New Agents of AbuseUnderstanding Prescription Drug Misuse by Adolescents

A large percentage of youths use and abuse psychoactive substances. According to the 2007 Monitoring the Future (MTF) survey, the percentage of US adolescents who used illicit drugs or drank alcohol continued a decade-long drop, revealing that 19% of 8th grad­ers, more than 36% of 10th graders, and 47% of all 12th graders have taken an illicit drug (other than alcohol) during their lifetime.¹ According to the National Survey on Drug Use and Health, the rate was 3.3% for misuse or nonmedical use of prescription drugs.² The misuse of prescription drugs among adolescents was second only to marijuana use. In fact, prescription drugs increasingly have become a part of the repertoire of drug-using adolescents.

When is misuse abuse?
Although too often any nonsanctioned use of psychoactive substances is labeled as “abuse,” there are specific definitions and criteria for terms such as abuse, dependence, misuse, and diversion³:

• Abuse: A pattern of substance use resulting in negative consequences and impairment.
• Dependence: A pattern of substance use and impairment in the presence of salient cognitive, behavioral, and physiological symptoms.
• Misuse: Use for a purpose not consistent with medical guidelines (eg, modified dose, use of substance to achieve euphoria, and so forth) or without a prescription for the individual using the medication. Misuse is synonymous with nonmedical use or without a clinician prescription, which would include ignoring medical instructions (by a physician or his or her designate) to take a medication at a specific dosing regimen for a named symptom or disorder.
• Diversion: The transfer of a medication from the individual for whom it was prescribed to someone for whom it is not prescribed.

Given the low level of regular use of prescription drugs, the prevalence of substance use disorder (SUD) among adolescents is less than 1% for each class of prescription drugs. It is interesting to note that neither misuse nor diversion presumes a pathological level of substance use, although specific characteristics of misuse and misusers may predispose to the development of a SUD.

Epidemiology
Data from recent national surveys and other published reports indicate that the lifetime prevalence of nonmedical prescription drug misuse in the United States is 20% (approximately 48 million) of persons 12 years or older.⁴ Among adults 26 or older who had previously misused any prescription psychotherapeutic drug, the rate of past-year use was higher among those who had initiated use before age 16 (25.7%) than among those who initiated use between the ages of 16 and 20 (18.2%).⁵ In 2004, 30.9% of adolescents aged 12 through 17 years and 37.3% of those aged 18 through 20 reported their primary substances of abuse as nonheroin opiates, tranquilizers, sedatives, amphetamines, or other stimulants.⁴

It has been suggested that the misuse of prescription drugs before age 16 leads to a greater risk of substance dependence later in life.⁵ One-third of all new misusers of prescription drugs in 2005 were adolescents between the ages of 12 and 17 years.² In the 2005 Partnership for a Drug-Free America Attitude Tracking Study (PATS)-a survey of 7216 adolescents in grades 7 through 12-19% reported using prescription drugs that were not prescribed for them.⁶ In a 2005 Web-based survey self-administered by 1086 secondary school students in grades 7 through 12, 31.5% reported using prescription medications only as medically prescribed (medical users), 17.5% reported both medical use and other use (ie, misuse), and 3.3% reported prescription drug misuse only.⁷ Reports of misuse among adolescents being treated for SUDs is more staggering, with 23% to 33% reporting misuse of Schedule II medications.² Examples of commonly misused prescription drugs are listed in the Table.

Commonly misused medications
Opiate analgesics are the most misused prescription drugs by adolescents. Detailed age breakdowns indicate that the average rate of past-year misuse or misuse of pain relievers increased steadily with age, from 2.5% at age 12 to 12.8% at age 17, and 13.9% at age 19.1 Pain relievers such as hydrocodone/paracetamol and oxycodone are the prescription drugs most commonly misused by teens.⁵ In a Web-based survey of students aged 10 through 18, misusers of prescription pain medication were 7 times more likely to smoke cigarettes, 5 times more likely to drink alcohol and smoke marijuana, almost 4 times more likely to binge drink, and 8 times more likely to have used other illicit drugs compared with their peers who did not misuse prescription pain medications.⁸

