Although the percentage of US adolescents who use illicit drugs or drink alcohol(Drug information on alcohol) continued a decade-long reduction in 2006, according to the Monitoring the Future (MTF) survey,1 the use of prescription drugs, such as narcotics, tranquilizers, sedatives, and stimulants remains at relatively high levels. Concerns about marijuana and alcohol, which are easily the most prevalent substances misused by adolescents, have obscured the increasing problem of prescription drug misuse in youth. This article presents information on prescription drug misuse and diversion based on surveys of high school and college students.
Nonsanctioned use of psychoactive substances is usually labeled as abuse; however, the terms abuse and dependence should refer to the specific type of substance use disorder, as defined by DSM-IV. Abuse connotes a pattern of substance use resulting in negative consequences and impairment. Dependence also requires a pattern of substance use and impairment in the presence of salient cognitive, behavioral, and physiological symptoms. Unfortunately, there are scant data on the prevalence of categorically defined prescription drug abuse or dependence in adolescents; thus, the main focus of this article is on patterns of prescription drug (nonheroin opiates, stimulants, tranquilizers) misuse.
Misuse refers to the use of a drug for a purpose not consistent with medical guidelines (eg, modifying the dosage, using the medication to achieve euphoria, using it with other nonprescribed psychoactive substances).2 Diversion is the transfer of medication from the person for whom it is prescribed to someone for whom it is not prescribed. Neither misuse nor diversion presumes a pathological level of substance use, although specific characteristics of misuse may predispose a substance use disorder to develop.Prevalence of misuse
According to the 2005 National Household Survey on Drug Abuse, persons aged 18 to 25 years had the highest prevalence of prescription drug misuse, relative to other age groups.3 There is growing evidence that prescription drug misuse has been increasing in the past decade among US undergraduate college students, and it is second only to marijuana as the most common form of substance abuse.4-6 Three percent of adolescents aged 12 to17 years reported abusing prescription drugs in 2005.7 Nearly 1 in 5 students in grades 7 to 12 reported using prescription medications that were not prescribed to them.8 In a 2005 survey of 1086 students in grades 7 to 12, 17.5% reported medical and nonmedical use of prescription drugs, and 3.3% reported nonmedical use only.9
Analgesics are currently the most misused prescription drugs by 12- to 17-year-old adolescents, followed by stimulants, tranquilizers, and sedatives.6 Approximately 2 of 5 adolescents reported having friends who had abused prescription analgesics.8 Nearly 1 in 10 high school seniors have taken hydrocodone(Drug information on hydrocodone) in the past year.1 On average, 6% of students in grades 8 to 12 said they had used hydrocodone and 3.5% said they had used oxycodone(Drug information on oxycodone) in the past year.1 In 2006, past-year misuse of oxycodone among eighth graders doubled during the past 4 years and past-year misuse of oxycodone by 10th graders increased 26%.1 Five of the top 6 drugs that 12th graders reported abusing in the past year were prescription cough and cold medicines.1
A survey from a national sample of 10,904 randomly selected students attending 4-year colleges in 2001 showed that the lifetime prevalence of misuse of benzodiazepine anxiolytics was 7.8%.10 Past-year rates of misuse ranged from 0% to 20%.
Multivariate regression analyses indicated misuse was more likely to occur among college students who were white, had both male and female sex partners, and had higher rates of substance abuse and other risky behaviors. Misuse of prescription benzodiazepines was less likely to occur among college students who attended colleges in the north central region and those who attended historically black colleges and universities.10
The 2006 MTF survey reported a slight decline in the misuse of methylphenidate(Drug information on methylphenidate) and amphetamine among high school seniors in the past year (4.4% and 8.1%, respectively, vs 5.1% and 11.1%).1 In a random sample of 9161 undergraduate students attending a large midwestern university, 6.9% reported lifetime misuse of prescription stimulants.11 These rates were similar to those found in other national studies of college students and young adults.3,4
Prescription stimulant misuse is highest among certain college students, in particular males, white students, members of fraternities or sororities, and those with lower grade point averages.5,11-13 The misuse of prescription stimulants varies across different types of colleges and universities.11,14 Findings that associate higher rates of nonmedical prescription stimulant use with more competitive admissions standards, membership in fraternities or sororities, and higher family income suggest an association with higher socioeconomic status.15Attitudes, perception, and motivation
Drug misuse by adolescents is probably caused by their perception of harm or safety and their motivation for use.8 Approximately 40% of the adolescents surveyed by McCabe and colleagues9 said they thought that prescription medicines were much safer to use than illegal drugs, even when the drugs were not prescribed by a doctor; 29% said they believed that prescription pain relievers--even when not prescribed by a doctor--were not addictive; and 31% said there was "nothing wrong" with using prescription medicines without a prescription once in a while.
