Prevalence and Etiology of the Non-Medical Use of Prescription - - PowerPoint PPT Presentation

Prevalence and Etiology of the Non-Medical Use of Prescription Medications among College Students

Amelia M. Arria, Ph.D. Associate Professor Department of Behavioral and Community Health Director, Center on Young Adult Health and Development University of Maryland School of Public Health For more information, email: aarria@umd.edu

Funded by NIH/NIDA R01-DA014845

Illinois Higher Education Center for Alcohol, Other Drug and Violence Prevention Eastern Illinois University April 4, 2017

Overview

1. National Estimates of Prevalence 2. Background on the College Life Study 3. What we know 4. What we suspect 5. What we can do

National Estimates of Prevalence

9.2 9.2 8.8 8.3 8.6 8.1 7.7 7.7 7.4 7.0 6.6 5.8 6.2 7.6 7.7 7.4 6.9 7.2 6.7 6.5 6.6 6.3 5.9 5.3 4.6 4.7 2.7 2.3 2.0 2.0 2.2 1.6 1.5 1.4 1.3 1.2 1.3 1.1 1.5 0.6 0.5 0.5 0.5 0.4 0.4 0.5 0.5 0.5 0.3 0.3 0.3 0.5 2.3 2.3 2.1 2.0 1.9 2.0 1.9 1.9 1.9 1.9 1.8 1.4 1.7 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

%

Past-Year Nonmedical Use of Prescription Drugs among 12- to 17-year-olds, 2002-2014 (SAMHSA, 2015)

Any Psychotherapeutics Pain Relievers Stimulants Sedatives Tranquilizers

14.4 14.6 14.9 15.1 15.7 15.0 14.9 15.1 14.3 12.7 13.7 12.2 11.8 11.4 12.0 11.9 12.4 12.5 12.2 12.0 12.0 11.1 9.8 10.1 8.8 7.8 4.0 3.8 4.0 3.8 4.2 3.5 3.4 3.7 3.6 3.1 3.9 3.7 3.9 0.5 0.5 0.5 0.6 0.6 0.6 0.5 0.5 0.5 0.4 0.3 0.4 0.4 4.9 5.3 5.2 5.5 5.5 5.2 5.4 5.4 5.3 4.5 5.0 4.5 4.1 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

%

Past-Year Nonmedical Use of Prescription Drugs among 18- to 25-year-olds, 2002-2014 (SAMHSA, 2015)

Any Psychotherapeutics Pain Relievers Stimulants Sedatives Tranquilizers

4.3 2.3 1.5 1.0 0.1 4.7 3.3 1.0 1.4 0.2 0.0 1.0 2.0 3.0 4.0 5.0 Any Psychotherapeutics Pain Relievers Stimulants Tranquilizers Sedatives

%

Prescription stimulants are the only class of prescription drugs that are nonmedically used more by full-time college students than part-time college and non-college peers (during the past month; ages 18-22; SAMHSA, 2015)

Full-time college students Part-time college students and non-college peers

6.1 5.1 1.2 1.4 0.2 7.1 5.6 1.5 2.2 0.4 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 Any Psychotherapeutics Pain Relievers Stimulants Tranquilizers Sedatives

%

Past-Year Nonmedical Use of Prescription Drugs, among 12- to 17-year-olds, by Gender (SAMHSA, 2013)

Males Females

Post College Year 4 24 Months: Interview (n=1,101) 88% Screening (n=3,401) 12 Months: Interview (n=1,142) 91% 36 Months: Interview (n=1,097) 88% 48 Months: Interview (n=1,019) 81% 60 Months: Interview (n=1,001) 80% Post College Year 3 84 Months: Interview (n=951) 76% Post College Year 2 Post College Year 1 Senior Year Junior Year Sophomore Year First Year Summer Orientation Baseline Interview (n=1,253) 72 Months: Interview (n=982) 78%

Data weighted to adjust for both sampling bias and attrition. Source: College Life Study. Not to be shown or redistributed without written permission from Amelia M. Arria, PI

Weighted lifetime prevalence of drug use in the first four years of college, by year

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 Marijuana Prescription Analgesics Prescription Stimulants Hallucinogens Inhalants Prescription Tranquilizers Ecstasy Amphetamines Cocaine Heroin