Among 12th graders, past year abuse of oxycodone increased 30% from 2002 through 2007.¹ Annual prevalence rates in 2007 for oxyco­done use were reported as 1.8% for 8th graders, 3.9% for 10th graders, and 5.3% for 12th graders. In other words, 1 in every 20 high school seniors had at least tried this drug in the past year. Past-year abuse of hydro­codone/paracetamol was particularly high among 8th, 10th, and 12th grad­ers. Rates of abuse remain close to recent peak levels with nearly 1 in 10 high school seniors reporting misuse; annual prevalence for 2007 was 2.7% for 8th graders, 7.2% for 10th grad­ers, and 9.6% for 12th graders.¹

In 2006, 2% of adolescents misused stimulants in the past year, a rate twice as high as that observed among adults aged 26 years and older.⁹ In the 2007 MTF survey, the percentage of high school seniors who reported methylphenidate and amphetamine use in the past year was 4.4% and 8.1%, respectively, down from recent peaks of 5.1% and 11.1%.¹ Adolescents who misused stimulants in the past year were at greater risk for engaging in delinquent behavior, and they were more likely to have used other illicit drugs in the past year or to have experienced a major depressive episode compared with youths who did not misuse stimulants.⁹

Levels of stimulant use among 8th and 10th graders reached their peak in 1996 and have declined by more than one-half and one-third, respectively. Peak use by 12th graders was seen in 2002; it has declined by one-third since then.¹ In 2007, 2.1% of 8th grad­ers, 2.8% of 10th graders, and 3.8% of 12th graders reported misusing methyl­pheni­date at least once in the past 12 months.¹

Sedative (barbiturate) use reached a peak annual prevalence of 7.2% in 2006 and has decreased to 6.2% in 2007.¹ Tranquilizer (benzodiazepine) use increased from 1992 to 2000 among 10th and 12th graders but has declined since then. Annual rates now range from 2.4% in 8th graders to 6.2% in 12th graders-only modestly below their recent peak levels.

The reasons for misuse
Approximately 40% of adolescents reported that they thought prescription medicines are much safer to use than illegal drugs, even if they are not prescribed by a doctor.⁶ In addition, 29% of adolescents (6.8 million) thought that prescription pain relievers-even if not prescribed by a doctor-are not addictive, and 31% (7.3 million) thought that there is “nothing wrong” with using prescription medicines without a prescription once in a while.⁶

The Figure presents the results of a survey that asked high school students what their motivation was for misusing opioid analgesics, as well as their reasons for use/misuse.¹⁰ Clearly, the reasons for misuse are many, and clinicians should be wary of making assumptions about motivations for this behavior.

The ease of acquiring these drugs is alarming. Nearly half (47%) of adolescents who abuse prescription drugs said they got them free from a relative or friend, 10% said they bought pain relievers from a friend or relative; another 10% said they stole the drugs; 62% (14.6 million) said prescription pain relievers are easy to get from parents’ medicine cabinets, 50% (11.9 million) said that these medications are easy to get through other people’s prescriptions, and 52% (12.3 million) said prescription pain relievers are “available everywhere.”⁶

The majority of adolescents (56% or 13.4 million) agreed that prescription drugs are easier to get than illegal drugs.⁶ According to another survey, more adolescents have been offered prescription drugs than other illicit drugs, excluding marijuana: 14% of adolescents aged 12 to 17 years have been offered prescription drugs for nonmedical use at some point; 10% have been offered cocaine, 9% have been offered Ecstasy, 6% have been offered meth­am­phet­amine, and 5% have been offered LSD.¹¹

Although adolescents said that getting prescription drugs online or by phone is easy, McCabe and associates^12,13 report that, according to their collegiate surveys, online access accounts for very little prescription drug misuse. 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 who were not users or students who obtained prescription medication from family members.^12,13

Poorer academic performance; past-year major depression; higher risk-taking levels; and past-year use of alcohol, cigarettes, marijuana, cocaine, or an inhalant were associated with misuse of prescription drugs.¹⁴ Major depression, cocaine or inhalant use, and 10 or more episodes of prescription misuse in the past year were also associated with symptoms of abuse or dependence among adolescent prescription drug misusers.¹⁴

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 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)

References:

