Introduction

Prescription drugs play an important role in U.S. health care. For millions of Americans, prescription drugs have saved lives, prevented or delayed the onset of chronic disease and disability, controlled or cured disease, and provided relief from pain (25). In 2007–2010, almost one-half of the U.S. population took at least one prescription drug in the preceding month and 1 in 10 reported taking five or more drugs (Table 93; data are for the civilian noninstitutionalized U.S. population only). Americans' use of prescription drugs has grown over the past half-century due to many factors, including the development of new and innovative drug therapies to treat infectious and chronic conditions, the expansion of prescription drug coverage by public and private payers, and the growth of marketing by pharmaceutical companies (25–27).

The introduction and widespread use of vaccines in the 20th century contributed to the control of infectious diseases such as measles, polio, and diphtheria, and the discovery of antibiotics led to significant declines in mortality from bacterial infections (28). By 2010, only pneumonia and influenza remained among the leading causes of death, accounting for just 2.0% of all U.S. deaths (Table 22). Newer drugs also help in the control of infectious disease. With the adoption of antiretroviral therapies, the death rate from human immunodeficiency virus (HIV) disease has decreased almost 80% since 1996 (Table 31 and Figure 24).

With the decline of infectious disease morbidity and mortality in the United States, prescription drug development and investment in the second half of the 20th century focused on chronic diseases such as cancer, heart disease, diabetes, and mental health. Drugs to treat these chronic conditions were among the most commonly used by adults (Figure 21) (29). The widespread use of chemotherapy and other biologics contributed to raising the 5-year, all-sites cancer survival rates to 67% in 2009 (30). Drug research has also led to better treatment and control of the risk factors for heart disease, such as hypertension, high cholesterol, and diabetes (6,31–34). The percentage of Americans with poor control of blood pressure, cholesterol, and diabetes is down since 1988–1994 (Tables 46, 65, and 66). Prescription drugs are an important component in the treatment of mental health disorders and have helped many patients avoid hospitalization (35,36). About 85% of people who received treatment for mental health conditions in 2009 received prescription drugs.

Several other factors have contributed to Americans' greater use of prescription drugs. These include the growth of third-party insurance coverage over the past few decades, which has made drugs more affordable (37,38). In 2006, Medicare Part D was introduced, offering a drug benefit as part of the insurance program relied on by most persons aged 65 and over. Discounts and other savings under the Affordable Care Act have already helped more than 6 million Medicare Part D enrollees save over $6 billion on prescription drugs since its introduction in 2010 (39). Another factor increasing the demand for drugs is more drug marketing to physicians and consumers since companies began promoting their prescription drug products directly to consumers by means of direct-to-consumer advertising in the 1980s. Although the vast majority of promotional spending for all drugs is targeted toward physicians, spending on direct-to-consumer advertising for all drugs more than tripled between 1996 and 2005, to $4.2 billion (40–42).

The greater role of prescription drugs in U.S. health care is reflected in the amount spent on drugs: $263 billion in 2011. This was 9.7% of all national health expenditures, up from 5.6% in 1990 (Table 114). From 1990 to 2000, prescription drug spending grew 11.6%—much faster than spending for hospital (5.2%) and physician and clinic (6.2%) care (Table 114). In response, many insurers instituted cost control efforts, including copays, cost-sharing, formularies, tiered pricing, and mail order pharmacies (43). These efforts, along with other factors including the ending of patent protection for a number of popular drugs, has led to slower growth in prescription drug spending in recent years (44). During 2009 through 2011, spending on prescription drugs remained flat (Table 114).

Although prescription drugs have been instrumental in improving health outcomes, misuse of some prescription drugs has resulted in serious public health problems. For example, antibiotics continue to be prescribed to treat viral infections, even though they are ineffective for this purpose. This misuse contributes to the development of antibiotic-resistant bacterial infections (45,46). Educational outreach to physicians and patients has helped decrease the use of antibiotics for colds and other viral conditions (Figure 26). Opioid analgesic pain relievers play an important role in appropriate pain management, but their misuse is a growing public health problem (47). Opioid analgesic consumption increased 300% between 1999 and 2010 (48), and death rates for poisoning involving opioid analgesics more than tripled between 2000 and 2010 (Table 32 and Figure 28) (49,50).

