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National trends in prescription drug expenditures and projections for 2024.

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Eric M Tichy, James M Hoffman, Mina Tadrous, Matthew H Rim, Sandra Cuellar, John S Clark, Mary Kate Newell, Glen T Schumock, National trends in prescription drug expenditures and projections for 2024, American Journal of Health-System Pharmacy , 2024;, zxae105, https://doi.org/10.1093/ajhp/zxae105

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In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2024 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2024 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, endocrine drugs, generics, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2024 were based on a combination of quantitative analyses and expert opinion.

In 2023, overall pharmaceutical expenditures in the US grew 13.6% compared to 2022, for a total of $722.5 billion. Utilization (a 6.5% increase), new drugs (a 4.2% increase) and price (a 2.9% increase) drove this increase. Semaglutide was the top drug in 2023, followed by adalimumab and apixaban. Drug expenditures were $37.1 billion (a 1.1% decrease) and $135.7 billion (a 15.0% increase) in nonfederal hospitals and clinics, respectively. In clinics, increased utilization drove growth, with a small impact from price and new products. In nonfederal hospitals, a drop in utilization led the decrease in expenditures, with price and new drugs modestly contributing to growth in spending. Several new drugs that will influence spending are expected to be approved in 2024. Specialty, endocrine, and cancer drugs will continue to drive expenditures.

For 2024, we expect overall prescription drug spending to rise by 10.0% to 12.0%, whereas in clinics and hospitals we anticipate an 11.0% to 13.0% increase and a 0% to 2.0% increase, respectively, compared to 2023. These national estimates of future pharmaceutical expenditure growth may not be representative of any health system because of the myriad of local factors that influence actual spending.

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• Published: 23 June 2020

The high cost of prescription drugs: causes and solutions

• S. Vincent Rajkumar   ORCID: orcid.org/0000-0002-5862-1833 1  

Blood Cancer Journal volume  10 , Article number:  71 ( 2020 ) Cite this article

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Global spending on prescription drugs in 2020 is expected to be ~$1.3 trillion; the United States alone will spend ~$350 billion 1 . These high spending rates are expected to increase at a rate of 3–6% annually worldwide. The magnitude of increase is even more alarming for cancer treatments that account for a large proportion of prescription drug costs. In 2018, global spending on cancer treatments was approximately 150 billion, and has increased by >10% in each of the past 5 years 2 .

The high cost of prescription drugs threatens healthcare budgets, and limits funding available for other areas in which public investment is needed. In countries without universal healthcare, the high cost of prescription drugs poses an additional threat: unaffordable out-of-pocket costs for individual patients. Approximately 25% of Americans find it difficult to afford prescription drugs due to high out-of-pocket costs 3 . Drug companies cite high drug prices as being important for sustaining innovation. But the ability to charge high prices for every new drug possibly slows the pace of innovation. It is less risky to develop drugs that represent minor modifications of existing drugs (“me-too” drugs) and show incremental improvement in efficacy or safety, rather than investing in truly innovative drugs where there is a greater chance of failure.

Causes for the high cost of prescription drugs

The most important reason for the high cost of prescription drugs is the existence of monopoly 4 , 5 . For many new drugs, there are no other alternatives. In the case of cancer, even when there are multiple drugs to treat a specific malignancy, there is still no real competition based on price because most cancers are incurable, and each drug must be used in sequence for a given patient. Patients will need each effective drug at some point during the course of their disease. There is seldom a question of whether a new drug will be needed, but only when it will be needed. Even some old drugs can remain as virtual monopolies. For example, in the United States, three companies, NovoNordisk, Sanofi-Aventis, and Eli Lilly control most of the market for insulin, contributing to high prices and lack of competition 6 .

Ideally, monopolies will be temporary because eventually generic competition should emerge as patents expire. Unfortunately, in cancers and chronic life-threatening diseases, this often does not happen. By the time a drug runs out of patent life, it is already considered obsolete (planned obsolescence) and is no longer the standard of care 4 . A “new and improved version” with a fresh patent life and monopoly protection has already taken the stage. In the case of biologic drugs, cumbersome manufacturing and biosimilar approval processes are additional barriers that greatly limit the number of competitors that can enter the market.

Clearly, all monopolies need to be regulated in order to protect citizens, and therefore most of the developed world uses some form of regulations to cap the launch prices of new prescription drugs. Unregulated monopolies pose major problems. Unregulated monopoly over an essential product can lead to unaffordable prices that threaten the life of citizens. This is the case in the United States, where there are no regulations to control prescription drug prices and no enforceable mechanisms for value-based pricing.

Seriousness of the disease

High prescription drug prices are sustained by the fact that treatments for serious disease are not luxury items, but are needed by vulnerable patients who seek to improve the quality of life or to prolong life. A high price is not a barrier. For serious diseases, patients and their families are willing to pay any price in order to save or prolong life.

High cost of development

Drug development is a long and expensive endeavor: it takes about 12 years for a drug to move from preclinical testing to final approval. It is estimated that it costs approximately $3 billion to develop a new drug, taking into account the high failure rate, wherein only 10–20% of drugs tested are successful and reach the market 7 . Although the high cost of drug development is a major issue that needs to be addressed, some experts consider these estimates to be vastly inflated 8 , 9 . Further, the costs of development are inversely proportional to the incremental benefit provided by the new drug, since it takes trials with a larger sample size, and a greater number of trials to secure regulatory approval. More importantly, we cannot ignore the fact that a considerable amount of public funding goes into the science behind most new drugs, and the public therefore does have a legitimate right in making sure that life-saving drugs are priced fairly.

Lobbying power of pharmaceutical companies

Individual pharmaceutical companies and their trade organization spent approximately $220 million in lobbying in the United States in 2018 10 . Although nations recognize the major problems posed by high prescription drug prices, little has been accomplished in terms of regulatory or legislative reform because of the lobbying power of the pharmaceutical and healthcare industry.

Solutions: global policy changes

There are no easy solutions to the problem of high drug prices. The underlying reasons are complex; some are unique to the United States compared with the rest of the world (Table 1 ).

Patent reform

One of the main ways to limit the problem posed by monopoly is to limit the duration of patent protection. Current patent protections are too long, and companies apply for multiple new patents on the same drug in order to prolong monopoly. We need to reform the patent system to prevent overpatenting and patent abuse 11 . Stiff penalties are needed to prevent “pay-for-delay” schemes where generic competitors are paid money to delay market entry 12 . Patent life should be fixed, and not exceed 7–10 years from the date of first entry into the market (one-and-done approach) 13 . These measures will greatly stimulate generic and biosimilar competition.

Faster approval of generics and biosimilars

The approval process for generics and biosimilars must be simplified. A reciprocal regulatory approval process among Western European countries, the United States, Canada, and possibly other developed countries, can greatly reduce the redundancies 14 . In such a system, prescription drugs approved in one member country can automatically be granted regulatory approval in the others, greatly simplifying the regulatory process. This requires the type of trust, shared standards, and cooperation that we currently have with visa-free travel and trusted traveler programs 6 .

For complex biologic products, such as insulin, it is impossible to make the identical product 15 . The term “biosimilars” is used (instead of “generics”) for products that are almost identical in composition, pharmacologic properties, and clinical effects. Biosimilar approval process is more cumbersome, and unlike generics requires clinical trials prior to approval. Further impediments to the adoption of biosimilars include reluctance on the part of providers to trust a biosimilar, incentives offered by the manufacturer of the original biologic, and lawsuits to prevent market entry. It is important to educate providers on the safety of biosimilars. A comprehensive strategy to facilitate the timely entry of cost-effective biosimilars can also help lower cost. In the United States, the FDA has approved 23 biosimilars. Success is mixed due to payer arrangements, but when optimized, these can be very successful. For example, in the case of filgrastim, there is over 60% adoption of the biosimilar, with a cost discount of approximately 30–40% 16 .

Nonprofit generic companies

One way of lowering the cost of prescription drugs and to reduce drug shortages is nonprofit generic manufacturing. This can be set up and run by governments, or by nonprofit or philanthropic foundations. A recent example of such an endeavor is Civica Rx, a nonprofit generic company that has been set up in the United States.

Compulsory licensing

Developed countries should be more willing to use compulsory licensing to lower the cost of specific prescription drugs when negotiations with drug manufacturers on reasonable pricing fail or encounter unacceptable delays. This process permitted under the Doha declaration of 2001, allows countries to override patent protection and issue a license to manufacture and distribute a given prescription drug at low cost in the interest of public health.

Solutions: additional policy changes needed in the United States

The cost of prescription drugs in the United States is much higher than in other developed countries. The reasons for these are unique to the United States, and require specific policy changes.

Value-based pricing

Unlike other developed countries, the United States does not negotiate over the price of a new drug based on the value it provides. This is a fundamental problem that allows drugs to be priced at high levels, regardless of the value that they provide. Thus, almost every new cancer drug introduced in the last 3 years has been priced at more than $100,000 per year, with a median price of approximately $150,000 in 2018. The lack of value-based pricing in the United States also has a direct adverse effect on the ability of other countries to negotiate prices with manufacturers . It greatly reduces leverage that individual countries have. Manufacturers can walk away from such negotiations, knowing fully well that they can price the drugs in the United States to compensate. A governmental or a nongovernmental agency, such as the Institute for Clinical and Economic Review (ICER), must be authorized in the United States by law, to set ceiling prices for new drugs based on incremental value, and monitor and approve future price increases. Until this is possible, the alternative solution is to cap prices of lifesaving drugs to an international reference price.

Medicare negotiation

In addition to not having a system for value-based pricing, the United States has specific legislation that actually prohibits the biggest purchaser of oral prescription drugs (Medicare) from directly negotiating with manufacturers. One study found that if Medicare were to negotiate prices to those secured by the Veterans Administration (VA) hospital system, there would be savings of $14.4 billion on just the top 50 dispensed oral drugs 17 .

Cap on price increases

The United States also has a peculiar problem that is not seen in other countries: marked price increases on existing drugs. For example, between 2012 and 2017, the United States spent $6.8 billion solely due to price increases on the existing brand name cancer drugs; in the same period, the rest of the world spent $1.7 billion less due to decreases in the prices of similar drugs 18 . But nothing illustrates this problem better than the price of insulin 19 . One vial of Humalog (insulin lispro), that costs $21 in 1999, is now priced at over $300. On January 1, 2020, drugmakers increased prices on over 250 drugs by approximately 5% 20 . The United States clearly needs state and/or federal legislation to prevent such unjustified price increases 21 .

Remove incentive for more expensive therapy

Doctors in the United States receive a proportionally higher reimbursement for parenteral drugs, including intravenous chemotherapy, for more expensive drugs. This creates a financial incentive to choosing a more expensive drug when there is a choice for a cheaper alternative. We need to reform physician reimbursement to a model where the amount paid for drug administration is fixed, and not proportional to the cost of the drug.

Other reforms

We need transparency on arrangements between middlemen, such as pharmacy-benefit managers (PBMs) and drug manufacturers, and ensure that rebates on drug prices secured by PBMS do not serve as profits, but are rather passed on to patients. Drug approvals should encourage true innovation, and approval of marginally effective drugs with statistically “significant” but clinically unimportant benefits should be discouraged. Importation of prescription drugs for personal use should be legalized. Finally, we need to end direct-to-patient advertising.

Solutions that can be implemented by physicians and physician organizations

Most of the changes discussed above require changes to existing laws and regulations, and physicians and physician organizations should be advocating for these changes. It is disappointing that there is limited advocacy in this regard for changes that can truly have an impact. The close financial relationships of physician and patient organizations with pharmaceutical companies may be preventing us from effective advocacy. We also need to generate specific treatment guidelines that take cost into account. Current guidelines often present a list of acceptable treatment options for a given condition, without clear recommendation that guides patients and physicians to choose the most cost=effective option. Prices of common prescription drugs can vary markedly in the United States, and physicians can help patients by directing them to the pharmacy with the lowest prices using resources such as goodrx.com 22 . Physicians must become more educated on drug prices, and discuss affordability with patients 23 .

