Our Nation’s Students: Prescription Medication Abuse

1. Our Nation’s Students:Prescription Medication Abuse Carol J. Boyd, PhD, MSN, FAAN Professor and Director Institute for Research on Women and Gender University of Michigan - Ann Arbor February 23, 2006

2. Acknowledgements • National Institutes of Health: National Institute on Drug Abuse (NIDA) • R03DA018271 (PI: Boyd) • T32DA07267 (PI: Boyd): • McCabe, Teter & Young, • previous T32 post-doctoral fellows • R03DA019492 (PI: McCabe) • R03AA014601 (PI: Young: funding from NIAAA)

3. Purpose • Draw attention to prescription medication use and abuse by secondary & college students: • Psychostimulants (e.g. Ritalin®, Adderall®, Concerta®, etc.); • Opioid analgesics (e.g.Vicodin®, OxyContin®, Tylenol #3®, etc.); • We will focus on diversion behaviors: • How do students get their drugs? • We will focus on motivations to misuse and abuse prescription medications: • Why do students abuse prescription medications? • We will examine poly-substance abuse in relation to the nonmedical abuse of prescription medications.

4. Schedule for Prescription Medications • 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]

5. Nonmedical Abuse (Illegal Use): Focus on Schedule II Drugs

6. Definitions • Medical misuseof prescription medications (drugs): • use of a prescribed medication by the person (and for the purpose) intended by the prescribing clinician; however, the medication is: • NOT used in the prescribed dose or not taken within a prescribed time interval. • Nonmedical abuse or illegal useof prescription medications (drugs): • use of prescription medication to “get high”/create an altered state; • use for reasons other than what the prescribing clinician intended. • Diversionof prescription medications (drugs): • exchange of prescription medications that leads to the use of these drugs: • by people other than whom the prescribing clinician intended or • under conditions associated with “doctor shopping.” (Note: Every study uses somewhat different operational definitions: 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”)

7. Nonmedical Abuse of Prescription Medications: • Studies indicate that the nonmedical use of prescription medications is increasing in the U.S. among adolescents and young adults(See: Johnston et al., 2004, 2005; Olfson et al., 2003; NSDUH, 2004; Robinson et al., 1999; 2002; Zito et al., 2003) • The nonmedical use of pain medication had largest number of new initiates in 2004: • 2.4 million new initiates (average age 23 years) • 2.1 million new initiates to marijuana (average age 18 years); • Nine percent of adolescents (12 to 17 years) used prescription drugs for nonmedical purposes in the past year: • 7.4% for pain medication and 2.0% for stimulant medication. (NSDUH, 2004)

8. Past Year Medical Use: * % reporting medical use ** ** • *p < 0.05, ** p < 0.01 based on Pearson chi-square tests Student Life Survey 2005

9. Secondary Students Are students who abuse prescription drugs more likely to abuse other substances?

10. Secondary Students who abuse prescription pain medications* are: • 8 times more likely to use other illegal drugs**; • 7 times more likely to smoke cigarettes; • 6 times more likely to smoke marijuana; • 5 times more likely to drink alcohol. *students who did NOT have a prescription; **excludes marijuana; SSLS, 2003 Source: Boyd, McCabe, Teter (2006).

11. College Students who Abuse Prescription medications: • 58% of students got diverted pain medications* from their peers (12% from family members): • These students were 8 times as likely to smoke marijuana and 4 times as likely to binge drink; • 68% of students got diverted stimulant medications from their peers (3% from family members): • 24 times more likely smoke marijuana and 7 times more likely to binge drink. SLS, 2003 Source: McCabe, Boyd (2005)

12. College Students Are students who abuse prescription drugs more likely to abuse other substances?

13. College Students Are there Gender and Race Differences?

14. Gender: Nonmedical Use of Prescription Drugs % *** ***p<.001 College Alcohol Study, 2001 data; N=10,904 Sources: McCabe et al, Addiction 2005; 100: 96-106 and McCabe et al Addictive Behav. 2005; 30:789-805

15. Race/Ethnicity: Nonmedical Use of Prescription Drugs % *** *** *** *** ***p<.001 College Alcohol Study, 2001 data; N=10,904 Sources: McCabe et al, Addiction 2005; 100: 96-106 and McCabe et al Addictive Behav. 2005; 30:789-805

16. College Students Where do students get the stimulants and pain pills?

17. Sources: Prescription Stimulant Medications * ** Lifetime use reported in 2005 SLS, *p<.05 **p<.01 The following sources were less than 1%: aunt/uncle, other family, abroad, and internet. Source:Teter, McCabe et al, under review

18. WOMEN MEN “I snorted my friend'sRitalin before finals last semester.” (White, junior) “Getting Adderall and Ritalin are probably easier than getting alcohol on this campus. I could find 500 pills in 20 minutes.” (White, senior) “I was given them by a friendat a party.” (White, freshmen) “From friendswith prescriptions, or from those who have bought large quantities from people with prescriptions.” (White, junior) “My friendsneed these drugs for ADD/ADHD and they give them out to myself and other friends.” (Hispanic, senior) “a friendhas a prescription and sells the pills to me.” (White, senior) Source: Scientific American. The Quest for a Smart Pill, Sept. 2003 Source:McCabe, Teter & Boyd, J Psychoactive Drugs, in press

