the term "nonmedical use" and instead use the term "misuse." Additional details on changes to the prescription drug questions and the implications for analysis are provided in Appendix A.

Survey Background NSDUH is an annual survey of the civilian, noninstitutionalized population of the United States aged 12 years old or older.6 The survey is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). The survey covers residents of households and individuals in noninstitutional group quarters (e.g., shelters, boarding houses, college dormitories, migratory workers' camps, halfway houses). The survey excludes people with no fixed address (e.g., homeless people not in shelters), military personnel on active duty, and residents of institutional group quarters, such as jails, nursing homes, mental institutions, and long-term care hospitals. NSDUH employs a stratified, multistage area probability sample that is designed to be representative of both the nation as a whole and for each of the 50 states and the District of Columbia. The 2015 NSDUH annual target sample size of 67,500 interviews was distributed across three age groups, with 25 percent allocated to adolescents aged 12 to 17, 25 percent allocated to young adults aged 18 to 25, and 50 percent allocated to adults aged 26 or older.7 NSDUH is a face-to-face household interview survey that is conducted in two phases: the screening phase and the interview phase. The interviewer conducts a screening of the eligible household with an adult resident (aged 18 or older) in order to determine whether zero, one, or two residents aged 12 or older should be selected for the interview.8 NSDUH collects data using audio computer-assisted self interviewing (ACASI) in which respondents read or listen to the questions on headphones and then enter their answers directly into a NSDUH laptop computer. ACASI is designed for accurate reporting of information by providing respondents with a highly private and confidential mode for responding to questions about illicit drug use, mental health, and other sensitive behaviors. NSDUH also uses computer-assisted personal interviewing (CAPI) in which interviewers read less sensitive questions to respondents and enter the respondents' answers into a NSDUH laptop computer. In 2015, screening was completed at 132,210 addresses, and 68,073 completed interviews were obtained, including 16,955 interviews from adolescents aged 12 to 17 and 51,118 interviews from adults aged 18 or older. Weighted response rates for household screening and for interviewing were 79.7 and 69.3 percent, respectively, for an overall response rate of 55.2 percent for people aged 12 or older. The weighted interview response rates were 77.7 percent for adolescents and 68.4 percent for adults.9 Further details about the 2015 NSDUH design and methods can be found on the web at https://www.samhsa.gov/data/.10

Notable 2015 NSDUH Questionnaire Changes The NSDUH questionnaire underwent a partial redesign in 2015 to improve the quality of the NSDUH data and to address the changing needs of policymakers and researchers with regard to substance use and mental health issues. As noted previously, the prescription drug questions were redesigned to shift the focus from lifetime misuse to past year misuse. Additionally, questions were added about any past year prescription drug use rather than just misuse. New methamphetamine questions were added, replacing the methamphetamine questions that were previously asked within the context of prescription stimulants. Substantial changes were also made to questions about smokeless tobacco, binge alcohol use, inhalants, and hallucinogens. These changes led to potential breaks in the comparability of 2015 estimates with estimates from prior years. Consequently, these changes potentially affected overall summary measures, such as illicit drug use, and other measures, such as initiation, substance use disorder, and substance use treatment. Additionally, certain demographic items were changed as part of the partial redesign. Education questions were updated, and new questions were added on disability, English-language proficiency, sexual orientation of adults, and military families. Due to these changes, only 2015 data are presented for certain estimates until comparability with prior years can be established. Trends will continue to be presented for items that are assumed to have remained comparable with earlier years. Details on the 2015 NSDUH questionnaire changes, reasons for the changes, and implications of the changes for NSDUH data users are summarized in a brief report on these questionnaire changes, in a report on the design changes for the 2014 and 2015 NSDUHs, and in the methodological summary and definitions report for 2015.11,12,13

Data Presentation and Interpretation Prescription drug use and misuse estimates are presented for people aged 12 or older, adolescents aged 12 to 17, and adults aged 18 or older. Estimates are based on 2015 NSDUH data, and results are presented separately by age group, gender, racial/ethnic groups,14 region of the country,15 and the type of county in which individuals reside.16 This report focuses on presenting the 2015 estimates and comparing estimates among people in different demographic and geographic subgroups. All estimates (e.g., percentages and numbers) presented in the report are derived from NSDUH survey data that are subject to sampling errors. The estimates have met the criteria for statistical reliability. Estimates that do not meet these criteria for reliability have been suppressed and are not shown.17 Statistical tests also have been conducted for comparisons that appear in the text of the report. Statistically significant differences are described using terms such as "higher," "lower," "more likely," or "less likely." Statements use terms such as "similar" or "the same" when a difference is not statistically significant. Graphics and tables contain estimates that support the statements in this report, and supplemental tables of estimates (including standard errors) are provided in Appendix B.

Use of Prescription Drugs The four categories of prescription drugs (pain relievers, tranquilizers, stimulants, and sedatives) cover numerous medications that currently are or have been available by prescription. NSDUH reports and tables combine these four prescription drug categories into a group referred to as "psychotherapeutics." Prescription pain relievers include opioids such as hydrocodone (e.g., Vicodin®), oxycodone (e.g., OxyContin® and Percocet®), and morphine. Opioid pain relievers act in the central nervous system to reduce the perception of pain. Questions about specific pain relievers in NSDUH focus only on opioid pain relievers. However, respondents may specify that they misused other nonopioid pain relievers that require a prescription. Prescription tranquilizers are often prescribed for anxiety relief or to relieve muscle spasms. These include benzodiazepine drugs such as alprazolam (e.g., Xanax®), muscle relaxants such as Soma®, and other prescription tranquilizers. Prescription stimulants are often prescribed for the treatment of attention-deficit hyperactivity disorder (ADHD) or obesity. For example, amphetamines (e.g., Adderall®) and methylphenidate (e.g., Ritalin®) are prescribed for ADHD. Although originally developed as a prescription stimulant, methamphetamine is no longer asked about in NSDUH as a prescription stimulant because it tends to be illegally manufactured and distributed. Prescription sedatives are often prescribed for the relief of sleep disorders such as insomnia. Zolpidem (e.g., Ambien®) is an example of a prescription sedative. For the first time, NSDUH respondents in 2015 were asked to report any past year use of these drugs, including the use of one's own prescription medication as directed by a doctor as well as misuse. Any Past Year Use of Prescription Psychotherapeutics Use of prescription psychotherapeutic drugs in the past year was fairly common in the United States. In 2015, an estimated 119.0 million Americans aged 12 or older were past year users of prescription psychotherapeutic drugs, representing 44.5 percent of the population (Figure 1).

Figure 1. Numbers of Past Year Prescription Psychotherapeutic Users among People Aged 12 or Older: 2015 D Note: Estimated numbers of people refer to people aged 12 or older in the civilian, noninstitutionalized population in the United States. The numbers do not sum to the total population of the United States because the population for NSDUH does not include people aged 11 years old or younger, people with no fixed household address (e.g., homeless or transient people not in shelters), active-duty military personnel, and residents of institutional group quarters, such as correctional facilities, nursing homes, mental institutions, and long-term care hospitals.

Note: The estimated numbers of past year users of different psychotherapeutics are not mutually exclusive because people could have used more than one type of psychotherapeutic in the past year.