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Vincent Rajkumar, S. The high cost of prescription drugs: causes and solutions. Blood Cancer J. 10 , 71 (2020). https://doi.org/10.1038/s41408-020-0338-x

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Life Course Patterns of Prescription Drug Use in the United States

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Jessica Y. Ho; Life Course Patterns of Prescription Drug Use in the United States. Demography 1 October 2023; 60 (5): 1549–1579. doi: https://doi.org/10.1215/00703370-10965990

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Prescription drug use has reached historic highs in the United States—a trend linked to increases in medicalization, institutional factors relating to the health care and pharmaceutical industries, and population aging and growing burdens of chronic disease. Despite the high and rising prevalence of use, no estimates exist of the total number of years Americans can expect to spend taking prescription drugs over their lifetimes. This study provides the first estimates of life course patterns of prescription drug use using data from the 1996–2019 Medical Expenditure Panel Surveys, the Human Mortality Database, and the National Center for Health Statistics. Newborns in 2019 could be expected to take prescription drugs for roughly half their lives: 47.54 years for women and 36.84 years for men. The number of years individuals can expect to take five or more drugs increased substantially. Americans also experienced particularly dramatic increases in years spent taking statins, antihypertensives, and antidepressants. There are also important differences in prescription drug use by race and ethnicity: non-Hispanic Whites take the most, Hispanics take the least, and non-Hispanic Blacks fall in between these extremes. Americans are taking drugs over a wide and expanding swathe of the life course, a testament to the centrality of prescription drugs in Americans' lives today.

• Introduction

Prescription drug use in the United States has reached record levels, rising to 6.3 billion prescriptions—approximately 19 prescriptions for every American—filled in 2020 alone ( IQVIA Institute for Human Data Science 2021 ). Now “the most common therapeutic intervention” ( World Health Organization [WHO] 2019 ), the modern prescription drug only emerged around the mid-twentieth century ( Tomes 2005 ). With few exceptions, most commonly used drugs today were developed after 1950. Beta-blockers were discovered in the mid-1960s, and statins and calcium channel blockers were not introduced until the late 1980s ( Chang and Lauderdale 2009 ; Moser 1997 ). Our most frequently prescribed drugs are relatively new medical innovations that have quickly become widespread over a short time period.

Prescription drugs have become accepted as an integral part of life in the United States—just under half (45.8%) of all Americans and 85.0% of older adults (aged 60+) interviewed in 2015–2016 reported having taken prescription drugs in the previous month ( Martin et al. 2019 ). However, we lack a full understanding of how important a role they play over the life course. This study answers the question, How many years can Americans now expect to spend taking prescription drugs? Understanding life course patterns of prescription drug use is particularly important given the high and rising rates of use. Although prescription drugs have contributed to tremendous improvements in health and life expectancy, they are not all equally beneficial or safe. As use has increased, concerns about overutilization, increasing costs, and the potential for negative health impacts have grown.

Drivers of Rising Drug Use

Several factors contribute to high and increasing levels of prescription drug use in the United States, including: population aging and rising burdens of chronic disease, medicalization (when aspects of normal life become viewed as medical conditions to be treated by drugs and other therapies; Conrad 2007 ), the ascendance of drugs to first-line treatment for an increasing array of medical conditions, the development of new drugs or new uses for existing drugs, and other institutional factors relating to the health care and pharmaceutical industries. Antibiotics, such as penicillin and sulfa drugs, were among the earliest drugs to be developed. As mortality from infectious diseases declined and the burden of chronic diseases rose over the course of the epidemiological transition ( Horiuchi 1999 ; Omran 1971 ), efforts to treat and prevent chronic diseases, such as cardiovascular disease and cancer, and other conditions (e.g., chronic pain) spurred drug development during the twentieth century ( Zajacova et al. 2021 ; Zimmer and Zajacova 2020 ).

Increasing medicalization has been the predominant trend in the United States ( Conrad 2005 ). Numerous aspects of daily life are increasingly regarded as conditions requiring medical diagnoses and treatment, especially using prescription drugs. Medicalized phenomena include obesity, substance use, hyperactivity, loneliness, childbirth, pain, and aging ( Armstrong 2003 ; Conrad and Schneider 1992 ; Owens 2020 ; Zajacova et al. 2021 ; Zimmer and Zajacova 2020 ). Society has come to expect and demand “a pill for every ill” ( Busfield 2010 :934). Prescription drugs thus moved from the periphery to the core of medicine. Drugs have become the go-to treatment, a shift reinforced by factors relating to the culture of medicine, changing institutional constraints in health care, and health policy. Increased prescribing is spurred by physicians' curative orientation and factors that became increasingly salient during the managed care era, including increased time constraints, the tying of physician pay to patient satisfaction, and uncertainty in clinical practice ( Busfield 2010 ; Ho 2017 , 2019 ; Tomes 2005 ). Insurance providers' reimbursement policies also constrain treatment options. Prescription drugs, and often specific drug classes, must frequently be tried before or have higher insurance coverage than nondrug therapies. For example, insurers had more generous coverage of opioids and fewer or no requirements for approval relative to non-opioid painkillers for pain-related conditions ( Thomas and Ornstein 2017 ).

Pharmaceutical companies contributed to increased prescribing through physician payments, sponsorship of medical conferences and educational seminars, and direct-to-consumer advertising. Between 1997 and 2016, medical marketing increased from $17.7 to $29.9 billion ( Schwartz and Woloshin 2019 ). Prescription drug advertising was a key driver of this expansion, with 4.6 million advertisements (including 663,000 TV commercials) amounting to $6 billion spent in 2016 alone ( Schwartz and Woloshin 2019 ). Growth of the generic drug market and policies such as Medicare Part D have also increased access to prescription drugs and their affordability ( Carr 2017 ; Catlin et al. 2008 ; Qato et al. 2008 ).

The Changing Nature of Drug Use

Individuals increasingly take large quantities of several prescription drugs simultaneously, for long durations, and for a widening array of conditions. Polypharmacy—the concurrent use of multiple prescription drugs—is high and increasing among adults and children ( Hales et al. 2018 ; Kantor et al. 2015 ; Qato et al. 2018 ). Older adults have the highest levels of polypharmacy: among adults aged 65+, 42% took five or more prescription drugs in 2012 ( IMS Institute for Healthcare Informatics 2013 ). Contributing factors include high burdens of chronic disease and multimorbidity, the intensification of treatment for chronic diseases, a growing propensity to treat earlier disease stages (e.g., prediabetes), fragmentation in the health care system, and increasing use of drugs to counter side effects of other drugs.

People are taking more drugs for longer durations. The earliest drugs—antibiotics—were typically taken for short periods to treat acute infections. With the rise of chronic diseases, people began to take drugs for extended periods—often from initial diagnosis through the remainder of their lifetimes. For example, individuals with hypertension are expected to take antihypertensive medications for the rest of their lives ( Lemelin 1989 ; van der Wardt et al. 2017 ). Similarly, the United Kingdom's National Health Service states, “You usually have to continue taking statins for life because if you stop taking them, your cholesterol will return to a high level within a few weeks” ( National Health Service 2018 ). Medicalization and expansions in prescription drug use mean that people are being prescribed drugs for more conditions. Antidepressant and other psychotherapeutic drug use has been rising since the 1950s, and hormone therapy for menopause began increasing in the early 1980s ( Goldman 2010 ; López-Muñoz and Alamo 2009 ).

Although transitioning people off prescription drugs is not presently a routine part of medical care, efforts involving deprescribing—a patient-centered approach to reduce or stop the use of drugs entirely—have intensified ( Hill et al. 2020 ; Rochon et al. 2021 ). Deprescribing often aims to address polypharmacy among older adults and decrease the use of drugs that are unnecessary, cause adverse effects, or have potential harms outweighing expected benefits ( Scott et al. 2015 ). Evidence indicates that deprescribing interventions have successfully reduced inappropriate medication usage ( Bloomfield et al. 2020 ).

Racial and Ethnic Differences in Drug Use

Racial and ethnic disparities in health care are a long-standing concern. Several studies have documented that racial and ethnic minorities have greater difficulty accessing care, receive lower quality of care, and are less likely to receive routine medical care ( Centers for Disease Control and Prevention [CDC] 2004a ; Kirby and Kaneda 2010 ; Schulman et al. 1999 ; Smedley et al. 2003 ). These differences persist even after accounting for socioeconomic characteristics and health status, and they contribute to racial and ethnic disparities in health and mortality ( CDC 2004b ; Williams and Jackson 2005 ). Prescription drug use is considerably lower among Blacks and Hispanics than non-Hispanic Whites ( Smedley et al. 2003 ). This pattern applies to children and older adults, with one study finding that Black and Hispanic Medicare beneficiaries used 10% to 40% fewer drugs than White beneficiaries with the same chronic conditions ( Briesacher et al. 2003 ; Gaskin et al. 2006 ; Hahn 1995 ; Mahmoudi and Jensen 2014 ). Several studies have documented racial and ethnic disparities in pain treatment and opioid prescribing ( Anderson et al. 2009 ; Burgess et al. 2014 ; Pletcher et al. 2008 ). Blacks and Hispanics are less likely to be prescribed painkillers for acute and chronic pain in many settings, including emergency room, ambulatory care, and palliative care settings, and they also receive lower dosages ( Meghani et al. 2012 ; Pletcher et al. 2008 ). Patterns of psychotropic medication use are mixed. Some studies have found that White children and adults were more likely to be prescribed such drugs than Blacks and Hispanics ( Akincigil et al. 2011 ; Cook et al. 2016 ; Zito et al. 1998 ), but others have found that Blacks were more likely to be prescribed antipsychotics ( Aggarwal et al. 2012 ; Segal et al. 1996 ). Although some studies were based on nationally representative data, others were restricted to small samples from single states, and most did not examine differences over the entire age range. One of this study's goals is to examine the implications of these patterns for racial and ethnic differences in prescription drug use over the life course.

Although Americans are taking drugs in record quantities, no estimates exist of the total number of years individuals can expect to take prescription drugs over their lifetimes. It is critical to understand a phenomenon that occurs across so much of the life course and whose importance shows no sign of lessening, only increasing. This study provides the first estimates characterizing life course patterns of prescription drug use in the United States between 1996 and 2019. These estimates allow us to identify how much of their lives Americans now spend taking prescription drugs and how these measures have changed over time, with particular attention to differences by gender, race, and ethnicity.

• Data and Methods

Data on prescription drug use come from the Medical Expenditure Panel Survey (MEPS), a long-running, annual survey that is nationally representative of the U.S. civilian noninstitutionalized population ( Agency for Healthcare Research and Quality 2021 ). Its sampling frame draws from a subsample of households interviewed in the prior year's National Health Interview Survey. The MEPS uses a panel design consisting of five interviews covering two calendar years, with a new panel of approximately 15,000 sample households selected each year. A single household respondent provides information about each household member. Multiple panels are used to capture the household's prescription drug use during each calendar year, but the panel structure is not used for other purposes in this study. The MEPS is the primary source of national estimates of health care use, expenditures, insurance coverage, sources of payment, and access to care ( Hill et al. 2014 ).

The MEPS Prescribed Medicines files provide information on all prescriptions purchased by household members. The drug names and therapeutic classes are supplied by the Multum Lexicon database, which is also used by other surveys (e.g., the National Health and Nutrition Examination Survey and the Health and Retirement Study). The MEPS prescription drug information is based on household reports and, if respondents grant permission, is verified by contacting pharmacies. These reports include all medications prescribed during any health care encounter, including outpatient visits, emergency room visits, and hospital stays ( Agency for Healthcare Research and Quality 2019 ; Hill et al. 2014 ). I link the Prescribed Medicines files to the MEPS Full-Year Consolidated Data files ( Blewett et al. 2019 ), which provide key demographic characteristics, including sex, birth year, race, and ethnicity.