In a survey of students at a large university, students who did not use stimulants when given the opportunity were 3.4 times as likely to associate occasional use with moderate to great risk than were the students who used prescription drugs. The association was somewhat weaker with prescription analgesics. Those who did not misuse prescription drugs were 1.8 times as likely to associate occasional misuse with moderate to great risk.16
When asked about their motivations to misuse opioid analgesics, 80% of high school students reported that they used the medications for the purpose of relieving pain, 16% as a sleeping aid, 20% for getting high, and 3% because they felt that prescription drugs were safer than street drugs. In a survey of 1086 youth aged 12 to 18 years, 69% reported using opioid medication soley for pain control and 79% reported that pain relief was at least one motivating factor, although other motives were also endorsed; 11% reported misusing drugs to get high.18
In addition, the most prevalent motivations for nonmedical use of prescription stimulants among college students were to improve concentration, enhance alertness, and to get high.19 More than half of the students who misused prescription drugs reported using prescription stimulants to get high; other nonprescription substance use rates were significantly higher among students who misused prescription drugs compared with students who did not, regardless of motivation for nonmedical use.19
However, performance enhancement remains the most common reason for stimulant use among college students, although most of this medication is diverted from the person for whom it was originally prescribed. Unlike college students, performance enhancement is rarely invoked as a motive for stimulant use by high school students.16,18Availability and diversion
Nearly half (47%) of adolescents who use prescription drugs said they get them for free from a relative or friend, 10% said they buy analgesics from a friend or relative, and another 10% said they took the drugs without asking.20 The Partnership Attitude Tracking Study reported that 62% of ado-lescents said that prescription pain relievers were easy to get from their parents' medicine cabinets; 50% said they were easy to get through other people's prescriptions; and 52% said prescription pain relievers were "available everywhere."8 Most of the adolescents (56%) said that prescription drugs are easier to get than illegal drugs.8
According to another survey of teens, more adolescents have been offered prescription drugs than other illicit drugs, excluding marijuana. Fourteen percent of those aged 12 to 17 reported being offered prescrip-tion drugs at some point, more than the number of adolescents who reported being offered cocaine (10%),3,4 methylenedioxymethamphetamine (MDMA or Ecstasy) (9%), methamphetamine (6%), and lysergic acid diethylamide (LSD) (5%).21 Thirty-nine percent of those aged 14 to 20 years said it is easy to get prescription drugs online or by phone. However, McCabe and associates11,22 found that Internet access accounted for very little prescription drug misuse.
Undergraduate college students are usually responsible for their own medication management and thus, prescription drugs may be readily diverted. Previous studies have identified parents and peers as possible sources for prescription drugs that are misused by adolescents and young adults.11,23,24 College men are more likely than college women to obtain prescription opioid medications from peer sources, while women are more likely to obtain them from family members.23Does use or misuse lead to abuse or addiction?