Of the four categories of prescription psychotherapeutic drugs presented in this report (i.e., pain relievers, tranquilizers, stimulants, and sedatives), prescription pain relievers were the most commonly used (Figure 1). Approximately 97.5 million people aged 12 or older were past year users of prescription pain relievers in 2015, representing more than one third (36.4 percent) of the population aged 12 or older. In addition, approximately 39.3 million people were past year users of prescription tranquilizers in 2015, representing 14.7 percent of people aged 12 or older. Approximately 17.2 million people were past year users of prescription stimulants in 2015, representing 6.4 percent of the population aged 12 or older. Approximately 18.6 million people were past year users of prescription sedatives in 2015, representing 6.9 percent of the population aged 12 or older. By Age Group Of the 119.0 million past year users of prescription psychotherapeutic drugs in 2015, 7.0 million were youths aged 12 to 17 (28.1 percent of youths), 15.5 million were young adults aged 18 to 25 (44.3 percent of young adults), and 96.6 million were adults aged 26 or older (46.4 percent of adults in this age group) (Table B.2 in Appendix B). Among the 97.5 million past year users of prescription pain relievers, 5.7 million were youths (22.7 percent), 12.1 million were young adults (34.8 percent), and 79.7 million were adults aged 26 or older (38.3 percent). Adults aged 26 or older were more likely than youths or young adults to have used prescription pain relievers in the past year. Of the 39.3 million past year users of tranquilizers, 1.1 million were youths aged 12 to 17 (4.3 percent of youths), 4.2 million were young adults aged 18 to 25 (12.1 percent of young adults), and 34.0 million were adults aged 26 or older (16.4 percent of adults in this age group) (Table B.2). Adults aged 26 or older were more likely than youths or young adults to have used prescription pain tranquilizers in the past year. Of the 17.2 million past year users of prescription stimulants, 1.8 million were youths aged 12 to 17 (7.3 percent of youths), 4.9 million were young adults aged 18 to 25 (14.1 percent of young adults), and 10.5 million were adults aged 26 or older (5.0 percent of adults in this age group) (Table B.2). Unlike the patterns for pain relievers and tranquilizers, young adults were more likely than youths or adults aged 26 or older to have used stimulants in the past year. Of the 18.6 million past year users of prescription sedatives, 0.6 million were youths aged 12 to 17 (2.4 percent of youths), 1.3 million were young adults aged 18 to 25 (3.8 percent of young adults), and 16.6 million were older adults aged 26 or older (8.0 percent of older adults) (Table B.2). Thus, the overall estimate of 6.9 percent of people aged 12 or older who used sedatives in the past year was driven by use among adults aged 26 or older. By Gender Among the population aged 12 or older in 2015, 47.8 percent of females and 40.9 percent of males used prescription psychotherapeutic drugs in the past year (Table B.2 in Appendix B). Females were more likely than males to have used prescription pain relievers (38.8 vs. 33.9 percent), tranquilizers (17.9 vs. 11.3 percent), and sedatives (8.2 vs. 5.6 percent). However, similar percentages of females and males used prescription stimulants in the past year (6.3 and 6.5 percent, respectively). By Hispanic Origin and Race In 2015, 46.1 percent of non-Hispanics aged 12 or older and 36.3 percent of Hispanics in this same age group used prescription psychotherapeutic drugs in the past year (Table B.2 in Appendix B). People aged 12 or older who were not Hispanic were more likely than Hispanics to be past year users for each category of prescription psychotherapeutic drugs (37.6 vs. 30.2 percent for pain relievers, 15.5 vs. 10.3 percent for tranquilizers, 6.7 vs. 4.9 percent for stimulants, and 7.5 vs. 4.2 percent for sedatives). The past year use of psychotherapeutic drugs in 2015 ranged from 26.7 percent among non Hispanic Asians to 52.9 percent among non-Hispanic individuals who reported two or more races (Table B.2). The percentages of people aged 12 or older who used prescription pain relievers in the past year ranged from 22.0 percent of non-Hispanic Asians to 44.8 percent of non-Hispanic people who reported two or more races. The percentages of people aged 12 or older who used prescription tranquilizers in the past year ranged from 4.6 percent of non Hispanic Asians to 17.8 percent of non-Hispanic whites. For prescription stimulants, the percentages of people aged 12 or older who reported use in the past year ranged from 2.9 percent of non-Hispanic Asians to 10.2 percent of non-Hispanic people who reported two or more races. Percentages of people aged 12 or older who used prescription sedatives in the past year ranged from 3.3 percent of non-Hispanic Native Hawaiians or Other Pacific Islanders to 8.3 percent of non-Hispanic whites. By County Type Among individuals aged 12 or older in 2015, 42.9 percent of those residing in large metropolitan areas, 46.5 percent of those in small metropolitan areas, and 46.2 percent of those in nonmetropolitan areas used prescription psychotherapeutic drugs in the past year (Table B.3 in Appendix B).15 An estimated 34.7 percent of the population aged 12 or older in large metropolitan areas, 38.6 percent of those in small metropolitan areas, and 38.5 percent of those in nonmetropolitan areas used prescription pain relievers in the past year. Among individuals aged 12 or older residing in large metropolitan areas, 13.9 percent used prescription tranquilizers in the past year, as did 15.7 percent each for individuals in small metropolitan areas and nonmetropolitan areas. Percentages of individuals aged 12 or older who used prescription stimulants in the past year were 6.4 percent for residents of large metropolitan areas, 6.8 percent of residents of small metropolitan areas, and 5.8 percent of residents of nonmetropolitan areas. Percentages of individuals aged 12 or older who used prescription sedatives in the past year were 6.6 percent for those residing in large metropolitan areas, 7.4 percent for those in small metropolitan areas, and 7.3 percent for those in nonmetropolitan areas. Past Year Use of Subtypes of Prescription Drugs NSDUH asked respondents in 2015 to identify the specific prescription pain relievers, tranquilizers, stimulants, and sedatives that they used in the past year. Names of similar prescription drugs (e.g., Vicodin®, Lortab®, Norco®, Zohydro® ER, and generic hydrocodone) and electronic images of these drugs were presented to respondents to aid them in recalling which prescription drugs they used. For each prescription psychotherapeutic drug category, these specific prescription drugs were further categorized into subtypes within the overall category. However, estimates typically were not made for the specific prescription drugs that respondents reported using because the data were based on respondent self-reports.18 Consequently, respondents may have reported that they used a brand name drug whose name they recognized (e.g., Vicodin®) when they may have actually taken the generic equivalent or some other drug containing the same ingredient (e.g., hydrocodone). For classification purposes, however, these reports would be equivalent. For example, respondents who reported the use of the pain relievers Vicodin® or hydrocodone were classified as users of hydrocodone products. Pain Relievers The specific pain relievers that individuals used in the past year were categorized into 11 subtypes, such as hydrocodone products (Figure 2).19 In 2015, the most commonly used prescription pain relievers were hydrocodone products, which include Vicodin®, Lortab®, Norco®, Zohydro® ER, and generic hydrocodone (Table B.4 in Appendix B). Approximately 58.3 million people aged 12 or older used hydrocodone products in the past year, representing 21.8 percent of the population. An estimated 27.9 million people aged 12 or older, or 10.4 percent of the population, used oxycodone products in the past year. Oxycodone products include OxyContin®, Percocet®, Percodan®, Roxicet®, Roxicodone®, and generic oxycodone. Of the 27.9 million people aged 12 or older who used oxycodone products, 9.1 million used OxyContin®. This number of people who used OxyContin® in the past year represents 3.4 percent of the population aged 12 or older. Estimates for the past year use of buprenorphine products and methadone among people aged 12 or older were 0.9 and 0.6 percent, respectively. These two products are used in medication-assisted treatment to help people reduce or quit their use of heroin or other opiates.

Figure 2. Subtypes of Prescription Pain Relievers in the 2015 NSDUH Questionnaire D Note: Prescription pain reliever categories shown in the red and blue boxes represent estimates for subtypes that are shown in Table B.4 in Appendix B . Estimates for the specific pain relievers Zohydro® ER and OxyContin® also are shown in Table B.4 .

Note: Codeine products (e.g., Tylenol® with codeine 3 or 4 and codeine pills) are included in estimates for the Past Year use and misuse of any prescription pain reliever. However, separate estimates were not created for codeine products because of concerns that respondents in 2015 might overreport the use and misuse of codeine products if they confused Tylenol® with codeine 3 or 4 with over-the-counter Tylenol®, which does not require a prescription; changes were made to the 2016 NSDUH questionnaire to emphasize that Tylenol® with codeine 3 or 4 is not the same as over-the-counter Tylenol®.

Note: The following drugs in this figure are generic drugs: Hydrocodone, Oxycodone, Tramadol, Extended-Release Tramadol, Morphine, Extended-Release Morphine, Fentanyl, Buprenorphine, Oxymorphone, Extended-Release Oxymorphone, Hydromorphone, Extended-Release Hydromorphone, and Methadone.

Tranquilizers The specific tranquilizers that individuals used in the past year were categorized into six subtypes, and some of these six subtypes were further subcategorized (Figure 3). For example, one of the six subtypes of tranquilizers was benzodiazepine tranquilizers, which was further subcategorized into four types of benzodiazepine tranquilizers, such as alprazolam products (e.g., Xanax®, Xanax® ER).20 The most commonly used prescription tranquilizers among people aged 12 or older in 2015 were benzodiazepine tranquilizers, and the use of benzodiazepine tranquilizers was driven by the use of alprazolam products (Table B.5 in Appendix B). Of the 39.3 million people aged 12 or older who used tranquilizers in the past year, 29.7 million (11.1 percent of the population aged 12 or older) used benzodiazepine tranquilizers, including 17.6 million people who used tranquilizers that contain alprazolam. An estimated 6.6 percent of the population aged 12 or older used alprazolam products.

Figure 3. Subtypes of Prescription Tranquilizers in the 2015 NSDUH Questionnaire D Note: Prescription tranquilizer categories shown in the red, blue, and gray boxes represent estimates for subtypes that are shown in Table B.5 in Appendix B .

Note: The following drugs in this figure are generic drugs: Alprazolam, Extended-Release Alprazolam, Lorazepam, Clonazepam, Diazepam, Cyclobenzaprine, Buspirone, Hydroxyzine, and Meprobamate.

Stimulants The specific stimulants that individuals used in the past year were categorized into the five subtypes that are shown in Figure 4 and in Table B.6 in Appendix B.21 The most commonly used subtype of prescription stimulants among people aged 12 or older in 2015 was amphetamine products, such as Adderall®, Adderall® XR, Dexedrine®, Vyvanse®, and generic amphetamines.22 Of the 17.2 million past year users of stimulants aged 12 or older, 11.3 million (or 4.2 percent of the population aged 12 or older) used amphetamine products. In addition, 3.5 million people aged 12 or older used methylphenidate products in the past year.21 This number represents 1.3 percent of the population aged 12 or older.

Figure 4. Subtypes of Prescription Stimulants in the 2015 NSDUH Questionnaire D Note: Prescription stimulant categories shown in the red and blue boxes represent estimates for subtypes that are shown in Table B.6 in Appendix B .

Note: Vyvanse® is included with Amphetamine Products because its active ingredient (lisdexamfetamine) is metabolized to dextroamphetamine.

Note: The following drugs in this figure are generic drugs: Dextroamphetamine, Amphetamine-Dextroamphetamine Combinations, Extended-Release Amphetamine-Dextroamphetamine Combinations, Methylphenidate, Extended-Release Methylphenidate, Dexmethylphenidate, Extended-Release Dexmethylphenidate, Benzphetamine, Diethylpropion, Phendimetrazine, and Phentermine.