Advantages of the MEPS include that it is nationally representative, has a large sample size, covers the entire age range, and has high response rates. Several MEPS features give us confidence in the quality of its prescription data. First, households are interviewed in person five times within two years, resulting in an average recall period of just five months ( Hill et al. 2011 ). This is a relatively short period compared with other surveys, which are typically fielded at least one and often multiple years apart. Shorter recall periods are associated with greater reporting accuracy ( Boudreau et al. 2004 ). Accuracy is generally greatest for drugs used to treat chronic or serious conditions ( Hill et al. 2011 ). The MEPS prompts respondents with lists of drugs they reported taking in prior interviews, asks them about both new prescriptions and refills, and asks about prescriptions phoned in by a doctor to a pharmacy ( Hill et al. 2011 ). Respondents are also asked whether medicines were prescribed during specific medical encounters, including emergency room visits, dentist visits, and inpatient stays. The MEPS verifies respondent-reported information using a follow-back survey of pharmacies ( Wang et al. 2008 ). In 2011, 69.7% of households permitted the MEPS to contact their pharmacies ( Hill et al. 2014 ). A validation study of the MEPS data (performed by matching to a sample of Medicare claims) found that the MEPS was highly accurate, with high levels of concordance on prescription drug use (an agreement rate of .97), average number of fills (37.4 in the MEPS vs. 38.2 in the Medicare sample), and mean annual expenditures ($2,426 in the MEPS vs. $2,331 in the Medicare sample) ( Hill et al. 2011 ). The MEPS prescription data are much more accurate than other commonly used surveys, such as the Medicare Current Beneficiary Survey and Consumer Expenditure Surveys, which have higher underreporting rates ( Poisal 2003 ; U.S. Bureau of Labor Statistics 2023 ).

For each year in 1996–2019, I combine the MEPS data with the corresponding sex-specific period U.S. life tables from the Human Mortality Database (HMD; 2021) . For the analyses by race and ethnicity, I combine the MEPS data with the corresponding race-ethnicity-sex-specific period life tables from the National Center for Health Statistics (NCHS) for each year in 2006 (the earliest year they are available) through 2019 ( NCHS 2022a ).

The analysis examines three dimensions of prescription drug use: (1) any use versus no use, (2) the number of drugs, and (3) the class of drugs. I start with two descriptive measures: the percentage of people at each age taking any drugs and the age-standardized percentages of people taking zero, one, two, three, four, or five or more drugs. The age standard is the 2010 U.S. population ( NCHS 2022b ).

Estimates of the number of years individuals can be expected to take prescription drugs are produced using Sullivan's method, the most widely used method for calculating health expectancies ( Sullivan 1971 ). Sullivan's method has been used to study many phenomena, including disability, loneliness, and health insurance coverage ( Jagger and Robine 2011 ; Kirby and Kaneda 2010 ; Raymo and Wang 2022 ). I combine the MEPS data with life tables from the HMD and NCHS to apportion the total number of years lived into years expected to be spent in different states (e.g., taking any prescription drugs, a certain number of drugs, or various classes of drugs). Sullivan's estimator is consistent and unbiased, and no additional assumptions are required beyond stationarity, the standard life table assumption ( Imai and Soneji 2007 ). In this application, the method takes into account mortality differentials between individuals taking drugs and those not taking drugs and between individuals taking different classes or numbers of drugs. The estimates are independent of population age structure, such that changes in the population age distribution will not drive estimated trends in drug use ( Jagger et al. 2014 ; Mathers 1991 ).

where x = 0, 1, 5, . . . , 85, n π a is the proportion of individuals in age group a to a + n taking prescription drugs (from the MEPS), n L a is the number of person-years lived in the age interval a to a + n (from the HMD or NCHS life tables), and l x is the number of survivors to exact age x (from the HMD or NCHS life tables). The interpretation of YLPD 0 in 2019 is the number of years a newborn in 2019 could expect to spend taking prescription drugs during their lifetime if, at each age, they experienced the prescription drug use prevalence and mortality rates observed in 2019.

Together, YLPD x and PDFLE x sum to life expectancy at age x .

where e x is life expectancy at age x .

and the expected number of years taking zero, one, two, three, four, and five or more drugs sum to overall life expectancy at age x .

To investigate the number of years individuals can expect to spend taking different types of drugs, I calculate n π a D C proportions specific to drug (sub)classes specified by the Multum Lexicon therapeutic classification system. Each drug is assigned to a primary therapeutic class. A consistent set of therapeutic classes is used to account for changes over time in the classification scheme. I specify 22 mutually exclusive and exhaustive classes of drugs: anti-infectives, antineoplastics, biologicals and immunologic agents, cardiovascular agents (excluding antihypertensives), antihypertensives, central nervous system (CNS) agents (excluding analgesics and opioids), analgesics (excluding opioids), opioids, coagulation modifiers, gastrointestinal agents, genitourinary tract agents, hormones and hormone modifiers, respiratory agents, psychotherapeutic agents (excluding antidepressants and antipsychotics), antidepressants, antipsychotics, metabolic agents (excluding statins), statins, topical agents, alternative medicines, nutritional products, and miscellaneous agents. 1 These drug classes include the most commonly used drugs ( Kantor et al. 2015 ), the top five classes in terms of spending ( Moeller et al. 2004 ), and the ones most commonly implicated in adverse drug events ( CDC 2023 ; Shehab et al. 2016 ). I also examine a subset of drugs referred to as “key prescription drugs” expected to be used over the longer term or for more severe or chronic conditions: antineoplastics, biologicals and immunologic agents, cardiovascular agents (excluding antihypertensives), antihypertensives, CNS agents (excluding analgesics and opioids), non-opioid analgesics, opioids, coagulation modifiers, gastrointestinal agents, genitourinary tract agents, hormones and hormone modifiers, respiratory agents, psychotherapeutic agents (excluding antidepressants and antipsychotics), antidepressants, antipsychotics, metabolic agents (excluding statins), and statins. In these analyses, I use an approach similar to the one described previously, using the proportion of individuals in each age group taking each class of drugs.

I conducted all analyses using Stata version 16.1 and used MEPS-provided weights to account for complex survey design.

Expected Years and Share of the Life Course Spent Taking Drugs

Prescription drug use has reached very high levels, with more than half of all men (52.2%) and women (62.0%) taking prescription drugs in 2019 (percentages are age-standardized). For the subset of key drugs, these figures remain fairly high, at 43.8% and 53.0% for men and women, respectively. Use is strongly patterned by age and sex (panel a, Figure 1 ). Among men, use decreases between childhood and young adulthood (between ages 1–4 and 20–24) and increases from age 25 onward. In contrast, use increases nearly continuously among women from age 5 onward. At all ages above 40, more than half of men take prescription drugs. Women cross the 50% threshold much earlier: at all ages above 15, the majority of women take prescription drugs. 2 These gender differences are partly related to women's 12% to 24% greater use at reproductive ages. Appendix Figure A1 (shown in the online appendix, along with all other figures and tables designated with an “A”) shows that if hormonal contraceptives were excluded, gender differences would be smaller but would not disappear; at reproductive ages, the reduction in the gender gap would be roughly one third. Other important contributors to gender differences include other hormones, analgesics, and psychotherapeutics.

Large differences across racial and ethnic groups exist (panel b of Figure 1 ), with use ramping up at much earlier ages for non-Hispanic Whites than for non-Hispanic Blacks and Hispanics. The age above which the majority of men take prescription drugs is 40 for Whites, 45 for Blacks, and 55 for Hispanics. For women, these disparities are even greater. More than half of all White women older than 15 take drugs, whereas Black and Hispanic women do not reach this rate until they are much older (40 and 45, respectively). Large gaps in use occur between Whites and the two other groups at young and prime adult ages. The percentage of White men taking drugs is an average of 11% to 12% higher at ages 10–44 and 10–84 than for Black and Hispanic men, respectively. The pattern for women is similar, although the differences are larger (at 16% to 18%, on average), and convergence occurs at age 50 for Black women and 65 for Hispanic women.

The percentages shown in Figure 1 translate to a considerable number of years that individuals can be expected to take drugs ( Table 1 ). For example, life expectancy for a newborn boy in 2019 was 76.59 years. Of those years, he could expect to take prescription drugs for 36.84 years (48% of his life) and not to take drugs for the remaining 39.75 years (52% of his life). A newborn girl in 2019, with a life expectancy of 81.72 years, could expect to take prescription drugs for many more years (47.54 years, nearly 60% of her life). The number of years U.S. men and women can expect to spend taking drugs has generally increased at every age during 1996–2019 (the exceptions are for women at ages 0 and 1).

The share of remaining life expectancy spent taking drugs also increased with age. For example, 25-year-old men and women in 2019 could expect to take prescription drugs for, respectively, 59.4% and 71.1% of their remaining years. For 65-year-old men and women, this share approached 90%. Between 1996 and 2019, the share of remaining life expectancy spent taking drugs increased at every age among men. Among women, it decreased slightly at ages below 50 and increased at ages above 50.

Compared with Whites, Blacks and Hispanics can expect to take prescription drugs for far fewer years (appendix Table A2 ). For example, in 2019, newborn boys in these groups could expect to take drugs for 39.01, 30.83, and 33.99 years, respectively. The corresponding figures for newborn girls were 50.99, 41.34, and 43.80 years. These differences partly reflect differences in life expectancy. Comparing the proportion of remaining life expectancy spent taking drugs helps account for those differences. Using this metric, I find that Black and Hispanic newborn boys could be expected to spend 43% of their lives taking drugs compared with 51% for White boys in 2019. In 2019, newborn Black and Hispanic girls could be expected to spend roughly 10% less of their lives (53% and 52%, respectively) taking drugs than newborn White girls (63%). These patterns hold through much of the age range, with convergence occurring at roughly age 65 for women and 80 for men.

Trends in the Use of Multiple Drugs

Figure 2 shows trends in the age-standardized percentages of people taking zero, one, two, three, four, and five or more prescription drugs. Most of the change has occurred at the extremes. Declines in the percentage of Americans taking only one drug have been matched by concomitant rises in the percentage taking five or more drugs (panel a, Figure 2 ). In the mid-1990s, among people taking any drugs, taking only one drug was the modal category. Within a decade, the percentages of people taking one and five or more prescription drugs had converged and remained fairly similar for both men and women through 2019, when they reached, respectively, 14% and 13% for men and 15% and 16% for women. In contrast, the percentages for the intermediate categories (i.e., taking two, three, or four drugs) were fairly stable over time.

These trends translate into large expansions in the share of life people take large numbers of prescription drugs. Figure 3 shows the years that individuals could expect to take zero, one, two, three, four, and five or more drugs at various ages in 1996 and 2019. With increasing age, many fewer years of remaining life are expected to be spent taking no drugs. The most dramatic change between 1996 and 2019 was the substantial increase in years of taking five or more drugs (red bars) that have occurred at each age. By 2019, the share of Americans' lives spent taking large numbers of drugs was nontrivial. A newborn boy in 2019 could expect to take five or more drugs for 11.56 years (or 15% of his life), compared with 16.29 years (a fifth of her life) for a newborn girl in 2019. These figures were considerably lower (9% and 16%, respectively) in 1996. Among 85-year-olds in 2019, men and women could expect to take five or more drugs for more than half (52% and 58%, respectively) of their remaining lives, up from 28% and 35%, respectively, in 1996.

There are important differences in the number of drugs taken across racial and ethnic groups (panel b of Figure 2 ). Between 2006 and 2019, the percentage taking no prescription drugs was consistently highest among Hispanics, intermediate for Blacks, and lowest for Whites. Correspondingly, the inverse of this pattern was generally replicated across each of the other categories (i.e., Whites had the highest percentages taking one, two, three, and four drugs, followed by Blacks and then Hispanics). Levels of polypharmacy (five or more drugs) were lowest for Hispanics but were very similar for Blacks and Whites. Over this period, the share of Black and White men taking five or more drugs was 14%, compared with 11% for Hispanic men. The corresponding figures for women were 18% and 14%, respectively.

These patterns are reflected in racial and ethnic differences in the proportions of remaining life expectancy expected to be spent taking prescription drugs (appendix Figure A2 ). Whites could expect not to take drugs for the smallest shares of their lives, whereas Blacks and Hispanics experienced similarly larger shares. For example, among newborns in 2019, White boys could expect not to take drugs for roughly half (49%) their lives, compared with 57% for Black and Hispanic boys. These differences were even larger for women. White newborn girls could expect not to take drugs for only a third (34%) of their lives, compared with 47% and 48% for Black and Hispanic girls, respectively. Similar patterns are observed at age 65, although the magnitudes of the differences are smaller given the racial and ethnic convergence in drug use with age. Interestingly, the distribution across the number of drugs among those taking any drugs is highly similar across racial and ethnic groups. In other words, much of difference across racial and ethnic groups is driven by the larger proportions of Blacks and Hispanics taking no drugs.