This Special Feature examines the use of prescription drugs in the United States. Data are presented on the number and classes of drugs used by Americans. Access problems—those who did not get prescription drugs in the past 12 months due to cost—are presented by insurance and poverty status. The impact of specific groups of drugs used to control chronic disease (i.e., antiretrovirals to treat HIV disease and antidepressant drugs) is presented. Quality issues are examined by looking at the misuse of antibiotics to treat cold symptoms; deaths from misuse of opioid analgesic drugs; and the adoption of electronic health record systems by providers, which may be used for ordering prescription drugs, providing warnings of drug interactions or contraindications, and other functions intended to improve safety. And finally, the growth in national spending on prescription drugs is shown. This group of charts provides an overview of the role of prescriptions drugs in the United States.

Prescription Drug Use

In 2007–2010, almost one-half of all Americans reported taking one or more prescription drugs in the past 30 days; use increased with age, from 1 in 4 children to 9 in 10 persons aged 65 and over.

Drugs are a frequently used therapy for reducing morbidity and mortality and improving the quality of life of Americans (29,51). In the past half-century, Americans' use of prescription drugs has increased (26,27). Prescription drug use is related to many factors, including health status, prescription drug coverage, and the availability of drug therapies. For many conditions, such as high cholesterol, high blood pressure, diabetes, and asthma, emphasis on treatment with evidence-based medications has increased (6,32–34,37,38).

Between 1988–1994 and 2007–2010, the percentage of Americans who reported taking no prescription drugs in the past 30 days decreased from 60.9% to 52.5%. The percentage taking five or more drugs in the past month increased from 4.0% in 1988–1994 to 10.1% in 2007–2010 (age-adjusted).

In 2007–2010, prescription drug use was higher among older age groups. About one-quarter of children (23.2%) reported taking one to four drugs in the past 30 days, compared with one-half (49.4%–50.0%) of adults aged 45 and over. The percentage taking five or more drugs in the past 30 days increased with age, from less than 1.0% of children to 39.7% of adults aged 65 and over.

Figure 20

Prescription drug use in the past 30 days, by number of drugs taken and age: United States, 1988–1994 through 2007–2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig20 NOTES: Except for age group estimates, percentages (more...)

Prescription Drug Use by Drug Class

In 2007–2010, cardiovascular agents (used to treat high blood pressure, heart disease, or kidney disease) and cholesterol-lowering (antihyperlipidemic) drugs were two of the most commonly used classes of prescription drugs among adults aged 18–64 and 65 and over.

Drugs increasingly play a role in the long-term treatment and control of chronic conditions, including hypertension, high cholesterol, and diabetes, which are major risk factors for heart disease (6,31–34). In 2007–2010, 17.7% of adults aged 18–64 took at least one cardiovascular agent in the past 30 days (29). Other commonly used prescription drug classes among this age group were cholesterol-lowering drugs, analgesics, and antidepressants. The use of cholesterol-lowering drugs among those aged 18–64 has increased more than six-fold since 1988–1994, due in part to the introduction and acceptance of statin drugs to lower cholesterol.

Among adults aged 65 and over, 70.2% took at least one cardiovascular agent and 46.7% took a cholesterol-lowering drug in the past 30 days in 2007–2010. Other commonly used classes for this age group include anti-acid reflux, antidiabetics, anticoagulants, and analgesics. The use of cholesterol-lowering drugs by this age group has increased more than seven-fold since 1988–1994. The use of antidepressants (4.6 times greater), anticoagulants (3.0 times greater), and anti-acid reflux drugs (2.9 times greater) also increased substantially between 1988–1994 and 2007–2010.