Sedatives The specific sedatives that individuals used in the past year were categorized into six subtypes, and one of these subtypes was further subcategorized (Figure 5).23 Specifically, the benzodiazepine sedatives subtype was further subcategorized into three subcategories: flurazepam, temazepam products, and triazolam products. In 2015, the most commonly used prescription sedatives were zolpidem products, such as Ambien®, Ambien® CR, generic zolpidem, extended-release generic zolpidem, and similar products (Table B.7 in Appendix B). An estimated 11.5 million people aged 12 or older used zolpidem products in the past year, representing 4.3 percent of the population. Thus, about 60 percent of the 18.6 million past year users of sedatives used zolpidem products in this period. About 2.5 million people (0.9 percent of the population aged 12 or older) used benzodiazepine sedatives. Only 0.2 percent of people aged 12 or older (452,000 people) used barbiturates in the past year.

Figure 5. Subtypes of Prescription Sedatives in the 2015 NSDUH Questionnaire D Note: Prescription sedative categories shown in the red, blue, and gray boxes represent estimates for subtypes that are shown in Table B.7 in Appendix B .

Note: The following drugs in this figure are generic drugs: Zolpidem, Extended-Release Zolpidem, Eszopiclone, Zaleplon, Flurazepam, Temazepam, Triazolam, and Phenobarbital.

Misuse of Prescription Psychotherapeutics The four categories of prescription drugs (pain relievers, tranquilizers, stimulants, and sedatives) in NSDUH cover many medications that currently are or have been available by prescription in the United States. Misuse of these drugs is defined as use in any way not directed by a doctor, including use without a prescription of one's own; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. Misuse of over-the-counter drugs is not included in the definition of misuse. As noted previously, NSDUH reports combine the four prescription drug categories into a category referred to as "psychotherapeutics." Beginning in 2015, the category of psychotherapeutics no longer includes methamphetamine, which is likely to be manufactured and distributed illegally. Past Year Misuse of Prescription Psychotherapeutics Among people aged 12 or older, an estimated 18.9 million misused prescription psychotherapeutic drugs in the past year, representing 7.1 percent of the population (Figure 6). Of the four categories of prescription psychotherapeutic drugs presented in this report (i.e., pain relievers, tranquilizers, stimulants, and sedatives), prescription pain relievers were the most commonly misused by people aged 12 or older. For example, approximately 12.5 million people misused prescription pain relievers in the past year, representing 4.7 percent of the population aged 12 or older. Approximately 6.1 million people misused prescription tranquilizers in the past year, representing 2.3 percent of the population aged 12 or older. An estimated 5.3 million people misused prescription stimulants in the past year, representing 2.0 percent of the population aged 12 or older. Approximately 1.5 million people misused prescription sedatives in the past year, representing 0.6 percent of the population aged 12 or older.

Figure 6. Numbers of Past Year Prescription Psychotherapeutic Misusers among People Aged 12 or Older: 2015 D Note: Estimated numbers of people refer to people aged 12 or older in the civilian, noninstitutionalized population in the United States. The numbers do not sum to the total population of the United States because the population for NSDUH does not include people aged 11 years old or younger, people with no fixed household address (e.g., homeless or transient people not in shelters), active-duty military personnel, and residents of institutional group quarters, such as correctional facilities, nursing homes, mental institutions, and long-term care hospitals.

Note: The estimated numbers of past year misusers of different psychotherapeutics are not mutually exclusive because people could have misused more than one type of psychotherapeutic in the past year.

By Age Group Of the 18.9 million people aged 12 or older in 2015 who misused prescription psychotherapeutic drugs in the past year, 1.5 million were youths aged 12 to 17 (5.9 percent of youths), 5.3 million were young adults aged 18 to 25 (15.3 percent of young adults), and 12.1 million were adults aged 26 or older (5.8 percent of adults in this age group) (Figure 7). Although adults aged 26 or older were more likely than people in other age groups to have used prescription drugs in the past year, young adults were more likely than youths and adults aged 26 or older to have misused prescription psychotherapeutic drugs in this period.

Figure 7. Past Year Misuse of Prescription Psychotherapeutics among People Aged 12 or Older, by Drug Type and Age Group: Percentages, 2015 D + Difference between this estimate and the 18 to 25 estimate is statistically significant at the .05 level.

Young adults aged 18 to 25 also were more likely than youths aged 12 to 17 and adults aged 26 or older to misuse prescription pain relievers, tranquilizers, stimulants, and sedatives in the past year (Figure 7). In addition, youths were more likely than adults aged 26 or older to have misused stimulants in the past year. However, similar percentages of youths and adults aged 26 or older misused prescription pain relievers, tranquilizers, and sedatives in the past year. Among youths aged 12 to 17, 3.9 percent misused prescription pain relievers, 1.6 percent misused prescription tranquilizers, 2.0 percent misused prescription stimulants, and 0.4 percent misused prescription sedatives in the past year (Figure 7). These percentages correspond to 969,000 youths who misused prescription pain relievers, 394,000 who misused prescription tranquilizers, 491,000 who misused prescription stimulants, and 102,000 who misused prescription sedatives. Percentages of young adults aged 18 to 25 who misused specific categories of prescription psychotherapeutic drugs were 8.5 percent who misused prescription pain relievers, 5.4 percent who misused prescription tranquilizers, 7.3 percent who misused prescription stimulants, and 0.8 percent who misused prescription sedatives in the past year (Figure 7). These percentages correspond to 3.0 million young adults who misused prescription pain relievers, 1.9 million who misused prescription tranquilizers, 2.5 million who misused prescription stimulants, and 0.3 million who misused prescription sedatives. Among adults aged 26 or older, 4.1 percent misused prescription pain relievers, 1.8 percent misused prescription tranquilizers, 1.1 percent misused prescription stimulants, and 0.5 percent misused prescription sedatives (Figure 7). These percentages correspond to 8.5 million adults in this age group who misused prescription pain relievers, 3.8 million who misused prescription tranquilizers, 2.2 million who misused prescription stimulants, and 1.1 million who misused prescription sedatives. By Gender Although females were more likely than males to have used most types of prescription psychotherapeutic drugs, males were more likely than females to have misused prescription psychotherapeutic drugs as a whole and most types of prescription psychotherapeutic drugs (Figure 8). In particular, males aged 12 or older were more likely than their female counterparts to have misused any prescription psychotherapeutic drug in the past year (7.8 vs. 6.4 percent). Males also were more likely than females to have misused prescription pain relievers (5.3 vs. 4.0 percent), prescription tranquilizers (2.4 vs. 2.1 percent), and prescription stimulants in the past year (2.3 vs. 1.6 percent). However, males were less likely than females to have misused prescription sedatives in the past year (0.5 vs. 0.7 percent).

Figure 8. Past Year Misuse of Prescription Psychotherapeutics among People Aged 12 or Older, by Drug Type and Gender: Percentages, 2015 D + Difference between this estimate and the estimate for females is statistically significant at the .05 level.

By Hispanic Origin and Race In 2015, percentages of non-Hispanics and Hispanics aged 12 or older were similar for the misuse in the past year of any prescription psychotherapeutic drug (7.1 and 7.0 percent, respectively), prescription pain relievers (4.6 and 5.0 percent, respectively), and prescription tranquilizers (2.3 and 2.0 percent, respectively) (Table B.2 in Appendix B). However, non-Hispanics were more likely than Hispanics to have misused prescription stimulants in the past year (2.1 vs. 1.5 percent). An estimated 0.6 percent of non-Hispanics and 0.4 percent of Hispanics misused prescription sedatives in the past year. The misuse of any prescription psychotherapeutic drug in the past year among individuals aged 12 or older in 2015 ranged from 3.1 percent of non-Hispanic Asians to 11.7 percent of non Hispanic individuals who reported two or more races (Table B.2). The misuse of prescription pain relievers in the past year ranged from 1.8 percent of non-Hispanic Asians to 8.4 percent of non-Hispanic individuals who reported two or more races. The misuse of prescription tranquilizers in the past year ranged from 0.7 percent of non Hispanic Asians to 3.6 percent of non-Hispanic individuals who reported two or more races. The misuse of prescription stimulants in the past year ranged from 0.7 percent of non-Hispanic African Americans to 4.1 percent of non Hispanic individuals who reported two or more races. Estimates for the misuse of prescription sedatives in the past year among racial groups were below 1.0 percent, except for an estimate of 1.4 percent among non-Hispanic individuals who reported two or more races. By County Type Among individuals aged 12 or older in 2015, 7.3 percent of those residing in large metropolitan areas, 6.9 percent of those in small metropolitan areas, and 6.4 percent of those in nonmetropolitan areas misused prescription psychotherapeutic drugs in the past year (Table B.3 in Appendix B).15 The past year misuse of categories of prescription drugs also showed little variation by county type. For example, 4.7 percent of individuals living in large metropolitan areas and 4.6 percent each of those in small metropolitan areas and nonmetropolitan areas misused prescription pain relievers in the past year. Prescription Drug Misuse among Users of Prescription Drugs Most people who used prescription psychotherapeutic drugs in the past year did not misuse them. For example, the 18.9 million Americans aged 12 or older who misused prescription psychotherapeutic drugs at least once in the past year represented only 15.9 percent of the 119.0 million people who reported any use of psychotherapeutic drugs in the past year (Figure 9). Stated another way, nearly 85 percent of people who used prescription psychotherapeutic drugs in the past year did not misuse them. Similarly, 12.8 percent of people aged 12 or older who used pain relievers in the past year reported misuse (the pie chart in Figure 10 labeled as 10a), as did 15.4 percent of people who used tranquilizers in the past year (the pie chart labeled as 10b). However, 30.5 percent of people who used prescription stimulants in the past year misused stimulants in that period (the pie chart labeled as 10c). An estimated 8.1 percent of people who used sedatives (the pie chart labeled as 10d) misused them.

