Nonmedical Use of Prescription Drugs Among Adolescents and Young Adults

1. Nonmedical Use of Prescription Drugs Among Adolescents and Young Adults Christian J. Teter, Pharm.D., BCPP Assistant Professor Northeastern University School of Pharmacy c.teter@neu.edu Clinical Research Pharmacist McLean Hospital Alcohol and Drug Abuse Treatment Program cteter@mclean.harvard.edu

2. Balance – Medical Necessity “This trend pisses me off. I've been taking Adderall for my ADHD since the 6th grade (was on something else years prior), and have never abused it. Because of all of this abuse by other students, I feel like a druggie or something because everybody is always talking about "my medication" essentially. I now pretend like I don't use it, so people won't ask me for some. If they end up outlawing this drug, or make it more complicated to get, or my insurance company takes it off of the co-pay because it is being abused, I'm gonna be SOL because it's the only ADHD medication that has ever worked on me. The other one's give me massive headaches...” (student, 12/6/05)

3. Whenever I want Ritalin, I just ask my friend; he has a prescription.” “Everyone at my school uses Adderall and they share it… the kids that do best at school use it.” “At school, it (ADD/ADHD medication) is free, friends will just give it to you.” “It’s better than Red Bull!” Stimulant Medications: From Peers

4. School Nurses • “Despite the limitations of this study, there are several implications for practice, policy, and future research. Physicians, parents, pharmacists, school nurses, social workers, counselors, and principals should be educated and pay particular attention to the use and misuse of prescription medication among school-age children and adolescents.” Source: McCabe, Teter, and Boyd. Substance Use and Misuse 2004

5. Abuse Potential • Scheduling (PROXY for abuse potential) • Controlled Substances Act (CSA) of 1970: categorizes drugs “based upon the substance's medicinal value, harmfulness, and potential for abuse or addiction” [www.dea.gov]

6. An Issue of “Balance” • Balance Medical Necessity vs. Abuse Risk • Stimulant medications • Effective first-line treatment for the symptoms of ADHD • Prescription opioids • Cornerstone of moderate to severe pain management

7. Studies of Nonmedical Use • MTF • NSDUH • SLS • CAS

8. Key Definitions • Nonmedical use of prescription drugs • National Survey on Drug Use and Health (NSDUH): “…not prescribed for you, or that you took for the experience or feeling it caused” • Monitoring the Future (MTF) study: “…without a doctor’s orders” • Student Life Survey (SLS): “…NOT prescribed to you” • CAS: “Do not include anything you used under a doctor’s orders”

9. Race and Nonmedical Use of Vicodin®by U.S. 12th grade students, MTF 2002 ** % reporting nonmedical use of Vicodin® *** ** p < 0.01, *** p < 0.001 based on logistic regression using Whites as reference group and adjusting for gender, race, region, GPA and grade level. Source: McCabe, Boyd & Teter. Journal of Substance Abuse Treatment 2005

10. Race and Nonmedical Use of Ritalin® by U.S. 8th, 10th & 12th grade students, MTF 2001 % reporting nonmedical use of Ritalin® *** *** *** p < 0.001 based on logistic regression using Whites as reference group and adjusting for gender, race, region and grade level. Source: McCabe, Teter, Boyd & Guthrie. Journal of Adolescent Health 2004

11. Lifetime Prescription Drug Use, 7th-12th grade, 2005(includes opioid, stimulant, sedative and sleeping medication) % reporting lifetime prescription drug use n=511 n=331 n=184 n=35 Source: McCabe et al., under review

12. College Studies – RX Stimulants

13. National Studies – RX Stimulants

14. Gender Differences in Drug Use Among Undergraduate Students in the Past Year, SLS 2005 * *** *** * * Note: The past-year prevalence rate for heroin, LSD and crystal methamphetamine was less than 1%.