Figure 21

Prescription drug use in the past 30 days among adults aged 18 and over, by age and selected drug class: United States, 1988–1994 and 2007–2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig21 NOTES: Cardiovascular (more...)

Polypharmacy

In 2007–2010, adults taking five or more drugs in the past 30 days were more likely to be aged 65 and over and in fair or poor health than those taking one to four drugs.

Drugs offer the opportunity to prevent, treat, and control many acute and chronic conditions. As Americans rely more on prescription drugs, some are taking multiple drugs each month. This is known as polypharmacy, which may increase the likelihood of drug interactions, adverse effects, and dosing and compliance issues. In some cases, multiple physicians may be prescribing for the patient and be unaware of all drugs the patient is taking. Polypharmacy is important because patients taking multiple drugs are more likely to confuse medication, dose, and timing (52,53). Polypharmacy is of particular concern for the elderly, who may be more at risk for significant side effects with some commonly prescribed medicines (54). In 2007–2010, 13.9% of Americans aged 18 and over took five or more prescription drugs in the past 30 days (Figure 20) (55).

In 2007–2010, adults taking five or more drugs in the past 30 days were older, with 10.8% aged 18–44, 41.7% aged 45–64, and 47.5% aged 65 and over. Among those taking one to four drugs, 40.7% were aged 18–44, 39.8% were 45–64, and 19.5% were 65 and over. Adults taking five or more drugs were more likely to classify themselves as in fair or poor health (39.6%) compared with those taking one to four drugs (14.3%). Adults taking no drugs in the past 30 days were younger (69.2% were aged 18–44, 26.9% were 45–64, and 3.9% were 65 and over) and reported better health status (12.5% reported fair or poor health and 49.7% reported excellent or very good health) (see data table for Figure 22).

Figure 22

Number of prescription drugs taken in the past 30 days among adults aged 18 and over, by selected characteristics: United States, 2007–2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig22 * Estimate is considered unreliable. (more...)

Nonreceipt of Needed Prescription Drugs Due to Cost

In 2012, adults aged 18–64 who were uninsured for all or part of the past year were more than four times as likely to report not getting needed prescription drugs due to cost as adults who were insured for the whole year.

Uninsured adults are more likely to delay or forego needed care, are less likely to receive needed medical care and prescription drugs due to cost, and are less likely to seek preventive care than the insured (20,56). Evidence suggests that underuse of medications due to cost concerns is associated with poorer health and increased use of other health care services (57,58).

During 2002 through 2012, the percentage of adults aged 18–64 who did not get prescription drugs in the past 12 months due to cost was at least four times as high for those who were uninsured for all or part of the past year as for those who were insured for the whole year. In 2012, 22.4% of uninsured adults aged 18–64 reported not getting needed prescription drugs due to cost, compared with 5.0% of adults who were insured for the whole year.

In 2011–2012, prescription drug access problems due to cost decreased as family income increased for both the insured and uninsured. Among adults insured for the whole year, those with family income levels below 200% of the poverty level were more likely to report problems getting needed prescription drugs due to cost than those with higher incomes. Among those uninsured for any part of the past year, access problems due to cost declined as family income increased. Of those living below the poverty level, 30.7% reported not getting needed prescription drugs due to cost, compared with 23.2% of those at 100%–199% of the poverty level, 19.4% of those at 200%–399% of the poverty level, and 14.9% of uninsured adults with incomes at 400% or more of the poverty level. The uninsured with high incomes (400% or more of the poverty level) were more likely to report prescription drug access problems (14.9%) than the insured with low incomes (below 200% of the poverty level) (10.8%–11.5%).

Figure 23

Nonreceipt of needed prescription drugs in the past 12 months due to cost among adults aged 18–64, by insurance status and percent of poverty level: United States, 2002–2012. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig23 (more...)

Deaths from HIV Disease

The introduction of highly active antiretroviral therapy (HAART) led to substantial declines in mortality from HIV disease, including a 73% decline among non-Hispanic white males and a 54% decline among non-Hispanic black males between 1995 and 1997.