Figure 9. Misuse and No Misuse of Prescription Psychotherapeutics in the Past Year among People Aged 12 or Older Who Used Prescription Psychotherapeutics: Percentages, 2015 D

Figure 10. Misuse and No Misuse of Prescription Psychotherapeutics in the Past Year among People Aged 12 or Older Who Used Prescription Psychotherapeutics, by Drug Type: Percentages, 2015 D

Prescription Drug Misuse among Users of Other Substances NSDUH asks respondents aged 12 or older about their past year use of alcohol, tobacco, and several illicit drugs: marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, and methamphetamine. Except for data that are collected on the use of alcohol in combination with the misuse of prescription drugs in the past month (not included in this report), NSDUH does not assess whether respondents misused prescription drugs and used other substances at the same time. This section provides estimates of past year prescription drug misuse among people who used other substances in that period, such as the percentage of past year alcohol users who misused prescription drugs in the past year. In 2015, the following numbers of people aged 12 or older used other substances at least once in the past year (regardless of whether they misused prescription drugs in the past year): 61.8 million smoked cigarettes,

175.8 million people drank alcohol,

36.0 million people used marijuana,

4.8 million people used cocaine,

828,000 people used heroin,

1.5 million people used lysergic acid diethylamide (LSD),

2.6 million people used Ecstasy,

1.8 million people used inhalants, and

1.7 million people used methamphetamine.1 Misuse of Any Prescription Psychotherapeutic Drug among Users of Other Substances As shown in Figure 11, the misuse of prescription psychotherapeutic drugs in 2015 among people aged 12 or older who used other substances in the past year ranged from 9.2 percent of alcohol users to 77.9 percent of heroin users. Among the estimated 175.8 million people aged 12 or older who consumed alcohol in the past year, 16.1 million people also misused prescription psychotherapeutic drugs over the same time period of time, or nearly 1 in 10 (9.2 percent) of past year alcohol drinkers. The large majority of past year heroin users aged 12 or older also misused prescription psychotherapeutic drugs in the past year (77.9 percent of past year heroin users, or 646,000 out of 828,000 users of heroin). About a quarter (25.8 percent) of past year marijuana users also misused prescription drugs in the past year (9.3 million of the 36.0 million past year marijuana users).

Figure 11. Past Year Misuse of Any Prescription Psychotherapeutic among People Aged 12 or Older Who Were Past Year Users of Other Substances, by Substance: Percentages, 2015 D LSD = lysergic acid diethylamide.

Misuse of Prescription Pain Relievers among Users of Other Substances Although 4.7 percent of the total population aged 12 or older misused prescription pain relievers in the past year, people who used substances other than prescription drugs were more likely to have misused pain relievers (Figure 12). For example, 5.9 percent of past year alcohol users (10.4 million of the 175.8 million past year alcohol users) also misused prescription pain relievers during the same time period. Among past year heroin users aged 12 or older, 72.1 percent (598,000 out of 828,000 past year heroin users) misused prescription pain relievers in the past year. Of the 36.0 million people aged 12 or older who used marijuana in the past year, 5.8 million (or 16.2 percent of past year marijuana users) also misused prescription pain relievers in the past year.

Figure 12. Past Year Misuse of Prescription Pain Relievers among People Aged 12 or Older Who Were Past Year Users of Other Substances, by Substance: Percentages, 2015 D LSD = lysergic acid diethylamide.

Misuse of Prescription Tranquilizers among Users of Other Substances Compared with the estimate of 2.3 percent of the population aged 12 or older who misused prescription tranquilizers in the past year, percentages were typically higher among people aged 12 or older in 2015 who used other substances (Figure 13). For example, 35.9 percent of past year heroin users also misused prescription tranquilizers during this same time period (297,000 out of 828,000 past year heroin users). In addition, more than 1 in 4 past year users of Ecstasy (29.0 percent), methamphetamine (28.9 percent), or cocaine (26.2 percent) misused tranquilizers in the past year. Of the 36.0 million people aged 12 or older who used marijuana in the past year, about 1 in 10 (9.8 percent, or 3.5 million people) misused prescription tranquilizers in the past year. An estimated 3.0 percent of past year alcohol users also misused prescription tranquilizers during the same time period (5.3 million out of 175.8 million past year alcohol users).

Figure 13. Past Year Misuse of Prescription Tranquilizers among People Aged 12 or Older Who Were Past Year Users of Other Substances, by Substance: Percentages, 2015 D LSD = lysergic acid diethylamide.

Misuse of Prescription Stimulants among Users of Other Substances People who used other substances in the past year were more likely than people aged 12 or older in the total population to have misused prescription stimulants in that period (Figure 14). For example, 33.8 percent of past year users of Ecstasy and 39.3 percent of past year users of LSD also misused prescription stimulants during the same time period. Among the estimated 175.8 million people aged 12 or older who consumed alcohol in the past year, 4.9 million misused prescription stimulants in the past year (2.8 percent of past year alcohol users). An estimated 22.1 percent of past year heroin users, 23.1 percent of past year methamphetamine users, and 27.1 percent of past year cocaine users misused prescription stimulants in that period.

Figure 14. Past Year Misuse of Prescription Stimulants among People Aged 12 or Older Who Were Past Year Users of Other Substances, by Substance: Percentages, 2015 D LSD = lysergic acid diethylamide.

Misuse of Prescription Sedatives among Users of Other Substances In 2015, the misuse of prescription sedatives in the past year among people aged 12 or older who used other substances in that period was not as pronounced as the misuse of pain relievers, tranquilizers, or stimulants. In 2015, 0.6 percent of the population aged 12 or older misused prescription sedatives in the past year (Table B.1 in Appendix B). In comparison, the percentages of users of other substances who misused sedatives in the past year ranged from 0.7 percent of alcohol users to 9.2 percent of heroin users (Table B.8). Among the estimated 175.8 million people aged 12 or older who consumed alcohol in the past year, 1.3 million misused prescription sedatives in the past year (0.7 percent of past year alcohol users). The estimated 9.2 percent of past year heroin users who misused prescription sedatives represent 76,000 out of 828,000 past year heroin users. Of the 36.0 million people aged 12 or older who used marijuana in the past year, 617,000 also misused prescription sedatives in the past year, or 1.7 percent of past year marijuana users. Prescription Drug Misuse among Adults with Any or Serious Mental Illness NSDUH collects information that is used to estimate the number adults aged 18 or older who had any mental illness (AMI) or serious mental illness (SMI) in the past year. Adults are defined as having AMI if they had any mental, behavioral, or emotional disorder in the past year that met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria (excluding developmental disorders and substance use disorders).24 Adults with AMI were defined as having SMI if they had any mental, behavioral, or emotional disorder that substantially interfered with or limited one or more major life activities.25 In 2015, an estimated 43.4 million Americans aged 18 or older had AMI in the past year, including an estimated 9.8 million adults who had SMI.1 Among the 43.4 million adults aged 18 or older in 2015 with AMI in the past year, 6.9 million misused prescription psychotherapeutic drugs during the same period of time. This number who misused prescription psychotherapeutic drugs in the past year corresponds to 15.8 percent of adults with AMI (Figure 15). Among the 9.8 million adults who had SMI in the past year, 2.1 million, or 21.5 percent, misused prescription psychotherapeutic drugs during the same period of time. In comparison, among adults who did not have a mental illness in the past year, 5.3 percent misused prescription psychotherapeutic drugs in the past year.

Figure 15. Past Year Misuse of Prescription Psychotherapeutics among Adults Aged 18 or Older, by Drug Type and Past Year Mental Illness Status: Percentages, 2015 D AMI = any mental illness; SMI = serious mental illness.

+ Difference between this estimate and the estimate for adults with no past year mental illness is statistically significant at the .05 level.

Among adults in 2015 who had AMI in the past year, about 1 in 9 (11.1 percent) misused prescription pain relievers, about 1 in 16 (6.1 percent) misused prescription tranquilizers, 4.3 percent misused prescription stimulants, and 1.5 percent misused prescription sedatives in the past year. These percentages correspond to 4.8 million adults with AMI who misused prescription pain relievers, 2.7 million who misused prescription tranquilizers, 1.8 million who misused prescription stimulants, and 634,000 who misused prescription sedatives in the past year. Among the 9.8 million adults in 2015 who had SMI in the past year, 15.2 percent (1.5 million adults) also misused prescription pain relievers during the same period of time. About 1 in 10 adults with SMI (9.8 percent, or 961,000 adults) misused prescription tranquilizers in the past year. An estimated 6.0 percent of adults with SMI (590,000 adults) misused prescription stimulants in the past year, and 2.9 percent (279,000 adults) misused prescription sedatives. Adults in 2015 who did not have a mental illness in the past year were less likely than adults with AMI or SMI to have misused prescription drugs in each of the four psychotherapeutic categories in the past year. Among adults in 2015 who did not have a mental illness in the past year, 3.3 percent misused prescription pain relievers, 1.5 percent misused prescription tranquilizers, 1.5 percent misused prescription stimulants, and 0.4 percent misused prescription sedatives in the past year. Prescription Drug Misuse among Individuals Who Had a Major Depressive Episode NSDUH also provides estimates of having a past year major depressive episode (MDE) among adults and adolescents. MDE is defined for both adults and adolescents using the diagnostic criteria from DSM-IV, although there are separate criteria for adults and youths.24 Adults were defined as having MDE if they had a period of 2 weeks or longer in the past 12 months when they experienced a depressed mood or loss of interest or pleasure in daily activities, and they had at least some additional symptoms, such as problems with sleep, eating, energy, concentration, and self-worth.26 Similar to adults, adolescents were defined as having an MDE if they had a period of 2 weeks or longer in the past 12 months when they experienced a depressed mood or loss of interest or pleasure in daily activities, and they had at least some additional symptoms, such as problems with sleep, eating, energy, concentration, and self-worth. However, some wordings to the questions for adolescents were designed to make them more developmentally appropriate for youths.27 This section provides estimates of prescription drug misuse among adults and adolescents who had an MDE in the past year. Data are presented separately for adults and adolescents because of the different wording of questions for adults and adolescents. Misuse among Adults Aged 18 or Older with a Past Year MDE In 2015, an estimated 16.1 million American adults aged 18 or older had at least one MDE in the past year.1 Among the 16.1 million adults who had MDE in the past year, 2.9 million misused a prescription psychotherapeutic drug during the same period of time. This number of adults who misused prescription psychotherapeutic drugs represents 17.9 percent of adults who had an MDE in the past year (Figure 16). Adults who did not have an MDE in the past year were less likely than adults who had a past year MDE to misuse prescription psychotherapeutic drugs in the past year (6.4 vs. 17.9 percent).