While none of the studies in this article determined the prevalence of specific substance use disorders, examination of the levels of other nonprescription substance use and problems associated with use may identify characteristics of youths who are at risk for substance use disorders. For example, college students who misuse stimulants have many of the same individual-level characteristics that have been shown to be associated with higher rates of substance abuse, including heavy episodic drinking24 and use of marijuana and MDMA.13 Using prescription drugs for the first time before age 16 was shown to lead to a greater risk of dependence later in life.25
The results of a survey of students aged 10 to 18 years showed that those who misused prescription pain medication were 7 times as likely to smoke cigarettes, 5 times as likely to drink alcohol and smoke marijuana, almost 4 times as likely to binge drink, and 8 times as likely to have used other illicit drugs than those who did not misuse prescription pain medication.26 Illicit drug users who obtained prescription medication from peers or other (nonfamily) sources reported significantly higher rates of alcohol and other drug use than those students who did not misuse prescription drugs or those who obtained prescription medication from family members.11,22
Factors influencing the risk of addiction to illicit drugs also influence prescription drug abuse. However, the students who misused prescription opioids and reported motives other than pain relief were 15 times as likely to experience 3 or more drug use- related problems than those who did not. In addition, findings from several other studies showed that students who misused prescription stimulants were dramatically more likely to use other drugs and to engage in other risky behaviors.15,19,27
The higher rates of substance use and other risky behaviors found among students who misuse prescription stimulants may indicate that the misuse is part of a larger cluster of problem behaviors among college students.28 Epidemiological studies have found that problem use and dependence behaviors develop in a significant proportion of those who misuse prescription stimulants.29,30
Key variables that influence the abuse and addiction potential of these agents include dosage, route of administration, co-administration with other drugs, context, and expectations.31 For example, long-acting stimulants appear to have less reinforcement effects than short-acting stimulants, thus possibly placing the user of short-acting stimulants at higher risk for the development of dependence and at greater risk for diversion or nontherapeutic use.Clinical recommendations
Regardless of the extent of prescription drug misuse, diversion, abuse, and dependence among youths, physicians should not hesitate to adequately treat pain, attention-deficit/hyperactivity disorder, or other medical conditions requiring drugs that may be misused or diverted. However, clinicians prescribing these medications should exercise caution and not overprescribe them to college students.
Physicians can limit the quantity of medication prescribed as well as the number of refills, thereby limiting supply. Careful screening of youths and their families for high-risk characteristics, such as a history of substance use disorders, specific drug-seeking behaviors (eg, insisting on specific types of drugs or formulations), lost prescriptions, or too-frequent refills can prevent many cases of diversion and ultimately misuse. When possible, physicians should prescribe medications that have low potential for abuse, such as NSAIDs rather than opiates for pain and long-acting rather than short-acting formulations of drugs.
Because family members may not be aware of possible contraindications or adverse consequences, there is a need to educate them on the potential dangers associated with diversion of prescription medications. Persons who obtain prescription medication for misuse from family members are unlikely to receive the appropriate information regarding adverse effects of the drug and possible negative interactions with other drugs.
Parents of adolescents who have misused prescription drugs or are likely to misuse prescription drugs should take additional steps to secure medication and control its administration, allowing only a limited supply of medication at a time. Similarly, college students may need to take steps to place their prescribed medication out of harm's way (eg, in a lockbox or safe). A physician's anticipatory discussion with children and adolescents about compliance and the risks involved with misuse or diversion of prescribed medication should be considered an integral part of psychoeducation. Patients who are in college should still be regularly seen by their physician during vacations to assess their sta- tus, use of, and ongoing need for medication.
Although colleges and universities should generally respect the independence and responsibility of their students, all educational institutions should monitor student use of substances with the potential for abuse, misuse, or diversion. Many colleges and universities are taking steps to prevent and manage binge drinking; similarly, education programs centered on the appropriate use of prescription drugs and the risks for misuse may be helpful. As an adjunct to prevention education, well-publicized sanctions should be delivered as needed to students who violate university rules.Conclusion
Misuse and diversion of prescription medication among high school and college students is an increasingly common problem. While misuse and diversion are not synonymous with substance abuse or dependence, specific characteristics of misusers predict more serious levels of nonprescription substance use and problems related to use. Physicians, families, and students can take specific steps toward decreasing the potential for diversion or misuse.
Dr Bukstein is associate professor in the department of psychiatry, Western Psychiatric Institute and Clinic, School of Medicine at the University of Pittsburgh. He reports that he receives research or grant support from Shire, Ortho-McNeil, Eli Lilly, and Sanofi Aventis; he is a consultant for Shire, Ortho-McNeil, Cephalon, and Forest Laboratories; and is a speaker for Shire, Ortho-McNeil, and Novartis.
Hydrocodone (Panacet, Vicodin, Zydone, others)
Methylphenidate (Concerta, Metadate, Ritalin)
Oxycodone (Endocodone, OxyContin, Roxicodone, others)
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