Weighted percent of students who used drug at least once in lifetime

63% 23% 30% 16% 13% 7% 3% 13% 1% 8%

Year 4 Pre- College Year 3 Year 2 Year 1

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 2003 2005 2007 2009 2011 2013

Estimated % with Past-Year Use

Year

Figure 1. Trends in past-year nonmedical use of prescription medications: 2003-2013

Sleeping Meds Sedatives Stimulants Opioids Any Meds

McCabe, S. E., West, B. T., Teter, C. J., & Boyd, C. J. (2014). Trends in Medical Use, Diversion, and Nonmedical Use of Prescription Medications among College Students from 2003 to 2013: Connecting the Dots. Addictive Behaviors, 39(7), 1176-1182.

What We Know

• Different drug classes = different harms
• Definition of nonmedical use
• Motives
• Research Studies of College Students
• Sources of obtaining drugs for nonmedical use
• Access and availability

What We Know, continued

• Diversion is prevalent and fuels nonmedical use
• Overestimation of others use
• Positive and Negative Expectancies
• High-risk Groups for use and diversion
• Strong association with other drug use

Motives

• Curiosity
• Improve concentration
• Stay awake longer to study
• Stay awake longer to party, drink more
• Get high
• Relieve depression symptoms?

But remember, motives are not the same as risk factors

How often do users take prescription stimulants nonmedically?

11.3 15.3 13.8 5 10 15 20 25 30 Year 2 Year 3 Year 4

Average number of times in the past year

Source: College Life Study. Not to be shown or redistributed without written permission from Amelia M. Arria, P

What about students with ADHD who have their own prescribed ADHD medications?

Sources: Arria, A.M., Caldeira, K.M., O’Grady, K.E., Vincent, K.B., Johnson, E.P., Wish, E.D. (2008). Nonmedical use of prescription stimulants among college students: Associations with attention-deficit-hyperactivity disorder and polydrug use. Pharmacotherapy, 28(2) 156-169. Wilens, T.E., Gignac, M., Swezey, A., Monuteaux, M.C., Biederman, J. (2006). Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications. J Am Acad Child Adolesc Psychiatry, 45(4), 408-14.

• 27% overused their own meds
• 16% nonmedically used someone else’s ADHD meds

Among 45 first-year college students with ADHD:

• 22% misused or took too much of their meds
• 10% got high on their meds
• 8% grinding/sniffing
• Nearly all of the misusers (83%) met criteria for CD and/or SUD,

and all were using immediate-release formulations.

In another sample of 55 males (mean age 21) with ADHD:

Sources

Among college students, friends and peers are the most common sources to obtain prescription medications used nonmedically

References: McCabe SE, Teter CJ, Boyd CJ. Medical use, illicit use and diversion of prescription stimulant medication. J Psychoactive Drugs 2006;38(1):43-56. McCabe SE, Boyd CJ. Sources of prescription drugs for illicit use. Addict Behav 2005;30(7):1342-1350. McCabe SE, Cranford JA, Boyd CJ, Teter CJ. Motives, diversion and routes of administration associated with nonmedical use of prescription opioids. Addict Behav 2007;32(3):562-575. Barrett SP, Darredeau C, Bordy LE, Pihl RO. Characteristics of methylphenidate misuse in a university student sample. Can J Psychiatry 2005;50(8):457- 461.

How are ADHD meds obtained for nonmedical use?

10 20 30 40 50 60 70 80 90 Friend w/ Rx Friend w/o Rx Other Self Internet $0 $1-4 $5+ Percent of users Year 1 Year 2 Year 3 Year 4 * Sources of Medication

*Denotes significant difference from years 1 and 2 (p<.05).

Garnier-Dykstra, L.M., Caldeira, K.M., Vincent, K.B., O’Grady, K.E., Arria, A.M. (2012). Nonmedical use of prescription stimulants during college: Four-year trends in exposure opportunity, use, motives, and sources. Journal of American College Health, 60(3), 226-234.

Cost

**Denotes significant difference from years 3 and 4 (p<.05).

**

DIVERSION

60.2% of one sample of college students with ADHD shared

• r sold their prescription stimulants;

35.4% of students with prescription analgesics diverted their medications.

Source: Garnier, L.M., Arria, A.M., Caldeira, K.M., Vincent, K.B., O'Grady, K.E., Wish, E.D. (2010). Sharing and selling of prescription medications in a college student sample. Journal of Clinical Psychiatry. 71(3), 262-269.

