(52) Barriers to Healthcare Utilization and Adolescent Prescription Drug Misuse During COVID-19

Background & Introduction: Prescription drug misuse (PDM) contributes to adolescent overdose fatalities, with prescription drugs identified in 5.76-13.26% of all fatal drug-related overdoses in 2021.¹ Adolescents most commonly source prescription drugs for misuse via friends/family (72.0%) or the medical system (30.5%).² Both sources were impacted by social distancing mandates enacted at the onset of the coronavirus disease (COVID-19) pandemic in March 2020. Additionally, the pandemic shifted the delivery of healthcare services to newer formats (i.e., telemedicine), but such adaptations were found to result in reduced quality of care for adolescents with mental illness or a substance use disorder.^3,4 We aimed to determine if there is an association between experiencing barriers to healthcare utilization and meeting diagnostic criteria for PDM among adolescents ages 12-17 years old living in the United States (U.S.) during the COVID-19 pandemic period.

Methods: The 2021 and 2022 National Survey on Drug Use and Health (NSDUH) were utilized for this cross-sectional study. Use of the 2020 NSDUH dataset was cautioned against by the developers given changes in the methods of data collection and therefore was not included for this study. Meeting PDM diagnostic criteria was defined as a dichotomous outcome in alignment with the guidelines established in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Descriptive statistics were used to characterize the study sample. Multivariable prevalence ratios (PRs) with 95% confidence intervals (CIs) were estimated to measure the association between any healthcare utilization barriers experienced and PDM diagnosis using a modified Poisson regression analysis with robust error variance. Significance testing of differences in prevalence by type of barrier experienced was also conducted between the two years of data to identify if temporal changes occurred in alignment with the lifting of social distancing mandates. All analyses were conducted using SAS 9.4 and complex survey weighting was performed to produce nationally representative estimates. Findings were considered statistically significant at alpha ≤0.05.

Results: A total of 21,274 adolescent participants had nonmissing data for all variables of interest, of which only 494 (2.15%) met diagnostic criteria for PDM. Slightly over three-fourths of the sample identified as either non-Hispanic White (50.57%) or Hispanic (25.48%), while the five other races/ethnicities made up the remainder of the sample. A limited number of adolescents self-reported being of fair/poor health across the overall sample (4.78%), but slightly more adolescents who met PDM criteria reported being of fair/poor health (n=81) than of excellent health (n=78). Amongst adolescents who met PDM criteria, almost all (n=484/494, 97.98%) were covered by some form of health insurance. Experiencing a past-year major depressive episode (MDE; 1.04%) or not (1.11%) was more evenly distributed amongst adolescents who met diagnostic criteria, compared to most adolescents who did not meet criteria also not experiencing an MDE in the past year (78.88%).

Compared to adolescents who did not experience any barriers to healthcare utilization, adolescents that had appointments moved to telehealth (PR 2.42, 95% CI [2.37, 2.48], p< 0.001), delayed/cancelled appointments (PR 1.48, 95% CI [1.40, 1.56], p< 0.001), or delayed prescriptions (PR 5.98, 95% CI [5.38, 6.64], p< 0.001) had higher prevalences of PDM diagnosis. Conversely, adolescents unable to access any form of healthcare had a lower prevalence of PDM diagnosis (PR 0.64, 95% CI [0.59, 0.69], p< 0.001). Prevalence differences between 2021 and 2022 were not statistically significant regardless of the type of barrier experienced.

Conclusion & Discussion: Study findings suggest that adolescents who experienced certain barriers to healthcare utilization during COVID-19 (i.e., had a healthcare appointment moved to telehealth, experienced delayed/cancelled appointments, or received their necessary prescriptions late) had a higher prevalence of PDM diagnosis compared to adolescents who did not experience any barriers to healthcare utilization, even after adjusting for other determinants of PDM diagnosis. As healthcare systems resume pre-pandemic care, efficacy studies of treatment and screening methods that incorporate delivery methods used during the pandemic, such as telepsychiatry or cancelling appointments in favor of family-based interventions, are needed to determine ideal healthcare delivery for adolescents at risk or with a current diagnosis of PDM. Future research should also focus on identifying potential patterns of prescription drug sourcing during the pandemic to mitigate changes in such sources during future public health emergencies.

References: 1. Friedman J, Godvin M, Shover CL, Gone JP, Hansen H, Schriger DL. Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA. 2022;327(14):1398-1400. doi:10.1001/jama.2022.2847

2. Hulme S, Bright D, Nielsen S. The source and diversion of pharmaceutical drugs for non-medical use: A systematic review and meta-analysis. Drug Alcohol Depend. 2018;186:242-256. doi:10.1016/j.drugalcdep.2018.02.010

3. Madigan S, Racine N, Cooke JE, Korczak DJ. COVID-19 and telemental health: Benefits, challenges, and future directions. Canadian Psychology/Psychologie Canadienne. 2021;62(1):5. doi:10.1037/cap0000259

4. Lassi N. Delayed and unmet prescription drug access linked to elevated anxiety symptoms during COVID-19: Retrospective findings from the NLSY79 child and young adult cohort. Explor Res Clin Soc Pharm. 2024;13:100411. doi:10.1016/j.rcsop.2024.100411