Trends in Types of Drugs Used

Figure 4 (panels a and b) shows trends in the number of years expected to be spent taking eight common classes of drugs (see also Table 2 and appendix Figures A4–A6 ). Among these classes, newborns could expect to be taking antihypertensives for the most years, followed by analgesics (through the early 2000s) or statins for men and CNS agents (post-2003) for women. Among 65-year-olds, antihypertensives are taken the most years, followed by statins (since the mid-2000s). Among men, antihypertensive drug use increased tremendously over the period studied. Newborn boys in 1996 could expect to take antihypertensives for 10.14 years; by 2019, this figure reached 17.21 years. Among men aged 65, this figure nearly doubled from 6.67 to 12.18 years. Women experienced large increases in antidepressant use. A newborn girl in 1996 could expect to take antidepressants for 5.55 years; by 2019, this figure more than doubled to 12.52 years. Antidepressant use among older women also grew substantially, from 1.89 to 5.13 years. Men could expect to spend many fewer years taking antidepressants than women—5.42 years for newborn boys (vs. 12.52 years for girls) and 2.29 years for men aged 65 (vs. 5.13 years for women aged 65) in 2019. Use of statins, CNS agents, and other metabolic agents also increased substantially over time. In contrast, years taking other cardiovascular agents remained fairly stable over time among men and decreased among women.

Disaggregating patterns by race and ethnicity reveals some similarities but also key differences ( Figure 4 , panels c and d). Members of all racial and ethnic groups could expect to spend the most years taking antihypertensives. In 2019, years taking antihypertensives were similar among men (with large increases occurring among Hispanics between 2006 and 2019), but Black and Hispanic women actually took antihypertensives for more years than White women. Among men, Whites took cardiovascular agents, CNS agents, and antidepressants for many more years than Blacks and Hispanics. Among women, Whites took cardiovascular agents, CNS agents, antidepressants, and opioids for more years. The discrepancies in antidepressant use are particularly large, amounting to roughly 10-year differences. In 2019, Black and Hispanic women could expect to take antidepressants for 4.83 and 6.76 years, respectively, compared with 15.94 years among White women. Black men and women took statins for the fewest years, but years of statin use were similar for White and Hispanic men and women in 2019.

Trends in opioid use are of interest, given the ongoing drug overdose epidemic and recommendations to reduce opioid prescribing. Although attention surrounding drug overdose increased in the 2000s, culminating in restrictions on opioid prescribing and a shift from prescribed to illicit drugs ( Ho 2019 ; Rudd et al. 2016 ), the expected number of years spent taking opioids continued to rise through 2015 ( Figure 4 ). Despite subsequent declines in years of life expected to be taking opioids among newborns between 1996 and 2019, expected years of taking opioids remained higher for men and women aged 65 in 2019 than in 1996. Years taking opioids declined from their peak for all racial and ethnic groups. Among men, declines were largest for Hispanics, followed by Whites and then Blacks. Among women, Blacks experienced the largest declines, followed by Hispanics and then Whites.

Figure 5 shows the share of remaining life expectancy at ages 0 and 65 spent taking specific classes of drugs for the total population. (Appendix Figure A7 shows the corresponding information by race and ethnicity, with patterns highly similar to those described here.) These classes account for the largest shares of drug use over individuals' lifetimes (see Table 2 for all drug classes). Individuals can expect to take cardiometabolic drugs, anti-infectives, and psychotherapeutics for the largest shares of their lives. For most of these drugs, the share of remaining life expectancy taking these drugs increases with age. Among men, shares of remaining life expected to be spent taking cardiometabolic drugs, psychotherapeutics, gastrointestinal agents, and coagulation modifiers increased between 1996 and 2019. The share of remaining life expected to be spent taking anti-infectives, topical agents, respiratory agents, and opioids decreased. Similar patterns are observed for women. The share of remaining years taking hormones and hormone modifiers increased for men but decreased for women at ages 0 and 65. Compared with men, women took several types of drugs for considerably greater shares of their lives. For example, women aged 65 and 85 in 2019 could expect to take antidepressants for, respectively, 24% and 22% of their remaining lives. Men could expect to take antidepressants for many fewer years than women: the shares of their lives spent taking antidepressants were roughly half those of women at ages below 85 in 2019. In 1996, a woman aged 85 could expect to take cardiometabolic drugs for 78% of her remaining years, compared with only 58% for a man aged 85. In 2019, a woman aged 45 could expect to take psychotherapeutics for 39% of her remaining lifetime, compared with only 25% for her male counterpart.

Prescription drug use has become a highly central, prevalent, and expanding part of the life course in the United States. However, for a phenomenon that occurs across so much of the life course and has enormous potential to affect health, well-being, and other outcomes, it remains surprisingly understudied. This study finds that newborn girls and boys in 2019 can now expect to spend more than or close to half their lives—47.54 and 36.84 years, respectively—taking prescription drugs. In other words, a newborn girl in 2019 can be expected not to take drugs for only approximately 40% of her life. Even as life expectancy has increased—albeit much more slowly since 2010 than in earlier decades ( Ho and Hendi 2018 )—the share of Americans' lives spent taking drugs increased at all ages for men and at all ages above 50 for women between 1996 and 2019. The years Americans can expect to spend taking drugs increased at most ages (except below age 5 for women); the number of years expected to be spent not taking any drugs also increased in some of the younger age groups. With future life expectancy increases, it will be interesting to observe whether those additional years are spent taking or not taking prescription drugs.

High levels of use begin early in the life course. The majority of women older than 15 take prescription drugs; the corresponding age for men is 40. This study also finds that the nature of drug use has shifted considerably over time. The share of Americans' lives spent simultaneously taking large numbers of drugs is substantial and expanded dramatically over time. In 1996, no men at any age could expect to take five or more drugs for more than a third of their remaining life expectancy. By 2019, men in all age groups above 50 could expect to take five or more drugs for 36% to 53% of their remaining life expectancy. Among women, the maximum share of remaining life taking five or more drugs was 38% in 1996. By 2019, women in all age groups above 50 could expect to take five or more drugs for 40% to 58% of their remaining years.

Americans are taking statins, antihypertensives, and antidepressants for large and growing portions of their lives. In 2019, newborns could be expected to take antihypertensives for nearly a quarter of their lives, compared with two thirds for 65-year-olds. The share of remaining years Americans could be expected to take statins increased more than fourfold at every age, compared with 30% to 68% for antihypertensives. These trends are likely related to several factors, including the growing burden of obesity, longer survival with chronic conditions, and the intensification of treatment of high blood pressure and cholesterol. The rising and potentially unnecessary use of psychotherapeutics, particularly among adolescents, is of growing concern ( Richtel 2022 ). This study finds that the share of newborns' lives expected to be spent taking antidepressants roughly doubled between 1996 and 2019.

This article documents striking gender differences. At every age, women have much higher rates of prescription drug use than men: women can expect to take drugs for more years and for a greater share of their remaining lifetimes and to take five or more drugs for a greater proportion of their lives. Men and women also take different types of drugs. Large gender differences in the number of years newborns in 2019 could expect to take drugs were observed for psychotherapeutics (8.45 years), particularly antidepressants (7.11 years); hormones and hormone modifiers (6.72 years); anti-infectives (6.09 years); and painkillers (3.73 years) (appendix Table A5 ). Gender differences in drug use are multifaceted and related to many factors, including the fact that contraceptives remain largely targeted toward women. These patterns also reflect physicians' long-standing tendencies to prescribe psychotherapeutics (particularly tranquilizers) to women since the late 1800s and early 1900s, Valium in the 1960s and 1970s, and benzodiazepines in recent decades ( Courtwright 1982 ; Herzberg 2006 ; Olfson et al. 2015 ). Other factors include gender differences in health care access and utilization, norms relating to care seeking and symptom presentation (especially related to pain relief), and morbidity (e.g., women experience a higher burden of pain-related chronic conditions, such as rheumatoid arthritis, migraines, and fibromyalgia) ( Case and Paxson 2005 ; Ho 2020 ; Roe et al. 2002 ). However, there is one class of drugs women take for fewer years of their lives than men: drugs to treat cardiovascular disease. Interestingly, these differences widened, rather than narrowed, over time (appendix Table A5 ). This widening is concerning in light of prior assessments that gender differences in prescribing may not be evidence-based and studies finding that women are more likely to be prescribed drugs for the management of depression, migraines, thyroid disorders, and other chronic conditions but less likely to be prescribed drugs for cardiovascular disease prevention ( Rochon et al. 2021 ).

This study also reveals complex patterns of racial and ethnic differences in prescription drug use. Use starts much earlier among Whites than among Blacks and Hispanics, with particularly large gaps at the young and middle adult ages among women before convergence at the older ages. As a result, for most of the age range (below ages 65 and 80 for women and men, respectively), Blacks and Hispanics can expect to take no prescription drugs for higher proportions of their remaining lifetimes than Whites. This finding is unlikely to be due to better health among Blacks and Hispanics, given that both groups experience higher mortality than Whites at these ages ( Cunningham et al. 2017 ; Fenelon et al. 2017 ). Instead, this difference likely reflects inequality across racial and ethnic groups in access to care or receipt of prescriptions. Some phenomena are shared across racial and ethnic groups, including greater levels of use among women than men, high polypharmacy levels, and high rates of antihypertensive use. However, we also observe key racial and ethnic differences in the proportions of life people can expect to spend taking certain classes of drugs (appendix Tables A3 and A4 ). Use of cardiometabolic drugs generally converged among women but remained lower for Black and Hispanic men than White men, particularly at young and middle adult ages. Black men can be expected to take statins for 4% to 14% less of their lives than White men, which is concerning given Black men's high rates of cardiovascular disease mortality and that these gaps did not narrow appreciably between 2006 and 2019. Opioid use was similar among Black and White men but lower among Hispanic men. Among women, who take opioids for greater shares of their lives than men, Blacks and Hispanics can generally be expected to take opioids for lower proportions of their lives than Whites. The most sizable differences are observed for psychotherapeutics. For example, newborn White girls in 2019 could be expected to take such drugs for nearly a third (32%) of their lives, compared with 18% and 20% for Black and Hispanic girls, respectively. The magnitudes of these differences are fairly stable over the life course. The patterns for newborn boys in 2019 are similar, although the differences are slightly smaller (e.g., 8% vs. 12–14%).

The study results have implications for health care spending. Prescription drug expenditures are high, reaching $335.0 billion—roughly a tenth of national health expenditures—in 2018 ( Centers for Medicare & Medicaid Services 2020 ; Hartman et al. 2020 ). Per capita drug spending is higher in the United States than in all other high-income countries ( Kesselheim et al. 2016 ; OECD 2023 ; Sarnak et al. 2017 ). Trends in drug use may have outsized impacts on specific programs. Medicare and Medicaid are among the largest payers for prescriptions, which accounted for nearly a fifth of Medicare spending in 2016 ( Kaiser Family Foundation 2019 ). The finding that men and women aged 65 in 2019 could expect to take prescription drugs for an additional 16.46 and 18.88 years—up from 12.74 and 16.00 years in 1996, respectively—is particularly salient for Medicare. For more than half of those 16.46 and 18.88 years, men and women can be expected to take five or more drugs. Out-of-pocket expenditures are also significant, accounting for 14% of drug spending. Not only are current levels of drug spending high, but they are projected to be the fastest-growing category of health care spending in the coming decade ( Centers for Medicare & Medicaid Services 2020 ; Cuckler et al. 2018 ; Hartman et al. 2020 ). By 2026, prescription spending is projected to increase to $875 billion, or 15.4% of national health expenditures ( Roehrig 2018 ).