Figure 16. Past Year Misuse of Prescription Psychotherapeutics among Adults Aged 18 or Older, by Drug Type and Past Year Major Depressive Episode (MDE) Status: Percentages, 2015 D + Difference between this estimate and the estimate for adults with no past year MDE is statistically significant at the .05 level.

Note: Adult respondents with unknown past year MDE data were excluded.

Among the 16.1 million adults in 2015 who had an MDE in the past year, 1.9 million misused prescription pain relievers, 1.3 million misused prescription tranquilizers, 834,000 misused prescription stimulants, and 321,000 misused prescription sedatives in the past year. Corresponding percentages among adults with a past year MDE were 12.0 percent for the misuse of prescription pain relievers, 7.9 percent for the misuse of prescription tranquilizers, 5.2 percent for the misuse of prescription stimulants, and 2.0 percent for the misuse of prescription sedatives. Adults in 2015 who did not have an MDE in the past year were less likely than adults who had an MDE to misuse prescription drugs in each of the psychotherapeutic categories in the past year. Specifically, among adults who did not have an MDE in the past year, 4.2 percent misused prescription pain relievers, 1.9 percent misused prescription tranquilizers, 1.7 percent misused prescription stimulants, and 0.5 percent misused prescription sedatives in the past year. Misuse among Adolescents Aged 12 to 17 with a Past Year MDE In 2015, an estimated 3.0 million adolescents aged 12 to 17 had at least one MDE in the past year.1 Among the 3.0 million adolescents who had an MDE in the past year, 370,000 misused a prescription psychotherapeutic drug during the same period of time. This number represents 12.2 percent of adolescents who had an MDE in the past year (Figure 17). Among adolescents who did not have an MDE in the past year, 4.9 percent misused prescription psychotherapeutic drugs in the past year, which was lower than the percentage among youths who had a past year MDE (12.2 percent).

Figure 17. Past Year Misuse of Prescription Psychotherapeutics among Youths Aged 12 to 17, by Drug Type and Past Year Major Depressive Episode (MDE) Status: Percentages, 2015 D + Difference between this estimate and the estimate for youths with no past year MDE is statistically significant at the .05 level.

Note: Youth respondents with unknown past year MDE data were excluded.

Among the 3.0 million adolescents who had an MDE in the past year, 236,000 misused prescription pain relievers, 103,000 misused prescription tranquilizers, 166,000 misused prescription stimulants, and 26,000 misused prescription sedatives during the same period of time. These numbers correspond to 7.8 percent of adolescents with a past year MDE who misused prescription pain relievers, 3.4 percent who misused prescription tranquilizers, 5.5 percent who misused prescription stimulants, and 0.8 percent who misused prescription sedatives during the past year. Adolescents in 2015 who did not have an MDE in the past year were less likely than their counterparts who had an MDE to misuse prescription drugs in each of the psychotherapeutic categories in the past year. Among adolescents who did not have an MDE in the past year, 3.3 percent misused prescription pain relievers, 1.3 percent misused prescription tranquilizers, 1.4 percent misused prescription stimulants, and 0.3 percent misused prescription sedatives in the past year. Prescription Drug Misuse among Adults with Serious Thoughts of Suicide NSDUH respondents aged 18 or older were asked if at any time during the past 12 months they had thought seriously about trying to kill themselves. This section provides estimates of the misuse of prescription drugs among adults who had serious thoughts of suicide in the past year. However, NSDUH does not assess whether respondents misused prescription drugs while they were having serious thoughts of suicide. In 2015, 9.8 million adults aged 18 or older thought seriously about trying to kill themselves at any time during the past 12 months.28 Among the 9.8 million adults who had serious thoughts of suicide in the past year, 2.2 million misused prescription psychotherapeutic drugs during the same period of time. This represents 22.9 percent of adults who had serious thoughts of suicide, or more than 1 in 5 (Figure 18). Among adults who did not have serious thoughts of suicide in the past year, 6.5 percent misused prescription psychotherapeutic drugs in the past year.

Figure 18. Past Year Misuse of Prescription Psychotherapeutics among Adults Aged 18 or Older, by Drug Type and Past Year Suicidal Thoughts: Percentages, 2015 D + Difference between this estimate and the estimate for adults with no Past Year suicidal thoughts is statistically significant at the .05 level.

Note: Adult respondents with unknown suicide information were excluded.