1. University of Michigan News Service.Teen drug use continues down in 2006, particularly among older teens; but use of prescription-type drugs remains high. Published December 21, 2006. http://www.monitoringthefuture.org/pressreleases/06drugpr.pdf. Accessed August 19, 2008.
2. Misuse of Prescription Drugs, National Survey on Drug Use and Health (NSDUH). Substance Abuse and Mental Health Services Administration (SAMHSA). 2006. Updated June 16, 2008. http://www.oas.samhsa.gov/prescription/toc. htm. Accessed August 19, 2008.
3. World Health Organization. Lexicon of alcohol and drug terms published by the World Health Organization. www.who.int/substance_abuse/terminology/ who_lexicon/en/index.html. Accessed August 19, 2008.
4. Substance Abuse Treatment Admissions by Primary Substance of Abuse According to Sex, Age Group, Race, and Ethnicity. 2004 Treatment Episode Data Set(TEDS). 2006. http://wwwdasis.samhsa.gov/teds00/ TEDS_2K_Tables.htm. Accessed August 21, 2008.
5. Department of Health and Human Services. Results from the 2005 National Survey on Drug Use and Health: National Findings. 2006. http://www.oas. samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm.Accessed August 19, 2008.
6. Partnership for a Drug-Free America. The Partnership Attitude Tracking Study (PATS): Teens in grades 7 through 12, 2005. May 16, 2006. http://www. drugfree.org/Files/Full_Teen_Report. Accessed August 19, 2008.
7. McCabe SE, Boyd CJ, Young A. Medical and nonmedical use of prescription drugs among secondary school students. J Adolesc Health. 2007;40:76-83.
8. Boyd CJ, Esteban McCabe S,Teter CJ. Medical and nonmedical use of prescription pain medication by youth in a Detroit-area public school district. Drug Alcohol Depend. 2006;81:37-45.
9. Nonmedical Stimulant Use, Other Drug Use, Delinquent Behaviors, and Depression Among Adolescents.National Survey on Drug Use and Health (NSDUH). Substance Abuse and Mental Health Services Administration (SAMHSA). 2008. http://www.oas.samhsa. gov/2k8/stimulants/depression.htm. Accessed September 9, 2008.
10. Boyd CJ, McCabe SE, Cranford JA, Young A. Adolescents’ motivations to abuse prescription medications. Pediatrics. 2006;118:2472-2480.
11. The National Center on Addiction and Substance Abuse at Columbia University. CASA* 2006 Teen Survey Reveals: Teen Parties Awash in Alcohol, Marijuana and Illegal Drugs-Even When Parents Are Present; 2006. http://www.casacolumbia.org/absolutenm/templates/PressReleases.aspx? articleid=451&zoneid=56. Accessed August 19, 2008.
12. McCabe SE, Teter CJ, Boyd CJ. Medical use, illicit use, and diversion of abusable prescription drugs. J Am Coll Health. 2006;54:269-278.
13. McCabe SE, Boyd CJ. Sources of prescription drugs for illicit use. Addict Behav. 2005;30:1342- 1350.
14. Schepis TS, Krishnan-Sarin S. Characterizing adolescent prescription misusers: a population-based study. J Am Acad Child Adolesc Psychiatry. 2008;47:745-754.
15. Riggs P. Non-medical use and abuse of commonly prescribed medications. Curr Med Res Opin. 2008; 24:869-877.
16. Bukstein OG, Bernet W, Arnold V; Work Group on Quality Issues. Practice parameter for the assessmenand treatment of children and adolescents with substance use disorders. J Am Acad Child Adolesc Psychiatry. 2005;44:609-621.
17. Wilens TE, Faraone SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/ hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics. 2003;111:179-185.
18. Mannuzza S, Klein RG, Moulton JL 3rd. Does stimulant treatment place children at risk for adult substance abuse? A controlled, prospective follow-up study. J Child Adolesc Psychopharmacol. 2003;13: 273-282.
19. Marsch LA, Bickel WK, Badger GJ, et al. Comparison of pharmacological treatments for opioiddependentadolescents: a randomized controlled trial.Arch Gen Psychiatry. 2005;62:1157-1164.
20. Spoth R, Trudeau L, Shin C, Redmond C. Long term effects of universal preventive interventions on prescription drug misuse. Addiction. 2008;103:1160-1168.

Evidence Based References

Bukstein OG, Bernet W,Arnold V; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with substance use disorders. J Am Acad Child Adolesc Psychiatry. 2005;44:609-621.
Marsch LA, Bickel WK, Badger GJ, et al. Comparison of pharmacological treatments for opioid-dependent adolescents. Arch Gen Psychiatry. 2005;62:1157-