Students overestimate how many others use

Source: Carroll, B. C., McLaughlin, T. J., & Blake, D. R. (2006). Patterns and knowledge of nonmedical use of stimulants among college students. Archives of Pediatrics and Adolescent Medicine, 160(5), 481-485.

Students who reported their peers used stimulants nonmedically Students who used stimulants nonmedically

High levels of positive expectancies about the purported benefit

• n performance

“It will work”

Low levels of negative expectancies about the purported benefit

• n performance

“I won’t get in trouble”

Nonmedical Use is also associated with:

Source: Bavarian N, Flay BR, Ketcham PL, Smit E, Illicit Use of Prescription Stimulants in a College Student Sample: A Theory-Guided Analysis. Drug and Alcohol Dependence 2013; 132:665-673.

High Risk Groups

• Students attending competitive colleges
• Students involved with Greek organizations
• High-risk drinkers and other drug users
• Students who are academically struggling
• Students who are not risk-aversive
• Students who have misperceptions of prevalence and what is normative
• Students who perceive drugs as benign, safe to use

Nonmedical prescription drug use is strongly associated with alcohol and other drug use

• Numerous studies report

past-year prevalence estimates for marijuana use

• f 85%+
• Cocaine: 35-60%
• Ecstasy: 52%
• Prescription Analgesics: 44%

Nonmedical Use Medically Supervised Use Medical Overuse

RISK FOR ILLICIT DRUG USE RISK FOR ILLICIT DRUG USE RISK FOR ILLICIT DRUG USE

NON-USERS

• f Rx Stimulants

(n=989) NONMEDICAL USERS

• f Rx Stimulants

(n=217)

Alcohol

93.5 % 100.0 %

Tobacco Cigarettes

55.3 89.4

Marijuana

62.8 93.5

Hallucinogens

7.0 41.5

Cocaine

2.8 18.0

Inhalants

4.8 15.7

Ecstasy

2.6 15.2

Amphetamines

0.9 8.8

Heroin

0.2 0.9

Nonmedical use of prescription analgesics

10.1 44.2

Nonmedical use of prescription tranquilizers

3.7 20.7

Overlap between nonmedical prescription stimulant use and other drug use

What We Suspect

Marijuana and other drug use might be driving academic problems, and nonmedical use

• f prescription stimulants is a

compensatory behavior… a shortcut, and largely unsuccessful.

Nonmedical stimulant users spend less time studying, skip classes more often, and earn lower grades.

Source: Arria AM, O'Grady KE, Caldeira KM, Vincent KB, Wish ED. (2008). Nonmedical use of prescription stimulants and analgesics: Associations with social and academic behaviors among college students. Journal of Drug Issues. 38(4), 1045-1060.

Nonmedical Use of Prescription Stimulants for Studying Time

Marijuana Use

Skipping Class Academic Performance

Marijuana Dependence

NPS use patterns from Year 2 to Year 3

• f the College Life Study (n=898).

Abstained from NPS n=618

Persisted in NPS n=150 Desisted n=52 Initiated NPS n=78

0.016

• 0.025

0.053

• 0.025
• 0.08
• 0.06
• 0.04
• 0.02

0.00 0.02 0.04 0.06 0.08 Change in GPA

Estimated marginal means and standard error bars for change in GPA during years 2-3, by NPS use pattern (n=898).

Desisted from NPS n=52 Persisted in NPS n=150 Abstained from NPS n=618 Initiated NPS n=78

• Note. Sample is restricted to individuals who were never diagnosed with ADHD by Year 3. Change in GPA is computed as the difference between

Year 3 GPA and Year 2 GPA, which were averaged from semesters 3-4 and 5-6, respectively. Results are adjusted for the effects of sex and Year 2 GPA. Normal distribution was assumed for GPA change score. Zero values for semester GPA were treated as missing because they cannot be distinguished from missing data due to studying abroad.

Overall sample y=0.005

Source: Arria, A.M., et al., Do college students improve their grades by using prescription stimulants nonmedically?, Addictive Behaviors (2016), http://dx.doi.org/10.1016/j.addbeh.2016.07.016

Interpersonal factors are important influences on nonmedical use…

• Academic self-efficacy
• Perception of risk
• Perception of reward

Academic Self-Efficacy

• Definition: Having confidence about your ability to complete

academic tasks

• Students who were less confident about their ability to avoid

nonmedical prescription stimulant use when they had a large amount of work in a short amount of time were more likely to use (Bavarian, 2013).