In addition to their fiscal impacts, trends in prescription drug use exert complex influences on health and mortality. On the one hand, prescription drugs are a cornerstone of disease management and contributed to health and life expectancy improvements over the past several decades. On the other hand, the opioid epidemic, which has resulted in over 1 million (1,082,050) drug overdose deaths as of 2021, constitutes one of the starkest manifestations of the unintended consequences of use ( CDC 2021a , 2021b ). The risks of drug–drug interactions and adverse drug events increase with the number of drugs taken. Each year, adverse drug events result in approximately 1.3 million emergency department visits, with blood thinners, diabetes medications, heart medications, seizure medications, and opioid painkillers most commonly implicated in these events ( CDC 2023 ). Rises in polypharmacy are particularly impactful for older adults, who are at the greatest risk of experiencing negative effects due to their greater likelihood of taking more drugs; metabolic changes associated with aging, including decreased renal and hepatic function; body composition (e.g., lower lean body mass); and higher prevalence of impaired cognition and mobility ( IMS Institute for Healthcare Informatics 2013 ; Masnoon et al. 2017 ). Polypharmacy increases the risk of falls, hospitalization, cognitive impairment, lower quality of life, and mortality ( Maher et al. 2014 ; Masnoon et al. 2017 ; WHO 2019 ). Deprescribing, as mentioned earlier, is an approach that seeks to reduce polypharmacy and inappropriate prescribing. Both domestic (e.g., U.S. Deprescribing Research Network) and international (e.g., International Group for Reducing Inappropriate Medication Use & Polypharmacy) networks provide information and coordinate efforts relating to deprescribing. Several frameworks or decision algorithms have been developed to identify inappropriate medication use and implement deprescribing ( Curtin et al. 2021 ; Farrell et al. 2016 ; Rochon et al. 2021 ; Scott et al. 2015 ). As such efforts become more widespread and accepted, adverse impacts associated with drug use might be reduced ( Reeve et al. 2017 ). Given the high prevalence and initiation of use at younger ages, extending deprescribing efforts beyond older adults may be beneficial.

The environmental impacts of prescription drug use pose additional concerns. The first reports documenting that heart medications, analgesics, contraceptives, and other pharmaceuticals were present in wastewater and other water resources in the United States date from the 1970s ( Caban and Stepnowski 2021 ). One study estimated that 80% of 139 streams sampled in 30 states contained pharmaceuticals in 1999–2000 ( Kolpin et al. 2002 ). Pharmaceutical ingredients have been detected in water supplies worldwide ( WHO 2012 ; Wilkinson et al. 2022 ). Prescription drugs can make their way into the environment through manufacturing, sewage and wastewater systems from residential areas and health care facilities, and improper disposal of unused or expired medicines ( Boxall 2004 ; WHO 2012 ). Because wastewater treatment plants do not entirely eliminate pharmaceuticals, people can be exposed to residues in drinking water and food ( OECD 2019 ). Growing antibiotic resistance is also a concern. Studies indicate that the levels present in the environment are below the thresholds that would pose health risks to humans ( Boxall 2004 ; WHO 2012 ). However, these studies generally study one substance at a time rather than capturing joint or interactive impacts of exposure, are typically of short duration, and rarely examine the effects of long-term, low-level exposure. Furthermore, several commonly used drugs (e.g., beta-blockers, antidepressants, analgesics, and anti-inflammatory drugs) have been found to negatively impact aquatic species and ecosystems ( Boxall 2004 ; Kusturica et al. 2022 ).

The present study's limitations include that the MEPS sample is restricted to the noninstitutionalized population and the potential for underreporting in the survey. Because the institutionalized population likely has higher levels of drug use, the estimates produced in these analyses should be conservative. The MEPS attempts to address potential underreporting of prescription drug use by following up with pharmacies, using multiple prompts to elicit information about prescription drug use (including asking respondents to bring medication containers to the interview), and using multiple rounds within each survey wave to enable shorter recall periods that improve reporting accuracy ( Boudreau et al. 2004 ; Hill et al. 2011 ; Nahin et al. 2019 ). The MEPS also prompts respondents by asking whether medicines are prescribed during various health care events, including emergency room visits, dentist visits, and inpatient stays ( Hill et al. 2014 ). A validation study of the MEPS based on matching the MEPS to Medicare claims data found the MEPS data to be highly accurate ( Hill et al. 2011 ). Furthermore, accuracy was highest for maintenance drugs and for drugs for serious conditions, which are the categories this study is most interested in capturing. One limitation of Sullivan's method is that it may underestimate or overestimate health expectancies when transition rates between health states are changing rapidly. Because drug use has been increasing over time, the estimates produced in these analyses are expected to be conservative ( Mathers and Robine 1997 ). Another potential concern is that short-term drug use may inflate estimates of lifetime drug use. However, this concern is somewhat mitigated because most prescription drug use is expected to be permanent rather than transient ( Lemelin 1989 ; National Health Service 2018 ; van der Wardt et al. 2017 ). Finally, this article focuses exclusively on prescription drugs, even though over-the-counter medications are also an important feature of medication use.

Over the past several decades, prescription drug use has become a highly central, prevalent, and expanding part of the life course in the United States. Americans today can expect to spend more than or close to half their lives taking prescription drugs. This is more than the share of their lives expected to be spent completing formal education, in a first marriage ( Hendi 2019 ), and perhaps even in the labor force. We are just beginning to be able to observe cohorts of older adults who experienced high, sustained levels of prescription drug use over several decades of their lives, but these conditions are likely to characterize all subsequent cohorts going forward. It will therefore be important to gain a full understanding of how sustained use of high levels of prescription drugs over decades of people's lives impacts health and well-being over the long run.

• Acknowledgments

Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R03AG073081. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

Some common examples include amoxicillin (anti-infective), used to treat bacterial infections like pneumonia; digoxin (cardiovascular agent), used to regulate heart rhythms; amlodipine (antihypertensive), used to treat high blood pressure; diazepam (e.g., brand name Valium) and alprazolam (Xanax), which are CNS agents used to treat anxiety, seizures, and panic disorders; naproxen (e.g., Aleve), a non-opioid analgesic, and oxycodone (e.g., OxyContin), an opioid analgesic, used for pain relief; warfarin (coagulation modifier), used to treat and prevent blood clots; omeprazole (e.g., Prilosec), a gastrointestinal agent used for heartburn; oxybutynin (e.g., Oxytrol), a genitourinary tract agent used for overactive bladder; contraceptives containing estrogen or progesterone and corticosteroids, examples of hormones; albuterol (respiratory agent), a bronchodilator used to treat asthma, bronchitis, and chronic obstructive pulmonary lung disease; sertraline (e.g., Zoloft), an antidepressant used for depression, posttraumatic stress disorder, and panic attacks; metformin (metabolic agent), used to treat type 2 diabetes; and atorvastatin (e.g., Lipitor), a statin used for high cholesterol.

This finding holds for the subset of key drugs (panel b of Figure 1 ). The age at which the majority of the population takes drugs is slightly older (at 45–49 for men and 25–29 for women) but still encompasses a substantial swathe of the life course.

Supplementary data

Data & figures.

Percentage of Americans taking (a) any prescription drugs by age and sex and (b) key prescription drugs by age, sex, race, and ethnicity in 2019. The key prescription drugs are antineoplastics, biologicals and immunologic agents, cardiovascular agents, CNS agents, coagulation modifiers, gastrointestinal agents, genitourinary tract agents, hormones and hormone modifiers, respiratory agents, psychotherapeutic agents, and metabolic agents. The dotted horizontal line indicates the point at which more than 50% of the population in that age group is taking prescription drugs. Source : Author's analysis of data from the MEPS, 2019.

Age-standardized percentage of U.S. men and women taking zero, one, two, three, four, and five or more key prescription drugs (a) for the total population in 1996–2019 and (b) by race and ethnicity in 2006–2019. The key prescription drugs are antineoplastics, biologicals and immunologic agents, cardiovascular agents, CNS agents, coagulation modifiers, gastrointestinal agents, genitourinary tract agents, hormones and hormone modifiers, respiratory agents, psychotherapeutic agents, and metabolic agents. Source : Author's analysis of data from the MEPS, 1996–2019.

Expected years taking zero, one, two, three, four, and five or more key prescription drugs at selected ages by sex for the total population in 1996 and 2019. The key prescription drugs are antineoplastics, biologicals and immunologic agents, cardiovascular agents, CNS agents, coagulation modifiers, gastrointestinal agents, genitourinary tract agents, hormones and hormone modifiers, respiratory agents, psychotherapeutic agents, and metabolic agents. Source : Author's analysis of data from the MEPS and the HMD, 1996 and 2019.

Expected years spent taking common classes of prescription drugs at age 0 by sex (a and b) for the total population between 1996 and 2019 and (c and d) by race and ethnicity between 2006 and 2019. Source : Author's analysis of data from the MEPS, the HMD, and the NCHS, 1996–2019.

Share of remaining life expectancy spent taking specific classes of prescription drugs at ages 0 and 65 for men and women in 1996 and 2019. Source : Author's analysis of data from the MEPS and the HMD, 1996 and 2019.

Expected years and percentage of remaining life expectancy taking key prescription drugs a for survivors to each age, by sex and year

Source: Data are from the author's calculations based on the MEPS and the HMD, 1996 and 2019.

Key prescription drugs are antineoplastics, biologicals and immunologic agents, cardiovascular agents, CNS agents, coagulation modifiers, gastrointestinal agents, genitourinary tract agents, hormones and hormone modifiers, respiratory agents, psychotherapeutic agents, and metabolic agents.

Change is calculated as expected years (or percentage of remaining life expectancy) taking prescription drugs in 2019 – expected years (or percentage of remaining life expectancy) taking prescription drugs in 1996.

Share of remaining life expectancy taking specific classes of prescription drugs at ages 0, 25, 45, 65, and 85 for men and women in 1996 and 2019: Percentages

Note: Main (nonindented) categories are mutually exclusive and exhaustive.

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Improving Prescription Drug Affordability Through Regulatory Action

• 1 Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
• Viewpoint New Reforms to Prescription Drug Pricing in the US: Opportunities and Challenges Thomas J. Hwang, MD; Aaron S. Kesselheim, MD, JD, MPH; Benjamin N. Rome, MD, MPH JAMA
• Original Investigation Prescription Drug Spending in Fee-for-Service Medicare, 2008-2019 Stacie B. Dusetzina, PhD; Haiden A. Huskamp, PhD; Xuanzi Qin, PhD; Nancy L. Keating, MD, MPH JAMA

Prescription drug prices in the US are more than 2.5 times as high as those in other similar high-income nations and are a leading health care concern among US residents. Given these factors, and in response to President Biden’s executive order promoting competition, the US Department of Health and Human Services (HHS) released a comprehensive plan to address drug prices in September 2021. 1 The plan highlighted 3 priorities: (1) making drug prices more affordable and equitable for all consumers and throughout the health care system, (2) improving competition throughout the prescription drug industry, and (3) fostering scientific innovation to promote better health care and improve health.

To support this agenda, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) conducts research on drug pricing, utilization, access, and innovation. For instance, a 2021 ASPE report found that more than 5 million Medicare beneficiaries reported difficulty affording medicines in 2019. 2 A recent journal article projected that savings from biosimilars from 2021-2025 would total at least $38 billion and as much as $124 billion—or approximately 6% to 19% of total spending on biosimilars. 3 A recent report on US and international generic drug utilization showed that US brand-name drug prices are 344% of prices in similar high-income countries, whereas US prices for generic drugs are actually lower than in comparator countries (84% of foreign prices). 4 A series of projects are also examining the drug supply chain, including an overview of stakeholders and relationships. In addition, the HHS plans to publicly track large price increases in prescription drugs to improve drug price transparency.

Using evidence and research to guide this work, the HHS plan outlined actions that the Biden administration is taking to reduce high drug prices. One key agency in this work is the Centers for Medicare & Medicaid Services (CMS), which is addressing prescription drug costs in Medicare, Medicaid, and the health insurance marketplace. In Medicare, a rule finalized in April established that price concessions that Medicare Part D plans receive from pharmacies must get passed along to beneficiaries at the pharmacy counter, saving an estimated $26.5 billion between 2024 and 2032. 5 For physician-administered drugs, paid for by Medicare Part B, the CMS implemented a provision from 2021 legislation that requires drug manufacturers without Medicaid drug rebate agreements to submit average sales price information for their Part B drugs, which will enable payment to be pegged to a lower rate than was previously in place for these drugs (including, for instance, common treatments such as hyaluronic acid injections, where payment may decline by ≥50% under this new rule). This change is projected to reduce Medicare costs by $3.5 billion over 10 years and produce significant savings to beneficiaries. In addition, Medicare is working with the US Food and Drug Administration (FDA) to share educational materials with clinicians about biosimilar and interchangeable biological products.