Among the 9.8 million adults who had serious thoughts of suicide in the past year, 1.6 million misused prescription pain relievers, 978,000 misused prescription tranquilizers, 683,000 misused prescription stimulants, and 221,000 misused prescription sedatives. Among adults who had serious thoughts of suicide in the past year, these numbers represent 16.4 percent of adults who misused prescription pain relievers, 10.0 percent who misused prescription tranquilizers, 7.0 percent who misused prescription stimulants, and 2.3 percent who misused prescription sedatives during the past year. Adults who did not have serious thoughts of suicide in the past year were less likely than those who had serious thoughts of suicide to have misused prescription drugs in each of the psychotherapeutic categories in the past year. Among adults who did not have serious thoughts of suicide in the past year, 4.2 percent misused prescription pain relievers, 2.0 percent misused prescription tranquilizers, 1.8 percent misused prescription stimulants, and 0.5 percent misused prescription sedatives in the past year. Past Year Misuse of Subtypes of Prescription Drugs As noted previously, NSDUH respondents in 2015 were asked to identify the specific prescription pain relievers, tranquilizers, stimulants, and sedatives that they used in the past year. For each prescription psychotherapeutic drug category, these specific prescription drugs were further categorized into subtypes within the overall category. The remainder of this section presents estimates for the misuse of specific subtypes of prescription drugs in the past year. Pain Relievers The specific pain relievers that individuals misused in the past year were categorized into 11 subtypes, such as hydrocodone products (Figure 2).19 In 2015, the most commonly misused subtype of prescription pain relievers were hydrocodone products, which include Vicodin®, Lortab®, Norco®, Zohydro® ER, and generic hydrocodone (Table B.4 in Appendix B). An estimated 7.2 million people aged 12 or older misused these products in the past year, representing 2.7 percent of the population. An estimated 4.3 million people misused oxycodone products in the past year; this number represents 1.6 percent of people aged 12 or older. Oxycodone products include OxyContin®, Percocet®, Percodan®, Roxicet®, Roxicodone®, and generic oxycodone. Misuse of OxyContin® in the past year occurred among 0.7 percent of the population aged 12 or older (1.7 million people) and among about 40 percent of the misusers of oxycodone products. An estimated 0.3 percent of people aged 12 or older misused buprenorphine products in the past year, and 0.2 percent misused methadone. Tranquilizers The specific tranquilizers that individuals misused in the past year were categorized into six subtypes, and some of these six subtypes were further subcategorized (Figure 3).20 For example, one of the six subtypes of tranquilizers was benzodiazepine tranquilizers, which was further subcategorized into four subtypes of benzodiazepine tranquilizers, such as alprazolam products (e.g., Xanax®, Xanax® ER). In 2015, benzodiazepine tranquilizers were the most commonly misused subtype of prescription tranquilizers that people aged 12 or older misused in the past year (Table B.5 in Appendix B). The misuse of benzodiazepine tranquilizers was driven by the misuse of alprazolam products, such as Xanax®, Xanax® XR, generic alprazolam, and generic extended-release alprazolam. Of the 6.1 million people aged 12 or older who misused tranquilizers in the past year, 5.4 million misused benzodiazepine tranquilizers, including 4.1 million people who misused alprazolam products. Individuals who misused alprazolam products represented 1.5 percent of the population. Although 6.6 million people reported any use in the past year of other prescription tranquilizers, only 202,000 reported misuse of other tranquilizers. Stimulants The specific stimulants that individuals misused in the past year were categorized into five subtypes (Figure 4).21 In 2015, the most commonly misused subtype of prescription stimulants in the past year among people aged 12 or older was amphetamine products, which include Adderall®, Adderall® XR, Dexedrine®, Vyvanse®, generic dextroamphetamine, generic amphetamine-dextroamphetamine combinations, and generic extended-release amphetamine-dextroamphetamine combinations (Table B.6 in Appendix B).22 Among the 5.3 million people aged 12 or older who misused prescription stimulants in the past year, 4.8 million misused amphetamine products. The number of people who misused amphetamine products in the past year represented 1.8 percent of the population. In contrast to the 2.7 million people aged 12 or older who reported any use of other prescription stimulants in the past year, only 96,000 reported misuse of other stimulants. Sedatives The specific sedatives that individuals misused in the past year were categorized into six subtypes, and one of these six subtypes was further subcategorized (Figure 5).23 Specifically, the benzodiazepine sedatives subtype was further subcategorized into three subcategories: flurazepam, temazepam products, and triazolam products. In 2015, the most commonly misused subtype of prescription sedatives was zolpidem products consisting of Ambien®, Ambien® CR, generic zolpidem, and extended-release generic zolpidem (Table B.7 in Appendix B). Of the 1.5 million people aged 12 or older who misused prescription sedatives in the past year, 1.1 million misused zolpidem products. The number of people who misused zolpidem products in the past year represented 0.4 percent of the population. An estimated 205,000 people aged 12 or older, or 0.1 percent of the population, misused benzodiazepine sedatives in the past year. Although about 5.4 million people aged 12 or older reported that they used other prescription sedatives in the past year, only 191,000 reported misuse of other sedatives. Main Reasons for Misusing Prescription Drugs Respondents in the 2015 NSDUH who reported misuse of any of the four categories of prescription psychotherapeutic drugs in the past year were asked to recall the last prescription drug in that category that they misused in the past year. For the first time in NSDUH, respondents were asked to report their reasons for misusing the prescription drug that last time. Respondents who reported more than one reason for misusing the last prescription drug were asked to report the main reason for misuse. If respondents reported only one reason for misusing their last prescription drug in a given psychotherapeutic category, then that reason was their main reason for misuse. As shown in Table B.11 in Appendix B, the main reasons for misuse varied by the psychotherapeutic categories. Reasons for the misuse of the last prescription pain reliever that were presented to respondents were (1) to relieve physical pain, (2) to relax or relieve tension, (3) to experiment or to see what the drug is like, (4) to feel good or get high, (5) to help with the respondent's sleep, (6) to help the respondent with his or her feelings or emotions, (7) to increase or decrease the effect(s) of some other drug, (8) because the respondent is "hooked" or has to have the drug, or (9) for some other reason. Except for "to relieve physical pain," the same reasons were presented for tranquilizers and sedatives; the first reason that was presented for these two psychotherapeutic categories was "to relax or relieve tension." Reasons that were presented for stimulants were (1) to help lose weight, (2) to help concentrate, (3) to help be alert or stay awake, (4) to help study, (5) to experiment or to see what the drug is like, (6) to feel good or get high, (7) to increase or decrease the effect(s) of some other drug, (8) because the respondent is "hooked" or has to have the drug, or (9) for some other reason. In addition, respondents could report "some other reason" for their misuse of a particular psychotherapeutic drug and then specify a reason that applied to another psychotherapeutic category. For example, respondents could specify that they also misused their last tranquilizer to relieve physical pain (i.e., a choice for pain relievers) and then specify that this other reason was the main reason for their last misuse. Main Reasons for Misusing Pain Relievers Among people aged 12 or older in 2015 who misused prescription pain relievers in the past year, the most commonly reported reason for their last misuse of a pain reliever was to relieve physical pain (62.6 percent), which is the reason pain relievers are prescribed (Table B.11). Even if the reason for misuse was to relieve physical pain, use without a prescription of one's own or use at a higher dosage or more often than prescribed still constituted misuse. Other commonly reported reasons for the last misuse among people who misused pain relievers in the past year were to feel good or get high (12.1 percent) and to relax or relieve tension (10.8 percent). Less common reasons among past year misusers of pain relievers included to help with sleep (4.4 percent), to help with feelings or emotion (3.3 percent), to experiment or see what the drug was like (2.5 percent), because they were "hooked" or needed to have the drug (2.3 percent), and to increase or decrease the effects of other drugs (0.9 percent). In addition, 1.2 percent of past year misusers of pain relievers reported that some other reason was their main reason. Main Reasons for Misusing Tranquilizers Among people aged 12 or older in 2015 who misused prescription tranquilizers in the past year, the most common reasons for misuse the last time were to relax or relieve tension (44.9 percent), followed by to help with sleep (20.4 percent); these are common reasons for prescribing tranquilizers (Table B.11). However, these individuals misused tranquilizers to achieve the effect for which tranquilizers are prescribed. Even if the reason for misuse was a reason for which tranquilizers are prescribed, use without a prescription, more often than prescribed, or at higher dosages than prescribed still constituted misuse. In addition, 12.3 percent of people aged 12 or older who misused prescription tranquilizers in the past year reported that the main reason for their last misuse was to feel good or get high, and 10.7 percent reported that their main reason was to help with feelings and emotions. Less common reasons for misuse included experimenting to see what the drug was like (6.4 percent), increasing or decreasing the effect of some other drug (1.5 percent), and because of being "hooked" or needing to have the drug (0.3 percent). An estimated 3.4 percent of people who misused tranquilizers in the past year reported that some other reason was the main reason for their last misuse. Main Reasons for Misusing Stimulants In 2015, the most commonly reported main reasons for the misuse of stimulants among people aged 12 or older who misused stimulants in the past year were to help be alert or stay awake (26.8 percent) and to help concentrate (26.5 percent), followed by to help study (22.5 percent) (Table B.11). Less commonly reported reasons for the last misuse of prescription stimulants among past year misusers were to experiment to see what the drug was like (5.7 percent), to help lose weight (4.2 percent), to increase or decrease the effect of some other drug (1.5 percent), and because of being "hooked" or needing to have the drug (0.1 percent). An estimated 2.2 percent of past year misusers of prescription stimulants reported some other reason as the main reason for their last misuse. Main Reasons for Misusing Sedatives Among people aged 12 or older in 2015 who misused prescription sedatives in the past year, the most common reason for the last misuse was to help with sleep (71.7 percent), which is the reason sedatives are prescribed (Table B.11). Even if people took sedatives to help them sleep, this use constituted misuse if people took them without a prescription, more often than prescribed, or at higher dosages than prescribed. Other reasons for the last misuse among people who misused sedatives in the past year were to relax or relieve tension (12.0 percent) and to feel good or get high (5.9 percent). Less commonly reported reasons included to help with feelings or emotions (3.7 percent), to experiment to see what the drug was like (3.7 percent), and to increase or decrease the effects of some other drug (1.2 percent). In addition, 1.8 percent of past year misusers of sedatives reported that some other reason was their main reason for their last misuse.

Initiation of Prescription Drug Misuse If NSDUH respondents in 2015 reported that they misused a specific prescription psychotherapeutic drug (e.g., OxyContin®) in the past 12 months, they were asked to report their age when they first misused it (i.e., initiation).29 NSDUH respondents were defined as being past year initiates for the misuse of prescription drugs in an overall psychotherapeutic category (e.g., pain relievers) if they reported initiating misuse in the past 12 months for all of the specific prescription drugs in that category that they misused in that same period, and they had not misused any other drug in that category before the past 12 months. Section A.4.3 in Appendix A provides more details about how the past year initiation of misuse of prescription drugs was measured and defined. The 2015 NSDUH measures whether an individual first misused all prescription drugs in a given psychotherapeutic category within the past 12 months (i.e., recent initiation), and, for recent initiates, the age when they first misused any prescription drug in that category. By definition, people who initiated the misuse of any psychotherapeutic drug within a category in the past 12 months will have had their first misuse at their current age or the year before their current age. More information about the methods for measuring and estimating the initiation of prescription drug misuse in NSDUH can be found in Section A.4.3 and on the web in the methodological summary and definitions report for the 2015 NSDUH.30 However, the focus on the misuse of specific prescription drugs in the past 12 months could cause some respondents to underreport the use or misuse of prescription psychotherapeutic drugs that occurred more than 12 months before the interview date (see Section A.4.3). For this reason, estimates are not included for the past year initiation of misuse for any prescription psychotherapeutic drug. Unlike previous sections, this section focuses on the number of people who were recent initiates for the misuse of drugs in specific categories of prescription psychotherapeutic drugs rather than on percentages. Information on the number of recent initiates can be useful to policymakers and program planners for anticipating future needs for health services both in the short term and in the longer term. However, care should be taken in interpreting apparent differences in the estimated numbers of initiates across population subgroups because some of these differences could reflect differences in the size of the respective subgroups. This section also presents the average age at first misuse for prescription drugs among recent initiates of prescription drugs in a given psychotherapeutic category. Although the numbers of initiates are shown for initiates aged 12 or older as well as by age group, the average ages at first misuse in this report are limited to past year initiates aged 12 to 49 to avoid extreme values from older initiates influencing the averages.31 For example, a small number of people who started misusing a substance at ages of 50 years or later could heavily influence the average age at first misuse among all initiates and cause instability in the estimated average. Figure 19 shows the numbers of past year initiates in 2015 for the misuse of prescription pain relievers, tranquilizers, stimulants, and sedatives among people aged 12 or older. In 2015, there were 2.1 million new misusers of pain relievers, 1.4 million new misusers of tranquilizers, 1.3 million new misusers of stimulants, and 425,000 new misusers of sedatives.

Figure 19. Numbers of People Aged 12 or Older (in Thousands) Who Initiated Prescription Drug Misuse in the Past Year, by Age Group: 2015 D

Figure 19 Table. Numbers of People Aged 12 or Older (in Thousands) Who Initiated Prescription Drug Misuse in the Past Year, by Age Group: 2015 Age Group Pain Relievers Tranquilizers Stimulants Sedatives 12 or Older 2,126 1,437 1,260 425 12 to 17 415 210 276 46 18 to 25 596 489 600 86 26 or Older 1,114 738 384 293

On average, past year initiates aged 12 to 49 in 2015 initiated the misuse of prescription drugs in their early to late 20s (Figure 20). The average ages at first misuse in 2015 among recent initiates aged 12 to 49 were 25.8 years for prescription pain relievers, 25.9 years for prescription tranquilizers, 22.3 years for prescription stimulants, and 28.3 years for prescription sedatives.