15. Source: Teter et al. Pharmacotherapy (in press)

16. Source: Teter et al. Pharmacotherapy (in press)

17. Sleeping Medication n=277 Sedative Medication n=287 Stimulant Medication n=183 Pain Medication n=2062 % NOTE: those approached to trade, sell or give away their prescribed medication. Source: McCabe, Teter & Boyd. J Am Coll Health 2006

18. Sources of Past-year Illicit Use of Prescription Stimulants, SLS 2003 (n = 458) • Peer category consisted of friends, peers, roommate, boyfriend, girlfriend and teammate. • Family category consisted of mother, family, parent, father, sibling, aunt, brother, husband and cousin. • Other category consisted of don’t know, over-the-counter, self, drug dealer, and abroad. Source: McCabe, Teter & Boyd. J Psychoactive Drugs 2006

19. Motives • Research on the motives for alcohol use has added to our understanding of drinking behavior • We hypothesized that understanding the motives for the illicit use of prescription stimulants would help provide insight into this behavior

20. Source: Teter et al. Journal of American College Health 2005

21. Motives • Results (Study #1) • Motives that were found in the open-ended responses included: • “curiosity and experimentation” • “to study” • Motives did not differ based upon having a prescription for stimulant medication Source: Teter et al. Journal of American College Health 2005

22. STUDY #2: Motives of Lifetime Illicit Use of Prescription Stimulants, SLS 2005 (n = 382) * *** * *** * Source: Teter et al. Pharmacotherapy (in press)

23. STUDY #2: Motives for the illicit use of prescription stimulants as a function of: • Gender • Age of initiation • (n=382) • -------------------- • <Gender> and <college vs. pre-college initiation> differences were statistically significant at: • p < 0.05 and p < 0.01, respectively. Source: Teter et al. Pharmacotherapy (in press)

24. Motives of Lifetime Nonmedical Use of Prescription Opioids, SLS 2005 *** *** * * *p<.05, **p<.01, ***p<.001 Source: McCabe et al, under review

25. Alcohol & Other Drugs • Cluster problem behavior • Students who report the illicit use of prescription medications report much higher rates of AOD use

26. AOD Use Among College Students (SLS 2001) Past-year illicit Past-year RX Past-year MPH users stimulant users non-stimulant users Got drunk in high 98.2% 54.2% 58.3% school or before Binge drinking in 98.2% 69.6% 48.3% the past two weeks Used marijuana in 91.2% 50.0% 28.1% high school or before Marijuana use in the 100.0% 50.0% 29.9% past year Ecstasy (MDMA) use 57.9% 12.5% 5.3% in the past year Any cigarette use in 77.2% 32.0% 22.0% the past month Source: Teter et al. Pharmacotherapy 2003

27. AOD Use Among College Students (SLS 2001) Past-year illicit Past-year RX stimulant Past-year non-stimulant MPH users users users Illicit drugs used 3.84 (0.14) 1.25 (0.21) 0.49 (0.02) in the past year, not including illicit Ritalin® (0-16) Illicit drugs used in 1.95 (0.08) 0.67 (0.13) 0.22 (0.01) the past month, not including illicit Ritalin® (0-16) Pre-college illicit 2.30 (0.13) 1.10 (0.20) 0.44 (0.02) drugs used, not including illicit Ritalin® (0-16) Drinks per occasion 7.02 (0.37) 4.70 (0.58) 4.10 (0.06) in the past 30 days (0-12) Primary AOD-related 9.68 (0.52) 4.39 (0.81) 3.90 (0.09) consequences index (0-23) Secondary AOD-related 5.28 (0.31) 3.60 (0.46) 3.20 (0.05) consequences index (0-10) Source: Teter et al. Pharmacotherapy 2003

28. *χ2 test results indicate the differences in the prevalence rates of AOD use between those endorsing a particular motive and the remaining illicit prescription stimulant users (i.e., the illicit stimulant users not endorsing that particular motive); due to multiple comparisons alpha was adjusted to 0.001. Source: Teter et al. Journal of American College Health 2005

29. Drug Abuse Screening Test by Motive for Nonmedical Use of Prescription Opioids, SLS 2005 *** *** % reporting three or more DAST-10 items n=1901 n=113 n=199 n=1936 n=140 n=181 ***p<.001 based on logistic regression adjusting for race/ethnicity, class year and living arrangement Source: McCabe et al, under review

30. Substance Use by Past Year Nonmedical Use of Ritalin®, U.S. 8th, 10th & 12th grade students, MTF 2001 *** *** *** *** Source: McCabe, Teter, Boyd & Guthrie, Journal of Adolescent Health 2004 *** p < 0.001 based on Chi-square tests

31. *** *** *** *** *** *** *** *** Substance Use by Lifetime Use of Prescription Stimulants, Secondary School Students, SLS 2002 Source: McCabe, Teter & Boyd. Substance Use & Misuse 2004

32. Substance Use in the Past Year by Nonmedical Use of Prescription Stimulants Among U.S. College Students, CAS 2001 (n = 10,904) *** *** *** *** *** Source: McCabe et al. Addiction 2005