The HHS is also taking actions related to private insurance and Medicaid. In May 2022, the department finalized regulations designed to prevent health insurance marketplace plans from discriminating against beneficiaries with certain health conditions through the use of selectively designed drug formularies. The rule contained examples of how drug formularies might be discriminatory and how issuers can correct them, building on prior research that found that some insurers were putting all drugs from certain classes (for instance, antiretrovirals for HIV) on the highest cost-sharing tier. In Medicaid, a new regulation effective in July 2022 incentivizes manufacturers to offer states the same value-based purchasing arrangements for high-cost drugs that they offer to other insurers, and the CMS will also be launching a new learning collaborative in October 2022 to support state efforts on drug cost management and transparency. Medicaid is also working to encourage uptake of generic and biosimilar drugs through education to state drug utilization review boards.

Meanwhile, the FDA has established policies that support a competitive marketplace for generic drugs and biosimilar products, which can lower prices . Through its Drug Competition Action Plan and Biosimilars Action Plan , the FDA is working to help remove barriers to generic and biosimilar market entry, including through workshops and guidance to facilitate product development; initiatives to improve the quality of applications and enhance the efficiency of review by the FDA; and efforts to reduce “gaming” that delays competition and extends monopolies beyond what Congress intended. The agency has issued policy documents designed to ensure timelier generic drug approvals and earlier patient access by reducing the number of assessment cycles , facilitating prompt labeling updates , and providing advice on how to avoid common application deficiencies that lead to approval delays.

The FDA approved the first interchangeable biosimilar insulin product last summer, Semglee (insulin glargine-yfgn), which is biosimilar to its reference product, a long-acting insulin analog called Lantus (insulin glargine). As noted in the research discussed earlier, biosimilar and interchangeable products can reduce drug costs significantly, given that biosimilar prices average 15% to 35% less than their reference products.

Legislation remains a critical potential tool in reducing drug prices and costs, and the HHS plan released last fall highlights priorities such as drug price negotiation in Medicare, caps on out-of-pocket costs, and policies to slow price increases over time on existing drugs. While Congress continues to explore legislative options in this area, the Biden administration has been tackling these issues through its available regulatory tools. None is a silver bullet, but collectively they offer the potential for substantial improvements in drug affordability for millions of people in the US. Future research to assess these policies will be critical in efforts to address high drug prices to protect consumers and health care programs more broadly.

Published: August 4, 2022. doi:10.1001/jamahealthforum.2022.3180

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Bush L et al. JAMA Health Forum .

Corresponding Author: Benjamin D. Sommers, MD, PhD, Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201 ( [email protected] ).

Conflict of Interest Disclosures: Dr Sommers reported receiving personal fees from the Health Research and Educational Trust, the Urban Institute, AcademyHealth, the American Economics Journal , and the Illinois Department of Healthcare and Family Services and receiving grants from Baylor Scott & White Health, the Commonwealth Fund, and the Robert Wood Johnson Foundation. No other disclosures were reported.

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Misuse of Prescription Drugs Research Report

About this resource:.

Source: National Institute on Drug Abuse

The last reviewed date indicates when the evidence for this resource last underwent a comprehensive review.

Workgroups: Older Adults Workgroup , Substance Use Workgroup

This report defines misuse of prescription drugs and describes the extent of prescription drug misuse in the United States. It also provides information about the safety of using prescription drugs in combination with other medicines, describes ways to prevent and treat prescription drug misuse and addiction, and lists resources that provide more information. In addition, the report includes information about prescription drug misuse in specific populations, like adolescents and older adults.

Objectives related to this resource (2)

Suggested citation.

National Institutes of Health, National Institute on Drug Abuse. (2020). Misuse of Prescription Drugs Research Report. Retrieved from https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

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How physicians interpret information about prescription drugs in scientific publications vs. promotional pieces

CDER researchers have conducted a randomized study to better understand how physicians make prescribing decisions.

As they make decisions about which drug products should be prescribed to their patients, physicians must process a great deal of relevant information in a limited amount of time. This information is from a wide range of sources, including but not limited to, FDA-approved labeling, peer-reviewed research published in scientific journals, continuing medical education, discussions with colleagues, and clinical practice guidelines. Physicians may also obtain information from drug advertising and promotion, including materials such as sales aids provided in person by sales representatives. CDER researchers recently conducted a randomized controlled study among primary care physicians to better understand how physicians process and interpret information that could guide prescribing decisions, and how such factors as time pressure, whether the information source is promotional in nature, and indicators of methodological rigor (e.g., sample size or duration) may influence physician’s perceptions of a drug product and prescribing.

The design of this study was based on concepts from the field of cognitive psychology and previous work that showed that when given a limited amount of time, people use heuristic or peripheral cues

(mental shortcuts) more than content in making decisions about a message. Over 600 doctors specializing in internal, family, or primary care medicine were asked to answer survey questions about a medical journal abstract describing the results of a clinical trial of a hypothetical diabetes. The physicians were randomly assigned to see the abstract presented in one of three ways: prominently labeled as a journal abstract, a sales aid without graphics, or sales aid with graphics. At two succeeding stages of randomization (Figure 1), physicians saw a version of the text that was either high or low in methodological rigor, and they had either unlimited time or only 30 seconds to view the text. Thus, this 3 x 2 x 2 design led to 12 different conditions to which the physicians could be assigned. Participants were asked a set of questions about their perceptions of the described study, the perceived benefits of the hypothetical drug, its riskiness, and whether they would prescribe it. CDER investigators statistically tested a set of relevant hypotheses about how information source (abstract, or promotion with or without graphics), methodologic rigor, and time pressure (Figure 2) influenced these outcome variables.

Among the main findings of the study were the following:

• Participants who viewed the abstract of the high-methodological rigor clinical study reported more perceived credibility and importance of the data, less need for interpreting the study data with caution, and less bias in the described study than those who viewed a low-rigor study (although there were not significant differences in perceptions of the benefits of using the hypothetical drug).

In discussing these findings, CDER researchers suggested that physicians consider methodological rigor when making decisions. Prominently disclosing information related to the methodological rigor of a study may help the audience form an accurate perception of the strength of the study and the support for claims in promotional communications. To better understand the impact of other advertising content, future research efforts could explore how physicians perceive studies that do not disclose detailed information about methodological rigor. The researchers also proposed that future examination of the role of evidence-based medicine training in physicians’ understanding of promotional materials.

• Study participants who were not under time pressure to read the text rated the fictitious study description as more credible, rigorous, and important, and had more confidence in study data than those who were under time pressure.

According to the authors, these results suggest that time pressure results in decisional caution, and that that future research could explore how selective attention, such as disinterest in a new drug to treat a specific disease, may influence time spent on an information piece. This finding may better explain how time pressure works in real-world scenarios. Additional research could also explore how time pressure when evaluating prescription drug promotional material increases the use of heuristic shortcuts, such as relying on brand names or study funding sources.

• No effects of source type (abstract, or promotion with or without graphics) were observed.

The authors of the study noted that when participants had unlimited time, they rated the information in the medical journal as more credible than they rated the sales aid, but when participants were pressed for time, they did not distinguish between the two. The investigators suggest that future work could also examine how different selection or framing of content may influence perceptions of source (e.g., promotional advertising or academic journal).

How does the source and quality of medical product information impact physician perceptions?

The results of this study suggest that prominently disclosing methodological rigor helps the audience form an accurate perception of the presented information. Further, additional findings showed that promotional communications without graphics that appear to be more closely related to study reprints or summaries may be approached and interpreted with less caution by physicians than promotional communications that fit the classic expectation of “promotion.” This highlights the importance that any promotional communications should be truthful and non-misleading.

Figure 2. study objectives, hypotheses and research questions addressed in the CDER research.

Aikin, Kathryn J., Amie C. O'Donoghue, Stephanie Miles, Maria DelGreco, and Panne Burke. "Physician interpretation of information about prescription drugs in scientific publications vs. promotional pieces." Research in Social and Administrative Pharmacy (2024).

Related Story: Advancing Our Understanding of How Drug Promotion Influences Consumers and Health Care Providers

August 19, 2021

Emerging Drug Trends

• Emerging drugs, which include designer drugs and new psychoactive substances , are substances that have appeared or become more popular in the drug market in recent years.
• Emerging drugs have unpredictable health effects . They may be as powerful or more powerful than existing drugs, and may be fatal.
• Because drug markets change quickly, NIDA supports the National Drug Early Warning System (NDEWS) , which tracks emerging substances. NIDA also advances the science on emerging drugs by supporting research on their use and on their health effects.

What are emerging drugs?

Emerging drugs are mind-altering substances that have become more common in recent years. They may be sold in drug markets or at convenience stores and online. Since 2013, the United Nations Office on Drugs and Crime has identified more than 1,000 emerging drugs worldwide. 1

These substances, which include designer drugs and new psychoactive substances , come from many sources. Some were first developed as potential treatments or research chemicals. Others originate in illicit labs and are created to mimic the effects of drugs regulated under the Controlled Substances Act . These emerging substances often produce similar effects and/or are chemically similar to illegal or prescription opioids, stimulants, benzodiazapines (“benzos”), or other existing types of drugs.

People may seek out these drugs for recreation or use them to self-medicate without medical supervision. They may also be added to other drugs without a buyer knowing it. As a result, the health effects of emerging drugs are largely unknown, potentially posing a public health threat and contributing to the overdose crisis . 2,3

NIDA monitors emerging drug trends through its Designer Drug Research Unit and through support for the National Drug Early Warning System (NDEWS) , which tracks drug-related emergency calls.

What are the effects of emerging drugs?

An emerging drug’s effects depend on the type of substance it is—for instance, if it is a new type of opioid , depressant , synthetic cannabinoid , psychedelic , or stimulant. Its effects may be unpredictable and unwanted, especially if it is an unknown ingredient in another drug. A person may not know what substance or substances they have really taken. And because these substances are new to the drug market, clinicians or researchers may not know their effects or how potent (powerful) they are until people begin to visit emergency departments or clinics with symptoms of negative health effects. 4

In addition, emerging substances are usually not included in emergency department drug tests and are not routinely included in the toxicology tests used after a fatal overdose. The delay in this data means there is also a delay in understanding how widespread use of the drug is, why and how these drugs have their effects, and how to care for people who experience negative effects of those substances.

NIDA researchers and grantees collaborate to identify how these emerging drugs work and their potential health effects, including those that have the potential to impact the overdose crisis. NIDA also supports the National Drug Early Warning System (NDEWS) to track emerging substances and their impact on drug-related emergency calls.

What are nitazenes?

Nitazenes are a class of lab-made (synthetic) opioids that may be as powerful or more powerful than fentanyl. 4   They were developed in research labs in the 1950s as potential pain relievers but never marketed. Nitazenes are most often sold as a white powder or tablets. People may not be aware that they have taken nitazenes, as they may be added to other substances, including fentanyl, heroin, and benzodiazepines. 5

Nitazenes began to re-emerge in the drug supply in 2019, after the U.S. Drug Enforcement Administration banned fentanyl-related substances. 6,7 Researchers and authorities are monitoring nitazenes, including isotonitazene, protonitazene, etonitazene, N-piperidinyl etonitazene, and metonitazene. Many nitazenes are listed as Schedule 1 drugs under the Controlled Substances Act. 

Like all opioids , nitazenes can slow breathing, blood pressure, and heart rate to dangerously low levels, potentially contributing to overdose . Preliminary NIDA-supported research shows that the opioid overdose reversal medication naloxone is effective with isonitazene, metonitazene, and etonitazene, though it may require repeated doses. More research is needed to confirm these findings with additional nitazenes and in larger groups of people. Fentanyl test strips do not detect nitazenes.

What is tianeptine?

Tianeptine is an antidepressant medication that is not approved for use in the United States. NIDA-funded research suggests that most people take tianeptine in dietary supplements marketed as cognitive enhancers or nootropics, often sold in convenience stores and online. It may be blended with or taken at the same time as other nootropics (like phenibut and racetams) and is also used with substances such as kratom , kava, and gabapentin.