Human immunodeficiency virus (HIV) disease, and the related acquired immunodeficiency syndrome (AIDS), emerged as a leading cause of death among adults aged 25–44 in the United States in the 1980s (59), and the death rate for HIV disease among this age group increased steadily through the early 1990s (60). During the early years of HIV, there were few treatment options and mortality was high (61,62). The first antiretroviral medication to treat HIV disease was approved in 1987 (62) and was soon followed by the introduction of other antiretroviral drugs. The health of individuals living with HIV improved when clinicians began to treat individuals with combinations of multiple antiretroviral drugs that act at different stages of the HIV disease cycle (63)—regimens known as HAART.

After HAART became the standard of care in 1996, there were marked reductions in morbidity and mortality associated with HIV disease (63–67). Between 1995 and 1997, the death rate from HIV disease among males declined by two-thirds, from 27.3 deaths per 100,000 population in 1995 to 9.6 in 1997. The decline ranged from 54% for non-Hispanic black males, to 66% for Hispanic males, to 73% for non-Hispanic white males and Asian or Pacific Islander males (see data table for Figure 24). Declines in HIV death rates also were seen for females in each of the racial and ethnic groups examined. After 1997, the rate of decline for HIV mortality slowed across all groups, although gender and racial and ethnic differences in HIV mortality persist.

Figure 24

Age-adjusted death rates for human immunodeficiency virus (HIV) disease for all ages, by sex and race and Hispanic origin: United States, 1990–2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig24 NOTES: HAART is highly (more...)

Use of Antidepressants

Between 1988–1994 and 2007–2010, among adults aged 18 and over, the use of antidepressants increased more than four-fold, from 2.4% to 10.8%.

Depression is a common and serious illness that takes a toll on functional status, productivity, quality of life, and physical health (35,68–70). In 2009, 7% of adults had a major depressive episode in the past year (35). The increased use of prescription antidepressants may be the result of several factors, including the introduction of a new class of drugs known as selective serotonin reuptake inhibitors (SSRIs) in 1988, improved public attitudes about seeking care for mental health issues, increased direct-to-consumer marketing of antidepressants, and expanded recommendations for the use of antidepressants for conditions other than depression (71). In addition to depression, antidepressants are used to treat obsessive-compulsive disorder, panic disorder, anxiety disorders, and perimenopausal and menopausal symptoms (71).

The use of antidepressants increased more than four-fold for men (from 1.6% to 6.6%, age-adjusted) and women (from 3.2% to 14.8%, age-adjusted) between 1988–1994 and 2007–2010. Increased use of antidepressants during this time period was seen for each of the age groups examined: 18–44, 45–64, and 65 and over.

In 2007–2010, the use of prescription antidepressants was higher among women than among men overall, and for each age group. For both men and women, antidepressant use was higher for those aged 45 and over compared with younger adults. Among men, adults aged 45 and over (8.9%–9.4%) were twice as likely to take antidepressants as younger adults aged 18–44 (4.4%). Among women, those aged 45 and over (17.0%–19.6%) were about 1.5 times more likely to take antidepressants than younger adults aged 18–44 (11.3%).

Figure 25

Use of prescription antidepressants in the past 30 days among adults aged 18 and over, by sex and age: United States, 1988–1994 through 2007–2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig25 NOTE: The 1988–1994 (more...)

Antibiotics Prescribed for Colds

Between 1995–1996 and 2009–2010, the prescribing of antibiotics during ambulatory care visits for cold symptoms declined 39%.

Antibiotics are a mainstay of treating bacterial infections, and the control of infectious diseases using antibiotics is considered one of the major public health achievements of the 20th century (28,46). But unnecessary antibiotic use can lead to adverse effects and contributes to antibiotic resistance, which may lead to longer hospital stays and unnecessary deaths (45,46,72). Of particular concern is the prescribing of antibiotics for colds and viral respiratory infections, because antibiotics are ineffective in treating these conditions (72).