19. Sources: Prescription Pain Medications *** *** *** Lifetime use reported in 2005 SLS, ***p<.0001 The following sources were 2% or less: aunt/uncle (2%), abroad (1%), and internet (0.2%). Source: McCabe et al, under review

20. WOMEN MEN “I was having back pain and my mom game me one of her T3s, she is a nurse, and I knew they would give me the same meds if I went to see a doc.” (junior) “A roommate had leftover Vicodin that I used.” (senior) “It (pain medication) was prescribed to a friend and he gave me a couple before we started drinking...” (junior) “My father is a virtual pharmacy from all his surgeries. If I'm in pain, he is going to give me pain medication.” (junior) “I tried one pill (Tylenol 3) and had 4 beers because my friend said it gives you a really nice buzz.” (junior) Source: McCabe, Teter & Boyd, Drug Alcohol Depend 2005; 77:37-47

21. Diversion of Prescription Drugs, (Medical users approached to divert their medication) % approached to divert their medication * W=97 M=59 W=84 M=52 W=59 M=76 W=517 M=450 *p<.05 Previous year approached; Student Life Survey, 2005

22. Secondary Students Where do students get the stimulants and pain pills?

23. “I had a headache so my mom gave me one (referring to hydrocodone).” “ I burned my hand real bad and on the way to the hospital, my mom gave me a #3.” “I borrow it (OxyContin) from my grandmother” Pain Medications: From Family

24. 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

25. SecondaryStudents: PercentageApproached to sell, trade or give away their medications: Lifetime in 2005: Stimulant=14/62; Pain=104/460; Sleeping=25/145; Anxiety=14/64

26. Motives to Abuse: College Students

27. Motives of Nonmedical Use: Prescription Pain Medication *** *** * * *p<.05, ***p<.001 Motives of Lifetime: 2005 Student Life Survey Source: McCabe et al, under review

28. Motives of Nonmedical Use: Prescription Stimulant Medications * *** * *** * *p<.05, ***p<.001 Motives of Lifetime: 2005 Student Life Survey Source: Teter et al, under review

29. Gender differences: Self-treatment among illegal users ** **p< .01 Student Life Survey, 2005

30. Motives to Abuse: Secondary Students

31. Secondary Students: • Students responded about motivations to abuse opioid analgesics: • 80% for the purpose of relieving pain; • 16% for the purpose of helping to sleep; • 20% of adolescents reported to get high; • 3% because they are safer than street drugs. (2005 SSLS Data; Check all that apply; Girls=127; Boys=58)

32. Secondary Students: • Students responded about motivations to abuse stimulant medications: • 52% for the purpose of getting high; • 40% for the purpose of increasing alertness; • 36% for the purpose of helping to concentrate; • 28% for the purpose of weight control; • 3% because they are safer than street drugs. (2005 SSLS Data; Check all that apply; n=25)

33. Summary: Students who abuse prescription medications are significantly more likely to smoke cigarettes, use marijuana and use other illegal drugs. (Boyd, McCabe, Teter, 2006; Boyd, McCabe Teter, 2005) Approximately 25% of secondary school students and 50% of college students prescribed stimulants for ADHD are approached to divert their medication. (Boyd, McCabe, Teter, 2006; McCabe, Teter & Boyd, 2004) Self-treatment appears to be one motivation for nonmedical abuse. College men are more likely than women to obtain prescription opioid medications from peer sources, while women from family. (McCabe, Teter & Boyd, 2005) Adolescent boys are less likely than girls to get prescription opioid medications from family members. (Boyd, 2005) Our samples are NOT obtaining prescription drugs directly via the internet. (Boyd, McCabe, Teter, 2006; McCabe & Boyd, 2005)

34. On Balance: Risks and Benefits The need to control and reduce abuse anddiversion of scheduled medications must be balancedagainst patients’ needs;physicians and patients must have access to legal medications that are used for legitimate medical purposes.

35. Preventing Medication Abuse Educational implications: We need prevention programs aimed at teaching adolescents the safe and legal use of medications; Clinical implications: Physicians and nurses must talk with their patients and their families; Research Implications: Epidemiological studies should further examine motives and diversion practices. Source: U.S. Food and Drug Administration, FDA Consumer magazine, September-October 2001, Prescription Drug Use and Abuse

36. References: • Available on request: • (caroboyd@umich.edu or 734-764-9537) • Boyd, McCabe & Teter, 2004; 2005; 2006; • McCabe, Boyd & Teter, 2005 • McCabe & Boyd, 2005; • Teter, McCabe, Boyd & Guthrie, 2003; • Teter, McCabe, Cranford, Boyd, & Guthrie, 2005