Tianeptine is not an opioid but at high doses it can have opioid-like effects, such as dangerous drops in blood pressure, heart rate, or breathing rate. Research shows that other effects include problems with brain, heart, and digestive function.

Research has shown that tianeptine can cause symptoms of a substance use disorder, including tolerance—which is when you need to take more of a drug for it to have the same level of effect—and withdrawal. Withdrawal from tianeptine has been associated with pain and problems with brain, heart, and digestive function. Early evidence suggests that tianeptine-related substance use disorder can be treated with medications for opioid use disorder , such as buprenorphine. 8

What are new psychoactive substances?

“New psychoactive substances” is a term used to describe lab-made compounds created to skirt existing drug laws . The category may include medications created by pharmaceutical companies or researchers that were never meant to reach the public .

These substances belong to a number of drug classes:

• Synthetic opioids. These drugs are chemically different from existing lab-made opioids like fentanyl . They include brorphine and U-47700. Researchers first identified brorphine in the unregulated drug supply in 2018. New synthetic opioids may slow breathing, blood pressure, and heart rate to dangerously low levels, potentially contributing to overdose. Emerging opioids can be as powerful or more powerful than fentanyl, which itself is 50 to 100 times more powerful than morphine.
• Synthetic cannabinoids , sometimes called “K2” or “Spice.” Lab-made cannabinoids are chemically similar to the cannabis plant but may have very different effects. Newer synthetic cannabinoids include ADMB-5,Br-BUTINACA and MDMB-4en-PINACA. MDMB-4en-PINACA has been associated with hallucinations, paranoia, and confusion. These substances have been found in people who died from accidental overdose. 9
• Synthetic cathinones , also known as “Bath Salts.” Lab-made cathinones are stimulants that are chemically related to, but not derived from, the khat plant. People sometimes take synthetic cathinones as a less expensive alternative to other stimulants, but cathinones have also been found as an added ingredient in other recreational drugs. Emerging cathinones include eutylone, N,N-dimethylpentylone (dipentylone), and pentylone. These substances have been found in people who died from overdose. 3
• Synthetic benzodiazapines. Benzodiazapenes are a class of lab-made depressants that include prescription medications such as diazepam (sometimes sold as Valium), alprazolam (sometimes sold as Xanax), and clonazepam (sometimes sold as Klonopin). Recent data show that new versions of recreationally manufactured bezodiazapines include bromazolam, disalkylgidazepam, and flubromazepam. 10

How does NIDA support research into emerging drugs?

NIDA supports research tracking the emergence of new drugs into the unregulated drug supply, including via the National Drug Early Warning System (NDEWS) , collaboration with other researchers, partners around the world, and social media. The Institute studies or supports research on changes in the lab-made drug supply and how these emerging substances work in the brain, as well as their health effects and potential as therapeutic treatments.

NIDA also researches ways to prevent substance use and misuse , and studies whether and how harm reduction methods may prevent, reverse, or reduce rates of overdose.

Latest from NIDA

Law enforcement seizures of psilocybin mushrooms rose dramatically between 2017-2022

Can science keep up with designer drugs?

Xylazine appears to worsen the life-threatening effects of opioids in rats

Find more resources on emerging drugs.

• See recent data on Overdose Rates from the Centers for Disease Control and Prevention (CDC). 
• Stay up to date on new and emerging substances at the National Drug Early Warning System website
• Early warning advisory on new psychoactive substances. United Nations Office on Drugs and Crime. Accessed April 15, 2024. https://www.unodc.org/LSS/Page/NPS
• Singh VM, Browne T, Montgomery J. The emerging role of toxic adulterants in street drugs in the US illicit opioid crisis . Public Health Rep . 2020;135(1):6-10. doi:10.1177/0033354919887741
• Gladden RM, Chavez-Gray V, O'Donnell J, Goldberger BA. Notes from the field: overdose deaths involving eutylone (psychoactive bath salts) - United States, 2020 . MMWR Morb Mortal Wkly Rep . 2022;71(32):1032-1034. Published 2022 Aug 12. doi:10.15585/mmwr.mm7132a3
• Pergolizzi J Jr, Raffa R, LeQuang JAK, Breve F, Varrassi G. Old drugs and new challenges: A narrative review of nitazenes . Cureus . 2023;15(6):e40736. Published 2023 Jun 21. doi:10.7759/cureus.40736
• Ujváry I, Christie R, Evans-Brown M, et al. DARK classics in chemical neuroscience: Etonitazene and related benzimidazoles . ACS Chem Neurosci . 2021;12(7):1072-1092. doi:10.1021/acschemneuro.1c00037
• Benzimidazole opioids, other name: nitazenes. Drug Enforcement Agency. Issued January 2024. Accessed April 15, 2024. https://www.deadiversion.usdoj.gov/drug_chem_info/benzimidazole-opioids.pdf
• Papsun DM, Krotulski AJ, Logan BK. Proliferation of novel synthetic opioids in postmortem investigations after core-structure scheduling for fentanyl-related substances . Am J Forensic Med Pathol . 2022;43(4):315-327. doi:10.1097/PAF.0000000000000787
• Trowbridge P, Walley AY. Use of buprenorphine-naloxone in the treatment of tianeptine use disorder . J Addict Med . 2019;13(4):331-333. doi:10.1097/ADM.0000000000000490
• Simon G, Kuzma M, Mayer M, Petrus K, Tóth D. Fatal overdose with the cannabinoid receptor agonists MDMB-4en-PINACA and 4F-ABUTINACA: A case report and review of the literature . Toxics . 2023;11(8):673. Published 2023 Aug 5. doi:10.3390/toxics11080673
• Ehlers PF, Deitche A, Wise LM, et al. Notes from the field: Seizures, hyperthermia, and myocardial injury in three young adults who consumed bromazolam disguised as alprazolam - Chicago, Illinois, February 2023 . MMWR Morb Mortal Wkly Rep . 2024;72(5253):1392-1393. Published 2024 Jan 5. doi:10.15585/mmwr.mm725253a5

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Substance Abuse and Public Health: A Multilevel Perspective and Multiple Responses

Substance abuse has been a thorny public health concern throughout human history. Manifestly, prevention and treatment are the two main strategies commonly adopted to tackle the problem of substance abuse. They are in fact cross-disciplinary, and they relate to the various domains of heredity, biology, psychology, cognitive science, family, social development and cultural structures. This special issue, “Substance Abuse, Environment and Public Health,” has published empirical studies from different regions and countries globally to enhance the international exchange of latest views and findings on the etiology, processes and influences of substance abuse across different domains, through which a multilevel perspective is considered more helpful for analyzing its complex nature, courses and consequences. This in turn suggests the possible need to employ multiple responses dynamically and integratively in the prevention and treatment of substance abuse.

1. Introduction

It is apparent that substance abuse is a cross-disciplinary topic of research and concern [ 1 , 2 ], which involves the need to employ concomitantly various theoretical explications and empirical evidence in collaborative efforts to strive for more optimal solutions to limit its contagiousness, and to curb any direct and indirect harm [ 3 , 4 ]. Substance abuse has been described as a “chronic relapsing disease”, with extremely high relapse rates that range from 56.8% to 81.8% [ 5 , 6 ]. Recently, the United Nations reported that “(i)n 2017, an estimated 271 million people, or 5.5 per cent of the global population aged 15–64, had used substances in the previous year” ([ 7 ], p.7). This is 11.5% higher than the estimated number of substance-using people in 2012 [ 8 ]. Due to the nature of recurrence and the rising number of substance users globally, a continuing upsurge in human, social, health and economic costs in the form of substance-related violence, criminal acts, health care needs, legal orders, rehabilitative services, reduced labor productivity and judicial expenditure is evident [ 4 , 6 , 9 ]. Undoubtedly, prevention and treatment are two main intervention approaches that have been commonly adopted to tackle substance abuse [ 2 , 10 ], in which the former focuses primarily on enhancing public awareness of the dangers of substance misuse and addiction, and the latter mainly emphasizes helping substance abusers to attain complete abstinence and avoid relapse. Both prevention and treatment of substance abuse are pertinent to public health, as the two approaches need to employ a multilevel perspective to conceptualize and solve fallout generated from drug trafficking, misuse and harm [ 11 , 12 ]. This points to the need to investigate human hereditary, biological, and psychological needs, cognitive and mental conditions, social development and cultural structures simultaneously and interactively.

For a comprehensive understanding of the nature, processes and impact of substance abuse on human individuals and societies as a whole, an international exchange of the latest scholarly views and empirical research findings is needed. This special issue, “Substance Abuse, Environment and Public Health,” aims to promote international exchange of empirical academic works on substance abuse and its related concerns. It includes 14 empirical research articles and one intervention paper from Bosnia, Croatia, Hong Kong, Italy, mainland China, Norway, Poland, Singapore, South Korea, Spain, Slovenia, Sweden and the United States, and covers the topics of substance misuse and addiction amongst various social groups, different types and forms of illicit and legally approved substances and multiple research methods and designs. Importantly, the scholarly works published in this special issue are expected to present an opportunity to enhance the international exchange of cross-disciplinary research and academic inquiries in the prevention and treatment of substance abuse.

2. Substance Abuse and Different Social Groups

When researching substance abuse and its harmful effects, researchers predominantly focus on certain social groups with a higher tendency towards substance taking and misuse, such as adolescents and male adults [ 13 , 14 , 15 , 16 , 17 , 18 ]. This is valid, as they may encounter various demanding life and social challenges, expectations, interpersonal alienation and biological impulses, all of which are relevant to the triggering of their initiation into drug experimentation as a form of self-medication. Substances may also act as a comforting “soul mate” to help users evade hard realities [ 19 , 20 ]. In this special issue, Zubak et al. [ 21 ] examined the effects of scholastic factors—for example, grade point averages, school and other unexcused absences and poor behavior—in relation to illicit drug misuse (IDM) and its initiation among adolescents in Bosnia and Herzegovina. Jee et al. [ 22 ] investigated the trajectories of different smoking groups of young South Korean male adults and the implication of the habit in their atherosclerotic cardiovascular disease (ASCVD) in middle age. However, substance takers are never restricted to any specific social groups; they can be found in communities of professionals, social talents, elders and university students. Devcic et al. [ 23 ] examined socio-demographics, sports-related factors, factors of hesitation, doping-related factors, consumption of dietary supplements, knowledge of doping and predictors of doping behavior in terms of misusing performance-enhancing substances among high-level competitive swimmers in Slovenia. Wang et al. [ 24 ] investigated how gender, residential areas and study majors were related to misconceptions about antibiotic use among Chinese university students, which in turn linked to their antibiotic misuse behavior. Through the use of a community-based participatory research design, Walter et al. [ 25 ] inquired how work-related musculoskeletal disorders (MSDs) and injuries among US fishing industry workers affected their use of prescription opioids to treat their pain, which in turn exposed them to increased risk of developing substance disorders. Apparently, different social groups are equally susceptible to the risk of substance abuse and addiction [ 3 , 4 , 12 ], and this is likely to be affected by their specific personal characteristics and environmental conditions. Hence, there is a need for researchers to discover both common and unique precursors germane to different social groups which lead to their substance using behavior.

3. Substance Abuse and Its Types and Forms

Substances that are misused or abused can be categorized into two forms. These include illicit and legally approved substances of various types. The most common illicit types of substances include cannabis, amphetamines, ketamine, methamphetamines, cocaine, ecstasy and heroin [ 2 , 6 ], which are largely banned in most countries. However, marijuana products have recently been legalized and commercialized in some northern American and Western states and regions under the umbrella of “control of reasonable use,” which casts a contemplative doubt over the original intent of reducing cannabis-related criminality and public health problems; hence, more research is needed on this subject [ 26 , 27 , 28 ]. Tobacco and alcohol are two legally approved types of substances that have been widely used by different social groups across different societies and cultures [ 6 , 11 , 29 ]. Some legally prescribed drugs, such as cough medications and the antibiotics mentioned above, can also be easily misused and abused by the general public, and these too merit the further attention of researchers [ 2 , 30 ].