Between 1995–1996 and 2009–2010, the prescribing of antibiotics during ambulatory care visits (to physician offices and hospital outpatient and emergency departments) for the sole diagnosis of cold symptoms has declined by two-fifths, from 44.7% of cold symptom visits to 27.1%. Significant declines were seen for both children and adults over this time frame.

Throughout the time period, prescribing of antibiotics for ambulatory care visits for the sole diagnosis of cold symptoms was higher for visits by adults aged 18 and over than for children. In 2009–2010, 21.5% of ambulatory care visits for cold symptoms among children aged 18 and under had antibiotics prescribed or ordered, compared with 39.5% for adults.

Figure 26

Antibiotics ordered or provided during emergency department, outpatient, and physician visits for cold symptom diagnoses, by age: United States, average annual, 1995–1996 through 2009–2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig26 (more...)

Computerized Systems for Prescription Drugs

In 2010, 53.7% of physician offices, 50.3% of hospital outpatient departments (OPDs), 58.1% of hospital emergency departments (EDs), and 19.7% of residential care facilities (RCFs) reported having computerized prescription ordering systems, a key element of electronic health records (EHRs).

EHRs and e-prescription software are thought to improve caregivers' decisions, coordination of care, health care safety, and patients' outcomes, and to make health care delivery systems more efficient (73,74).

To promote health care providers' adoption of EHRs, the Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments through Medicare and Medicaid to providers who implement EHRs with specific elements that are thought to improve processes and outcomes (73,75). Several of these elements relate to prescription drugs, and in 2010, physician offices, OPDs, EDs, and RCFs were surveyed about their EHR systems, including questions about specific elements related to prescription drugs.

In 2010, about one-half of physician offices and OPDs, 58.1% of EDs, and one-fifth of RCFs reported having a computerized system for ordering prescription drugs. Almost one-half of physician offices (46.0%) and EDs (45.9%), 38.7% of OPDs, and 17.9% of RCFs had a computerized system for warning of drug interactions or contraindications. Almost one-half of physician offices (44.6%), 30.3% of OPDs, 19.7% of EDs, and 8.2% of RCFs could submit prescriptions to the pharmacy electronically. More than one-half of physician offices (51.0%), 56.4% of OPDs, 66.0% of EDs, and 28.3% of RCFs had a computerized system of clinical notes, including a list of patient medications and allergies. In 2010, 33.3% of physician offices, 24.3% of OPDs, 15.7% of EDs, and 3.3% of RCFs had all four of these elements of EHRs.

Figure 27

Computerized systems for prescription drugs, by provider and system type: United States, 2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig27 NOTE: See data table for Figure 27.

Deaths Involving Opioid Analgesics

Drug poisoning deaths involving opioid analgesics among those aged 15 and over more than tripled in the past decade, from 1.9 deaths per 100,000 population in 1999–2000 to 6.6 in 2009–2010 (age-adjusted).

Opioid analgesics are prescription pain relievers, such as oxycodone and hydrocodone, and they play an important role in the appropriate management of both acute and chronic pain, which are often difficult to treat (76). Opioid analgesic consumption increased 300% between 1999 and 2010 (48). Misuse of opioid analgesics is increasingly seen as a significant public health concern because poisoning death rates involving opioid analgesics more than tripled between 2000 and 2010 (Table 32) (47,49,50).

Between 1999–2000 and 2009–2010, among those aged 15 and over, the age-adjusted death rate for poisoning involving opioid analgesics increased from 1.9 deaths per 100,000 population to 6.6. Poisoning death rates involving opioid analgesics in the past decade increased for both males and females, for all age groups aged 15 and over, and for all racial and Hispanic origin groups examined.

In 2009–2010, among racial and Hispanic origin groups, the death rate for non-Hispanic white persons aged 15 and over was highest, at 8.9 deaths per 100,000, followed by the rate among the American Indian and Alaska Native population (7.1). Opioid analgesic poisoning death rates among the non-Hispanic black (2.7) and Hispanic populations (2.4) were about one-third that of the non-Hispanic white population. Among those aged 15 and over, the death rate involving opioid analgesics for males was 8.1 deaths per 100,000, compared with 5.1 for females. Those aged 35–54 had the highest death rate for opioid analgesics (9.9), followed by those aged 25–34 (8.1) and 55–64 (6.0).