33. Drug Abuse Screening Test Results by Lifetime Use of Prescription Drugs, 7th-12th graders, 2005 *** *** % reporting three or more DAST-10 items n=511 n=331 n=184 n=35 *** p < 0.001 based on logistic regression using non-users as reference group and adjusting for gender, race/ethnicity and grade level. Source: McCabe et al., under review

34. Medical & Illicit Use • Relationships between medical and illicit use suggest that prescription stimulants have the highest illicit to medical use ratio

35. Past Year Medical Use of Prescription Drugs Among College Students (SLS 2003) % Sleeping Medication n=8489 Stimulant Medication n=8487 Pain Medication n=8476 Sedative Medication n=8487 Source: McCabe, Teter & Boyd. J Am Coll Health 2006

36. Past Year Illicit Use of Prescription Drugs Among College Students (SLS 2003) % Sleeping Medication n=8489 Sedative Medication n=8487 Stimulant Medication n=8487 Pain Medication n=8476 Source: McCabe, Teter & Boyd. J Am Coll Health 2006

37. Sleeping medication Sedative medication Stimulant medication Pain medication n=8489 n=8487 n=8487 n=8476 Source: McCabe, Teter & Boyd. J Am Coll Health 2006

38. Risk Factors • Men (vs. women) • White students • Northeast colleges (vs. other regions) • Competitive admission criteria • Fraternity/Sorority member

39. Gender Differences in Illicit Use of Prescription Stimulants, CAS 2001 (n=10,904) *** Source: McCabe et al. Addiction 2005

40. Racial Differences in Illicit Use of Prescription Stimulants, CAS 2001 (n=10,904) *** *** Source: McCabe et al. Addiction 2005

41. Fraternity/Sorority Membership and Illicit Use of Prescription Stimulants, CAS 2001 (n=10,904) *** Source: McCabe et al. Addiction 2005

42. Admission Criteria and Illicit Use of Prescription Stimulants, CAS 2001 (n=10,904) ** ** Source: McCabe et al. Addiction 2005

43. Race and Nonmedical Use of Prescription Drugs, CAS 2001 % *** *** *** N=10,904 N=10,904 *** p < 0.001 based on logistic regression results using “White” as reference group Sources: McCabe et al, Addiction 2005; McCabe et al Addictive Behav. 2005

44. Admission Criteria and Nonmedical Use of Prescription Drugs, CAS 2001 % ** * ** ** n=10,904 n=10,904 * p < 0.05, ** p < 0.01 based on logistic regression results using “less competitive” as reference group. Sources: McCabe et al, Addiction 2005; McCabe et al Addictive Behav. 2005

45. Past Year Nonmedical Use of Prescription Stimulants by Race/Ethnicity (n = 4,478) Source: Teter et al. Pharmacotherapy (in press)

46. Number of schools . 25 20 15 10 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Percent of students reporting nonmedical use of prescription stimulants (Ritalin, Dexedrine and Adderall) Past Year Nonmedical Use of Prescription Stimulants Across 119 Colleges, 2001 CAS (n = 10,904 students) Source: McCabe et al. Addiction 2005

47. Conclusions • Students are using prescription medications nonmedically for many purposes • AOD use are significantly higher among those who use prescription medications nonmedically • Possible exception: “pain only” motive • Our findings suggest that factors associated with nonmedical use of prescription medications are similar to other illicit substances

48. Conclusions • Prevention efforts must strike a balance between the medical necessity to effectively treat patients and the need to reduce nonmedical use of these abusable medications

49. Conclusions Clinical implications: • Education for clinicians in all disciplines regarding the prevalence and risks of prescription drug abuse • Screening and intervention training for clinicians (e.g., similar to the CAGE or AUDIT for alcoholism) Source: U.S. Food and Drug Administration, FDA Consumer magazine, September-October 2001, Prescription Drug Use and Abuse

50. Acknowledgements • Drs. Sean McCabe, Carol Boyd, Jim Cranford & Sally Guthrie • National Institutes of Health, National Institute on Drug Abuse research grants: • T32DA07267 (PI: Boyd) • R03DA018239 (PI: McCabe) • R03DA018271 (PI: Boyd) • R03DA019492 (PI: McCabe) • The University of Michigan; Northeastern University; McLean Hospital • Harvard College Alcohol study (Dr. Henry Wechsler) • Monitoring the Future study staff