Figure 20. Mean Age at First Misuse of Prescription Psychotherapeutics among People Aged 12 to 49 Who Initiated Misuse in the Past Year, by Drug Type: 2015 D

Initiation of Pain Reliever Misuse Historically, the number of past year initiates for the misuse of pain relievers has been second only to marijuana among illicit drugs.32 In 2015, the 2.1 million recent initiates for the misuse of pain relievers average to about 5,800 initiates per day. This number of recent initiates includes 0.9 million males aged 12 or older (0.7 percent of males) and 1.2 million females (0.9 percent of females) who initiated the misuse of prescription pain relievers in the past year (Figure 19 and Table B.14 in Appendix B). By Age Group In 2015, approximately 415,000 adolescents aged 12 to 17 (1.7 percent of adolescents) misused pain relievers for the first time in the past year (Figure 19 and Table B.14 in Appendix B). This averages to approximately 1,100 adolescents each day who initiated the misuse of pain relievers. There were 596,000 young adults aged 18 to 25 (1.7 percent of young adults) and 1.1 million adults aged 26 or older (0.5 percent of adults in this age group) in 2015 who initiated the misuse of pain relievers in the past year. These numbers average to about 1,600 young adults and about 3,100 adults aged 26 or older each day who initiated the misuse of pain relievers. Initiation of Tranquilizer Misuse The estimated 1.4 million people aged 12 or older in 2015 who misused tranquilizers for the first time within the past year average to about 3,900 initiates per day. About 0.8 million females aged 12 or older (0.6 percent of females) and 0.6 million males (0.5 percent of males) misused tranquilizers for the first time in the past year (Figure 19 and Table B.14 in Appendix B). By Age Group In 2015, approximately 210,000 adolescents aged 12 to 17 (0.8 percent of adolescents), 489,000 young adults aged 18 to 25 (1.4 percent of young adults), and 738,000 adults aged 26 or older (0.4 percent of adults in this age group) misused tranquilizers for the first time in the past year (Figure 19 and Table B.14). Each day, therefore, about 600 adolescents, 1,300 young adults, and 2,000 adults aged 26 or older initiated the misuse of tranquilizers. Initiation of Stimulant Misuse In 2015, the estimated 1.3 million people aged 12 or older who misused stimulants for the first time average to about 3,500 initiates per day. These numbers of initiates include 629,000 females aged 12 or older (0.5 percent of females) and 631,000 males (0.5 percent of males) (Figure 19 and Table B.14). By Age Group Approximately 276,000 adolescents aged 12 to 17 (1.1 percent of adolescents), 600,000 young adults aged 18 to 25 (1.7 percent of young adults), and 384,000 adults aged 26 or older (0.2 percent of adults aged 26 or older) in 2015 misused stimulants for the first time in the past year (Figure 19 and Table B.14). Thus, about 800 adolescents per day, 1,600 young adults per day, and 1,100 adults aged 26 or older per day initiated the misuse of stimulants. Initiation of Sedative Misuse In 2015, the approximately 425,000 people aged 12 or older who misused sedatives for the first time within the past year average to about 1,200 initiates per day for misuse of sedatives. About 270,000 females aged 12 or older (0.2 percent of females) and 155,000 males (0.1 percent of males) misused sedatives for the first time in the past year (Figure 19 and Table B.14). By Age Group In 2015, approximately 46,000 adolescents aged 12 to 17 (0.2 percent of adolescents), 86,000 young adults aged 18 to 25 (0.2 percent of young adults), and 293,000 adults aged 26 or older (0.1 percent of adults aged 26 or older) misused sedatives for the first time in the past year (Figure 19 and Table B.14). Thus, about 100 adolescents, 200 young adults, and 800 adults aged 26 or older initiated the misuse of sedatives each day in 2015.

Prescription Drug Use Disorders NSDUH includes a series of questions to estimate the percentage of the population aged 12 or older who had substance use disorders (SUDs) in the past 12 months. Respondents were asked questions about prescription drug use disorders if they reported misuse of prescription drugs in the past 12 months. These SUD questions classify people as having an SUD in the past 12 months and are based on criteria specified in DSM-IV. 24 The criteria include symptoms such as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference with major obligations at work, school, or home. Because of the creation of a new section in the interview for methamphetamine (see the "Introduction"), SUDs for prescription stimulants in 2015 do not include methamphetamine. (In 2014 and earlier years, SUD estimates for prescription stimulants included data from respondents who used methamphetamine in the past year.) Instead, new questions were added to the survey in 2015 that ask about SUD symptoms that respondents specifically attributed to their use of methamphetamine in the past year, separate from SUD symptoms that were associated with the misuse of prescription stimulants. Prescription Psychotherapeutic Use Disorder An estimated 2.7 million people aged 12 or older in 2015 had a prescription drug use disorder in the past year (Figure 21). This number of people who had a prescription drug use disorder represents 1.0 percent of the population. An estimated 216,000 adolescents aged 12 to 17 in 2015 (0.9 percent of adolescents) had a prescription drug use disorder in the past year (Figure 22 and Table B.16). Among young adults aged 18 to 25, about 687,000 had a prescription drug use disorder in the past year (2.0 percent of young adults). Approximately 1.8 million adults aged 26 or older in 2015 had a prescription drug use disorder in the past year, representing 0.9 percent of adults aged 26 or older.

Figure 21. Substance Use Disorder for Prescription Psychotherapeutics in the Past Year among People Aged 12 or Older: Numbers (in Thousands) and Percentages, 2015 D

Figure 22. Substance Use Disorder for Prescription Psychotherapeutics in the Past Year among People Aged 12 or Older, by Age Group: Numbers (in Thousands), 2015 D Note: In the figure, visibility of the numbers of youths aged 12 to 17 and young adults aged 18 to 25 who had a sedative use disorder is affected by the small numbers of youths and young adults with that particular disorder.

Figure 22 Table. Substance Use Disorder for Prescription Psychotherapeutics in the Past Year among People Aged 12 or Older, by Age Group: Numbers (in Thousands), 2015 Age Group Any Psycho-

therapeutic Pain Relievers Tranquilizers Stimulants Sedatives 12 or Older 2,742 2,038 688 426 154 12 to 17 216 122 77 38 26 18 to 25 687 427 234 159 22 26 or Older 1,800 1,500 376 229 106

Pain Reliever Use Disorder In 2015, an estimated 2.0 million people aged 12 or older had a pain reliever use disorder (Figure 21). This number represents 0.8 percent of the population and nearly three fourths of the 2.7 million people who had any prescription drug use disorder. An estimated 122,000 adolescents aged 12 to 17 in 2015 (0.5 percent of adolescents) had a pain reliever use disorder in the past year (Figure 22 and Table B.16). Approximately 427,000 young adults aged 18 to 25 and 1.5 million adults aged 26 or older in 2015 had a pain reliever use disorder in the past year. These numbers represent 1.2 percent of young adults and 0.7 percent of adults aged 26 or older. Tranquilizer Use Disorder An estimated 688,000 people aged 12 or older in 2015 had a tranquilizer use disorder (Figure 21), or 0.3 percent of the population. An estimated 77,000 adolescents aged 12 to 17 in 2015 (0.3 percent of adolescents) had a tranquilizer use disorder in the past year (Figure 22 and Table B.16). Approximately 234,000 young adults aged 18 to 25 (0.7 percent of young adults) and 376,000 adults aged 26 or older in 2015 (0.2 percent of adults aged 26 or older) had a tranquilizer use disorder in the past year. Stimulant Use Disorder In 2015, an estimated 426,000 people aged 12 or older had a stimulant use disorder in the past year (Figure 21), which represents 0.2 percent of the population. About 38,000 adolescents aged 12 to 17 in 2015 (0.2 percent of adolescents) had a stimulant use disorder in the past year (Figure 22 and Table B.16). Approximately 159,000 young adults aged 18 to 25 and 229,000 adults aged 26 or older in 2015 had a stimulant use disorder in the past year. These numbers represent 0.5 percent of young adults and 0.1 percent of adults aged 26 or older. Sedative Use Disorder An estimated 154,000 people aged 12 or older in 2015 had a sedative use disorder (Figure 21), which represents 0.1 percent of the population. An estimated 26,000 adolescents aged 12 to 17 (0.1 percent of adolescents) had a sedative use disorder in the past year (Figure 22 and Table B.16). Approximately 22,000 young adults aged 18 to 25 and 106,000 adults aged 26 or older in 2015 had a sedative use disorder in the past year. These numbers represent 0.1 percent of young adults and 0.1 percent of the adults aged 26 or older.