Figure 28

Drug poisoning deaths involving opioid analgesics among persons aged 15 and over, by race and Hispanic origin, sex, and age: United States, 1999–2000 through 2009–2010. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig28 (more...)

Spending on Prescription Drugs

The annual growth in spending on retail prescription drugs slowed from 14.7% in 2001 to 2.9% in 2011.

In 2011, spending on prescription drugs was $263 billion. Although hospital care (31.5%) and physician and clinical services (20.0%) accounted for greater shares of national health expenditures, the share for prescription drugs increased from 4.7% in 1980 to 9.7% of all national health spending in 2011 (Table 114).

The growth in spending on prescription drugs was in the double digits from the mid-1990s through the mid-2000s, when it fell below 10% (Table 115). Between 2001 and 2011, the annual percent change in spending on retail prescription drugs slowed from 14.7% to 2.9%. This recent slowdown is the result of a variety of factors, including cost control efforts introduced by insurers, such as copays, formularies, tiered pricing, generic substitution, and the use of mail order pharmacies. In addition, several popular drugs ended their patent protection during this time frame (43,44).

Spending on prescription drugs is projected to grow slowly through 2012 and 2013 (77–79). Starting in 2014, spending is expected to pick up due to expanded insurance coverage as a result of the Affordable Care Act (ACA) and because fewer drugs are expected to lose patent protection in 2013 compared with 2012 (21,78).

In 2011, private health insurance, out-of-pocket spending, and Medicare paid for almost 90% of all prescription drug spending. A decade earlier, in 2001, private health insurance, out-of-pocket spending, and Medicaid paid the biggest share of all prescription drug spending. The shift in spending from Medicaid to Medicare between 2001 and 2011 is largely the result of the introduction of Medicare Part D in 2006 (39,80). Dual eligibles (people with both Medicare and Medicaid) who enrolled in a Medicare Part D plan had much of their drug spending paid for in 2011 by Medicare instead of Medicaid.

Figure 29

Retail prescription drug expenditures, annual percent change, and spending by payer: United States, 2001–2011. Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2013.htm#fig29 NOTES: Medicaid includes Children's Health Insurance Program (more...)

Data Tables for Special Feature: Figures 20-29

Data table for Figure 20. Prescription drug use in the past 30 days, by number of drugs taken and age: United States, 1988–1994 through 2007–2010

Data table for Figure 21. Prescription drug use in the past 30 days, by age and selected drug class: United States, 1988–1994 and 2007–2010

Data table for Figure 22. Number of prescription drugs taken in the past 30 days among adults aged 18 and over, by selected characteristics: United States, 2007–2010

Data table for Figure 23. Nonreceipt of needed prescription drugs in the past 12 months due to cost among adults aged 18–64, by insurance status and percent of poverty level: United States, 2002–2012

Data table for Figure 24. Age-adjusted death rates for human immunodeficiency virus (HIV) disease for all ages, by sex and race and Hispanic origin: United States, 1990–2010

Data table for Figure 25. Use of prescription antidepressants in the past 30 days among adults aged 18 and over, by sex and age: United States, 1988–1994 through 2007–2010

Data table for Figure 26. Antibiotics ordered or provided during emergency department, outpatient, and physician visits for cold symptom diagnoses, by age: United States, average annual, 1995–1996 through 2009–2010

Data table for Figure 27. Computerized systems for prescription drugs, by provider and system type: United States, 2010

Data table for Figure 28. Drug poisoning deaths involving opioid analgesics among persons aged 15 and over, by race and Hispanic origin, sex, and age: United States, 1999–2000 through 2009–2010

Data table for Figure 29. Retail prescription drug expenditures, annual percent change, and spending by payer: United States, 2001–2011