New Agents of Abuse
Understanding Prescription Drug Misuse by Adolescents

Prevention
Patient and family education is the basis for prevention of prescription drug misuse. Physicians and other health care providers should inform and educate patients about diagnoses for which medications are prescribed, with directions for use, dosage, target symptoms, anticipated duration of treatment, adverse effects, interactions with other medications or foods, and the rationale for taking the medication as prescribed.¹⁵ A proactive discussion regarding medication adherence and the risks involved with misuse or diversion of prescribed medication should be considered an integral part of psychoeducation. The possibility of diversion should be anticipated with warnings about the consequences of misuse and diversion as well as consideration of special issues such as having family members with drug problems and living in college dormitories. In addition, patients need to be educated about the need for safe and secure storing of prescription medications and immediate disposal when the drugs are no longer needed.

Although physicians and other prescribing clinicians should make every effort to appropriately recognize and treat pain, anxiety, and attention disorders, they should consider prescribing alternatives with less potential for misuse (eg, NSAIDs or opiates for pain or long-acting instead of short-acting stimulants for attention and hyperactivity disorders).

Youth at risk for prescription drug problems often have other preexisting problems, such as conduct problems and attention-deficit/hyperactivity disorder (ADHD), which place them at risk for the development of prescription drug use or other SUDs.¹⁶ Wilens and colleagues¹⁷ have suggested that medical treatment of ADHD with stimulants in childhood may be protective or decrease the level of SUDs in adolescents. Although subsequent studies have called the protective effects of stimulants into question, the early medical use of stimulants does not elevate the level of substance use or SUDs during adolescence.¹⁸

Optimal prevention of prescription drug misuse includes careful screening of youth and their families for high-risk characteristics and behaviors, including a history of SUD, specific drug-seeking behavior (eg, insisting on specific types of drugs or formulations), lost prescriptions, or too-frequent refills. Careful attention to these warning signs can prevent cases of diversion and ultimate misuse.¹⁵ Additional efforts include good documentation of the diagnosis and the rationale for prescription medication, the number of pills dispensed, dosage, and tracking of prescription refill timelines.

For adolescents, parents should take additional steps to secure medication from family and others and should control administration, allowing the adolescent only a limited amount of medication. However, these precautions should be balanced against respecting the natural desire for increasing autonomy that characterizes adolescent development. Similarly, college students may need to take steps to keep their prescribed medication out of harm’s way (eg, using a lock box or safe).

Clinical management
For more detailed guidelines to both evaluation and treatment, the reader is referred to the “Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders.”¹⁶ The increasing prevalence of prescription drug problems among adolescents in treatment for SUDs demands attention to specific questions about the range of prescription drugs with a potential for abuse or dependence. In addition, including prescription drugs on toxicological tests (eg, urine drug screens) is essential.

Based on the combination of empirical research and current clinical consensus, the clinician who treats adolescents with SUDs should develop a plan that includes:

• Motivation and engagement.
• Family involvement to improve supervision, monitoring, and communication between parents and adolescents.
• Improved problem solving, social skills, and relapse prevention.
• Comorbid psychiatric disorders through psychosocial and/or medication treatments.
• Social ecology that increases pro­social behaviors, peer relationships, and academic functioning.
• Adequate duration of treatment and follow-up care with self-support groups (Alcoholics or Narcotics Anonymous) as adjuncts to these modalities.

There are no psychosocial treatment modalities for adolescents that specifically address prescription drug problems, although types of family therapy and/or cognitive-behavioral therapies appear to be effective in decreasing cannabis and alcohol(Drug information on alcohol) use disorders. Therefore, these should be the types of evidence-based psycho­social treatments used for prescription drug problems in adolescents.¹⁶ Because adolescents with prescription drug problems are likely to misuse other drugs and may have comorbid psychiatric disorders, they may need more intensive, multimodal treatments at higher levels of care. Adolescents with prescription opiate dependence may benefit from bupre­norphine, a partial opiate agonist that has been shown to have positive results in adolescents.¹⁹

Although there have been few, if any, studies designed to specifically prevent prescription drug misuse, universal prevention interventions appear to reduce some types of prescription drug misuse among adolescents and young adults.²⁰

Drugs Mentioned in This Article
Alprazolam (Xanax)
Buprenorphine (Suboxone)
Chlordiazepoxide (Librax, others)
Clonazepam (Klonopin, Rivotril)
Dextroamphetamine (Dexedrine)
Diazepam (Valium)
Fentanyl (Actia)
Hydrocodone/paracetamol (Vicodin)
Hydromorphone (Palladone, Dilaudid, others)
Lorazepam (Ativan)
Meperidine (Demerol hydrochloride)
Methylphenidate (Ritalin LA)
Mixed amphetamine salts (Adderall XR)
Oxycodone (OxyContin)
Pentobarbital (Nembutal, others)
Secobarbital (Seconal)
Temazepam (Restoril)
Zolpidem (Ambien)