In this special issue, Lo et al. [ 31 ] explored how far using illicit drugs, smoking cigarettes and drinking alcohol predicted sexual misconduct among Macau youths, while simultaneously adjusting for the effects of susceptibility to peer influence and school attachment/commitment. Assari et al. [ 32 ] attempted to assess the impact of subjective and objective socioeconomic status on the cigarette smoking and alcohol use of older African Americans by controlling the effects of pertinent covariates, which included demographic factors (age and gender), living arrangement and family type, health insurance status, chronic medical conditions, self-rated health, sick days, depression and chronic pain. Muller et al. [ 33 ] investigated changes in exercise and nicotine use among 1464 Norwegian prison inmates by classifying them into harmful and non-harmful substance use pre-incarceration groups, according to the Drug Use Disorders Identification Test (DUDIT) and the Alcohol Use Disorders Identification Test (AUDIT), both of which are commonly used by healthcare practitioners and researchers to assess the severity of illicit drug and intoxicant use. Wang et al. [ 34 ] analyzed the sources of antibiotics leftovers in the home and the risk factors of keeping them in relation to antibiotic self-medication among Chinese university students. Taken together, the relationships between the use of illicit drugs and legally approved substances are complex and intertwined or mutually reinforcing [ 35 , 36 ]. They may be affected by the personal circumstances and environmental conditions of the abusers, and may cause other forms of behavioral maladjustment [ 17 , 37 , 38 ]. Nevertheless, our current understanding of this complicated phenomenon of substance abuse is limited, and so more cross-disciplinary research is again recommended.

4. Researching Substance Abuse: Methods and Designs

As has been mentioned, substance abuse is a public health concern that involves human biological and physical needs, psychosocial demands, cognitive and spiritual fulfillment, and environmental formulations. Therefore, cross-disciplinary research using different methodologies and designs is much needed to scrutinize substance abuse in respect of etiology, maintenance, consequences, abstinence and relapse. Generally speaking, empirical studies using quantitative methods are more common than research involving qualitative inquiry, analysis of secondary data and/or documentary inspection [ 16 , 39 , 40 ]. In fact, research based on a range of methods and designs is useful in enhancing our comprehension of the nature and impact of substance abuse from different perspectives. This special issue incorporates empirical studies conducted by quantitative, qualitative and documentary methods. For quantitative research designs, study findings based on a representative sample or any of the random sampling procedures are desirable, and can strengthen empirical evidence and provide greater external validity [ 41 ]. For example, Oh et al. [ 42 ] investigated whether those who had current or previous experience of facial flushing would drink for different primary reasons, compared with those who had no experience of facial flushing. The sample comprised 4590 college students who were recruited by stratified random sampling procedures proportionately in 82 colleges in South Korea. There are other empirical studies in this special issue that similarly used a representative sample [ 21 , 24 , 31 , 34 ]. However, using quantitative methods to survey empirically the attitudes and behaviors of certain health and human service professional groups is less likely to require a representative sample, and so it is necessary to use non-probabilistic sampling procedures such as quota, purposive or snowballing sampling designs. Molina-Mula et al. [ 43 ] analyzed the attitudes and perceptions of emergency and mental health nurses with regard to alcoholics. Their findings will hopefully help to develop appropriate professional and clinical responses to substance abuse.

Qualitative research methods can help reveal in-depth and formative information related to the processes and development of substance abuse. For their qualitative study, Chan et al. [ 44 ] interviewed 67 drug abusers to explore how their psychological experiences—with special emphasis on interpersonal relatedness—affected their drug taking and relapse behaviors. Walter et al. [ 25 ] used qualitative interviewing to examine knowledge of and attitudes towards opioid use among 21 fishing industry workers in the US. In addition, use of secondary data or documentary information can efficiently and objectively assist in the transition processes of substance users. For example, Asharani et al. [ 45 ] employed and analyzed recorded data from the Registry of Birth and Death, Immigration and Checkpoint Authority of Singapore to investigate the unnatural deaths of 42 treatment seekers of substance addiction between 2011–2015. Their findings provide evidence of the lethal consequences of substance abuse in an unobtrusive manner. Moreover, Chmielowiec et al. [ 46 ] examined the relationship between the mesolimbic dopamine system and addiction in a group of 299 addicted subjects and another group of 301 non-addict controls by analyzing two polymorphisms in their genes (a variable number of tandem repeats in DRD4 and DAT1), which are mainly responsible for dopaminergic transmission, representing a human reward system that is closely related to substance abuse and misuse. It is clear that research using different methods and designs is useful in fortifying and enhancing currently established concepts and knowledge of substance abuse. Therefore, more novel research methods and designs should be encouraged, so that patterns of substance abuse can be more efficiently dissected.

5. Conclusions

Substance abuse has been an issue of public health for hundreds of years [ 47 ]. Nevertheless, professionals and researchers of different domains tend to adopt a one-dimensional view based on their particular expertise when examining, explaining and trying to find solutions to this complex problem [ 10 , 48 , 49 ]. Thus, various and often competing perspectives rooted in the paradigms of heredity, biology, psychology, cognitive science, family, social development and cultural structures can exist simultaneously, thereby unwittingly compounding the problem [ 1 , 2 , 39 , 50 ]. However, as substance abuse is composed of layers of individual development, family and social influences, cultural values and environmental conditions, a multilevel perspective is needed to analyze its etiology, maintenance and consequences. Various theories and models from different scholarly paradigms at different levels of social systems should be employed concomitantly to help examine and resolve the issues as part of a dynamic and comprehensive process [ 2 , 3 , 12 ]. Employing such a multilevel perspective requires researchers and practitioners to explore the interaction of hereditary, physical, psychological, cognitive, mental, family, social, cultural and environmental factors, and to show exactly how such synergy leads to and/or maintains substance use and addiction. Doing so will help in the design of improved multiple responses to the fallout from substance abuse.

As substance abuse is never limited to particular social groups in human societies, it is essential to understand the unique psychological, personality, cognitive, socioeconomic, familial and cultural differences of various social groups, and to explore what common and unique characteristics they hold in terms of the initiation, processes and consequences of substance abuse [ 4 , 6 ]. If researchers, service practitioners, educators and policy makers were able to understand the common and unique etiological causes and stimulants that incur experimentation and the subsequent maintenance of substance abuse, more effective prevention and treatment strategies and programs could be introduced. Furthermore, because each society or nation is comprised of multiple differing social groups, a knowledge and understanding of their unique cultural and ethnic structures would be empirically useful for researchers trying to unearth the common and distinct etiological causes and stimulants of substance use and abuse. This is a largely unchartered area of research.

The abuse of different types and forms of substances may generate different levels of addiction and harm [ 2 , 51 ], which in turn may trigger distinct social maladjustment and craving behaviors [ 12 , 52 ]. Therefore, future research should discern and clarify the effects of different types and forms of substances on the progress, abstinence and relapse of addicts; this would lead to a better comprehension of the nature and impact of substance abuse. Quantitative methods and designs should be adopted to this end, in addition to other methods and designs that will broaden our perspectives on the topic. In other words, future addiction research should consider the employment of mixed-method designs to investigate the nature of different types and forms of substances and their effects on different social groups. Furthermore, the interaction between the biological, individual, family, social and cultural factors that lead to substance abuse is worthy of research, but will require more advanced methodological designs and mathematical and statistical procedures.

The processes and consequences of substance abuse can be seen to evolve in step with social, technological and cultural developments [ 4 , 39 ]. The patterns and forms of substance abuse can vary according to different social groups. Therefore, comparative and longitudinal research is more useful and insightful in helping to reveal its precarious and dynamic influences. In fact, polysubstance abuse—in which substance addicts expect to achieve higher substance-synergy effects of enjoyability by simultaneously abusing multiple types of drugs and substances—has become more common in the past decade [ 53 , 54 ]. This apparently presents an even greater challenge to treatment and healthcare services. In the face of this new phenomenon, the role of empirical research becomes more pivotal in helping to configure effective approaches and solutions.

In conclusion, substance abuse has long been a thorny public health problem, and it continues to evolve. Multiple responses supported by the employment of a multilevel research perspective are needed. Cross-disciplinary collaboration and concerted research are urgently required if we are to optimize our current strategies and remediation.

Author Contributions

T.W.L., J.W.K.Y., and C.H.L.T. conceived the topic for the Special Issue and were the guest editors. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

'Drug Take Back Day' is Saturday: Check for Leftover Opioids in Your Home

'Drug Take Back Day' is Saturday: Check for Leftover Opioids in Your Home

By Ernie Mundell HealthDay Reporter

FRIDAY, April 26, 2024 (HealthDay News) -- Each year, thousands of Americans head home after a surgery clutching prescription opioids to help ease post-surgical pain.

Trouble is, most won't use all those pills, and that could lead to a lot of misuse and addiction, one study found.

And with National Prescription Drug Take Back Day slated for Saturday, it's time yet again to raise awareness, one expert said.

“While the larger battle against opioid misuse rages on, let’s not overlook the simple steps that can be taken post-surgery to prevent these powerful drugs from becoming a public health hazard by employing safer storage strategies," said study co-author Dr. Asif Ilyas .

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"It’s time to ensure that the aftermath of surgical recovery doesn't inadvertently fuel the crisis we’re trying so desperately to quell," said Ilyas, who is president of the Rothman Orthopaedic Institute Foundation for Opioid Research & Education. The foundation is dedicated to finding solutions to the epidemic of opioid abuse.

In the study , Ilyas and his colleagues surveyed 469 adults who'd been discharged with a prescription opioid following an orthopedic surgery.

The results suggest there are a lot of unused, highly addictive opioids lying around in American homes.

“Nearly every statistic from this study is a call to action," Ilyas said in a foundation news release.

"A staggering 94% of patients had leftover opioids post-surgery," he noted. "While some might see this as a testament to the effectiveness of modern pain-management techniques, it also underlines a massive surplus of potent drugs ripe for potential misuse or diversion."

More than two-thirds (68%) of patients said they had disposed of these excess opioids, but their means of doing so varied greatly. Pharmacies were the preferred locale to dispose of unwanted opioids, the survey found.

“But it's not just about disposal," added Ilyas, who is also a professor of orthopaedic surgery at Thomas Jefferson University in Philadelphia.

"Alarmingly, 86% of patients stored their opioids in unlocked locations," he noted. "This casual storage approach can turn homes into inadvertent hubs for drug diversion, especially given that these powerful medications are often kept in easily accessible places like bathrooms and kitchens. This statistic should be particularly unsettling for anyone with teenagers or frequent guests."

On Saturday's National Prescription Drug Take Back Day , the Drug Enforcement Agency works with police departments, hospitals and other safe disposal sites to rid homes of dangerous drugs.

But having events like these "one or two days a year isn’t enough," Ilyas stressed. "The conversation must be ongoing, emphasizing the dangers of misuse and the importance of secure storage and proper disposal."

Patients may also need even more robust counseling on the use and dangers of misuse of any opioids they bring home, he added.

More information

Find out more about the safe use of opioid painkillers at Medicare.gov .

SOURCE: Rothman Orthopaedic Institute Foundation for Opioid Research & Education, news release, April 8, 2024

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Prescription Drug Coverage and Elderly Medicare Spending

The introduction of Medicare Part D has generated interest in the cost of providing drug coverage to the elderly. Of paramount importance -- often unaccounted for in budget estimates -- are the salutary effects that increased prescription drug use might have on other Medicare spending. This paper uses longitudinal data from the Medicare Current Beneficiary Survey (MCBS) to estimate how prescription drug benefits affect Medicare spending. We compare spending and service use for Medigap enrollees with and without drug coverage. Because of concerns about selection, we use variation in supply-side regulations of the individual insurance market -- including guaranteed issue and community rating -- as instruments for prescription drug coverage. We employ a discrete factor model to control for individual-level heterogeneity that might induce bias in the effects of drug coverage. Medigap prescription drug coverage increases drug spending by $170 or 22%, and reduces Medicare Part A spending by $350 or 13% (in 2000 dollars). Medigap prescription drug coverage reduces Medicare Part B spending, but the estimates are not statistically significant. Overall, a $1 increase in prescription drug spending is associated with a $2.06 reduction in Medicare spending. Furthermore, the substitution effect decreases as income rises, and thus provides support for the low-income assistance program of Medicare Part D.

This research was supported by the Hagopian dissertation award and the Bing Center for Health Economics.. The views expressed herein are those of the author(s) and do not necessarily reflect the views of the National Bureau of Economic Research.

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