Treatment for the Misuse of Prescription Psychotherapeutics NSDUH respondents who used alcohol or illicit drugs in their lifetime are asked whether they ever received substance use treatment (i.e., treatment for their use of alcohol or illicit drugs), and those who received substance use treatment in their lifetime are asked whether they received treatment in the 12 months prior to the survey interview (i.e., the past year). Substance use treatment refers to treatment received for illicit drug or alcohol use or for medical problems associated with the use of illicit drugs or alcohol. This includes treatment received in the past year at any location, such as a hospital (inpatient), rehabilitation facility (outpatient or inpatient), mental health center, emergency room, private doctor's office, prison or jail, or a self-help group, such as Alcoholics Anonymous or Narcotics Anonymous. Respondents who reported receiving substance use treatment in the past year had the opportunity to indicate the specific substances for which they received treatment during their most recent (e.g., last or current) substance use treatment. Data on the substances for which people received their most recent treatment are not mutually exclusive because respondents could indicate that they received treatment for their use of more than one substance. In 2015, 3.7 million people aged 12 or older received substance use treatment in the past year. Of these, 822,000 received treatment for the misuse of pain relievers during their most recent treatment in the past year (Figure 23). The 822,000 people who received treatment for the misuse of pain relievers during their most recent treatment in the past year represent 22.4 percent of people aged 12 or older who received treatment for alcohol or illicit drug use in the past year. An estimated 293,000 people aged 12 or older received treatment for tranquilizer misuse during their most recent treatment in the past year (8.0 percent of people who received treatment in the past year), 139,000 received treatment for stimulant misuse during their most recent treatment (3.8 percent of people who received treatment in the past year), and 116,000 received treatment for sedative misuse during their most recent treatment (3.2 percent of people who received treatment in the past year).

Figure 23. Prescription Psychotherapeutics for Which Most Recent Treatment Was Received among People Aged 12 or Older Who Received Substance Use Treatment in the Past Year: Numbers (in Thousands) and Percentages, 2015 D

Treatment for Prescription Pain Reliever Misuse, by Age Group The 822,000 people aged 12 or older in 2015 who received treatment for prescription pain reliever misuse during their most recent substance use treatment in the past year (Figure 23) included about 25,000 adolescents aged 12 to 17, 165,000 young adults aged 18 to 25, and 632,000 adults aged 26 or older (Table B.17 in Appendix B). Treatment for Prescription Tranquilizer Misuse, by Age Group In 2015, of the 293,000 people aged 12 or older who received treatment for prescription tranquilizer misuse during their most recent substance use treatment in the past year (Figure 23), about 19,000 were adolescents aged 12 to 17, 89,000 were young adults aged 18 to 25, and 185,000 were adults aged 26 or older (Table B.17). Treatment for Prescription Stimulant Misuse, by Age Group In 2015, the 139,000 people aged 12 or older who received treatment for prescription stimulant misuse during their most recent substance use treatment in the past year (Figure 23) included 16,000 adolescents aged 12 to 17, 46,000 young adults aged 18 to 25, and 76,000 adults aged 26 or older (Table B.17). Treatment for Prescription Sedative Misuse, by Age Group In 2015, the 116,000 people aged 12 or older who received treatment for prescription sedative misuse during their most recent substance use treatment in the past year (Figure 23) included 7,000 adolescents aged 12 to 17, 28,000 young adults aged 18 to 25, and 81,000 adults aged 26 or older (Table B.17).

Source of Prescription Pain Relievers This section presents information for how all people aged 12 or older who misused prescription pain relievers in the past year obtained these pain relievers the last time they misused them. This section also discusses how past year misusers of pain relievers obtained pain relievers the last time they misused them according to approximately increasing levels of problem misuse. Source of Prescription Pain Relievers among All Past Year Misusers Among all people aged 12 or older in 2015 who misused prescription pain relievers in the past year, the most common source for the last pain reliever that was misused was from a friend or relative (Figure 24). More than half (53.7 percent) of people who misused pain relievers in the past year reported that they obtained the pain relievers the last time from a friend or relative. Specifically, 40.5 percent of people who misused pain relievers in the past year obtained pain relievers the last time by getting them from a friend or relative for free, 9.4 percent bought their last pain reliever from a friend or relative, and 3.8 percent took their last pain reliever from a friend or relative without asking. About one third of people who misused pain relievers in the past year (36.4 percent) indicated that they obtained pain relievers the last time through a prescription or health care provider, typically getting the pain relievers through a prescription from one doctor (34.0 percent). About 1 in 20 people who misused pain relievers in the past year (4.9 percent) reported that they bought the last pain reliever they misused from a drug dealer or stranger.

Figure 24. Source Where Pain Relievers Were Obtained for Most Recent Misuse among People Aged 12 or Older Who Misused Prescription Pain Relievers in the Past Year: Percentages, 2015 D Note: The percentages do not add to 100 percent due to rounding.

Note: Respondents with unknown data for the Source for Most Recent Misuse or who reported Some Other Way but did not specify a valid way were excluded.

Source of Prescription Pain Relievers, by Type of Misuser Another way of understanding the misuse of prescription pain relievers is to examine whether the sources for the most recently misused prescription pain relievers vary by the type of misuser of pain relievers. These user types were defined in terms of approximately increasing levels of misuse. Specifically, past year misusers of pain relievers were categorized into the following mutually exclusive groups: (a) past year initiates without a pain reliever use disorder, (b) past year misusers who initiated misuse more than 12 months ago and did not have a pain reliever use disorder, and (c) past year misusers with a pain reliever use disorder, which included past year initiates whose misuse progressed in the past 12 months from initiation to having a pain reliever use disorder. As noted previously, individuals who misused pain relievers in the past year were defined as having a pain reliever use disorder in the past year based on criteria specified in DSM-IV.24 Past year initiates were defined as people who first misused prescription pain relievers within the past 12 months. For all three types of past year misusers, the two most commonly reported sources of the prescription pain relievers that were misused the last time were (a) obtaining the drugs from a friend or relative and (b) receiving the drugs through prescription(s) or health care providers (Figure 25). Obtaining pain relievers from a friend or relative was the most common source for both past year initiates (53.5 percent) and less recent initiates who misused pain relievers in the past year and did not have a pain reliever use disorder (57.4 percent). This source was followed by obtaining pain relievers through prescription(s) or health care providers, which was reported by 41.4 percent of past year initiates and 33.6 percent of less recent initiates who did not have a pain reliever use disorder. In comparison, the most common source for past year misusers with a pain reliever use disorder was through prescription(s) or health care providers (43.7 percent), followed by friends or relatives (39.0 percent).

Figure 25. Source Where Pain Relievers Were Obtained for Most Recent Misuse for People Aged 12 or Older Who Misused Prescription Pain Relievers in the Past Year, by Past Year Initiation Status and Pain Reliever Disorder Status: Percentages, 2015 D Note: Respondents with unknown data for the Source for Most Recent Misuse or who reported Some Other Way but did not specify a valid way were excluded.

1 Past Year Initiate without Disorder is defined as individuals who initiated pain reliever misuse in the past year but who did not have a past year pain reliever use disorder.

2 Past Year Misuser without Disorder and Not Past Year Initiate is defined as individuals who misused pain relievers in the past year, were not past year initiates for pain reliever misuse, and did not have a past year pain reliever use disorder.

3 Past Year Misuser (Including Initiates) with Disorder is defined as individuals who misused pain relievers in the past year (including initiates and noninitates) and had a past year pain reliever use disorder.

Past year misusers with a pain reliever use disorder also were more likely than misusers in the other two groups to have obtained their last prescription pain relievers from a drug dealer or other stranger (13.4 percent) (Figure 25). In comparison, 1.9 percent of past year initiates without a disorder and 3.5 percent of less recent initiates who misused in the past year and did not have a pain reliever use disorder bought their last prescription pain relievers from a drug dealer or other stranger. More than 1 in 8 past year misusers with a pain reliever use disorder (13.8 percent) bought their last pain relievers from a friend or relative (Table B.13 in Appendix B), followed by past year misusers who initiated misuse more than 12 months ago but did not have a pain reliever use disorder (9.3 percent), then by recent initiates (5.4 percent). Past year misusers with a pain reliever use disorder also were less likely to obtain their last pain relievers from a friend or relative for free (22.1 percent) compared with past year initiates without a pain reliever use disorder (45.5 percent) and less recent initiates who were past year misusers but did not have a pain reliever use disorder (43.9 percent).

New Directions in Measuring Prescription Drug Use and Misuse in the 2015 NSDUH A number of changes were made to the 2015 NSDUH questionnaire and data collection procedures to collect new information and to address current substance use and mental health policy and research needs. As noted in the section at the beginning of the report titled "Notable Questionnaire Changes for the 2015 NSDUH," these changes included the redesign of the prescription drug questions. Collecting more detailed information on use, misuse, and recent initiation of a comprehensive set of specific prescription drugs was determined to be more useful for policy and research purposes, in part because of public health concerns about increases in addiction, overdoses, and deaths involving prescription drugs. This section provides a brief summary of enhancements to the NSDUH prescription drug questions and some analyses that are now possible with these new prescription drug data. Notable limitations are also summarized. Additional information on these changes and related issues can be found in Appendix A. Key Enhancements Several enhancements or improvements were made to the prescription drug questions in the 2015 NSDUH, as described below. Changes to the Definition of Misuse The definition of misuse was changed to focus on specific behaviors that constitute misuse and to incorporate more ways in which people misuse prescription drugs, including overuse of medication despite having a prescription. The definition of misuse before 2015 included a behavior (i.e., use without a prescription of one's own) and a motivation (i.e., use only for the experience or feeling that a drug caused). Also, use "for the experience or feeling" that a drug caused could be misinterpreted by respondents to apply to use of prescribed medications for their intended effects (e.g., use of prescription tranquilizers to reduce feelings of anxiety).4 Inclusion of Relevant Prescription Drugs for Estimating Past Year Use and Misuse Because of the focus of the 2015 NSDUH questions on the past year reference period for the use and misuse of specific prescription drugs (i.e., instead of the lifetime period prior to 2015), attention was given to identifying the specific prescription drugs that were likely to be most relevant for estimating past year use and misuse. Decisions to add specific pr