• The more students procrastinate, the more likely they are to use

prescription stimulants nonmedically. A possible solution: create a personalized study plan that outlines study times, learning goals (and class attendance) (Ponnet, 2015).

Academic Self- Efficacy

Experiences

Practice

(Ability) Influences and Attitudes

• f Others

Individuals with low academic self-efficacy might be at high risk for NPS use

Risk and Reward…

• 1. Is it risky?
• 2. Is there a benefit to using?
• 3. Does the benefit outweigh the risk?

% using

5 10 15 20 25 30 35 40 45

High Perceived Harm Low Perceived Harm Stimulants Analgesics

Nonmedical use is higher among students who perceive lower levels of harm

Source: Arria AM, Caldeira KM, Vincent KB, O'Grady KE, Wish ED. (2008). Perceived harmfulness predicts nonmedical use of prescription drugs among college students: Interactions with sensation-seeking. Prevention Science. 9(3), 191-201.

Source: Arria AM, Caldeira KM, Vincent KB, O'Grady KE, Wish ED. (2008). Perceived harmfulness predicts nonmedical use of prescription drugs among college students: Interactions with sensation-seeking. Prevention Science. 9(3), 191-201.

However… among sensation-seekers, perceived harm did not influence analgesic use

What we can do

• 1. Improve physician education and vigilance
• 2. Intervene by discussing both risk and reward perceptions
• 3. Correct student misperceptions
• 4. Educate parents
• 5. Focus on more subtle consequences
• 6. Give non-using students a louder voice

• 1. Monitor medication and other drug use

– Pill counts – Frequent office visits – Urine toxicology screens

• 2. Prescribe medications with lower abuse potential

– Non-stimulants – Extended-release preparations

• 3. Dose judiciously
• 4. Discuss compliance, “extra doses,” and treatment

failure

Clinicians:

Considerations for Treating ADHD in High-Risk Patients

Clinicians:

Considerations for Treating ADHD in High-Risk Patients

• 5. Utilize regular dosing, not PRN
• 6. Advocate for safe storage (don’t

advertise)

• 7. Ask about changes in euphoria,

cravings

• 8. Discuss ethical and legal issues

around diversion

• 9. Support prescription drug

monitoring programs

Improving Clinical Practice on College Campuses

Increase vigilance regarding diversion and nonmedical use among college-bound patients. Partner with local university health centers to promote staff awareness of diversion and the risks of nonmedical use.

Work with counseling center staff to recognize signs of mental health issues and drug problems… and intervene with students who are academically struggling.

Screen ADHD patients for illicit drug use and convey risks of diversion.

Students

 Spread the word to other

students about the true risks of nonmedical use and connection to marijuana use.

 Challenge misperceptions

about “how many people are doing it.”

 Link nonmedical drug use to

illicit drug use.

 Dispel “smart drug” myth.

THC concentrations have increased dramatically from 1995 to 2014

3.96 11.84

0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

CBD THC

ElSohly, M. A., Mehmedic, Z., Foster, S., Gon, C., Chandra, S., & Church, J. C. (2016). Changes in cannabis potency over the last 2 decades (1995-2014): Analysis of current data in the United States. Biological Psychiatry, 79(7), 613-619.

International concern exists regarding high-potency cannabis, especially because of the implications for mental health

Students on Medication

 Adhere to your provider’s

medication instructions.

 Never share your medication… not

with anyone.

 Protect your medication from theft.  Encourage responsible help

seeking.

 Convey messages about risks of

nonmedical use.

Parents



Dispel “smart drug” myths.



Do not condone or facilitate nonmedical use.



Empower parents to take a central role in preventing nonmedical use of prescription drugs.



Raise awareness about the opportunities for “new” drug use in college.



Educate parents to recognize signs of emerging mental health and drug problems.



Educate parents regarding medication adherence and role modeling of proper use



Parent effectively to reduce risk of use

Colleges and Universities



Sponsor ongoing dialogues that raise awareness and share experiences of college professionals



Develop multidisciplinary campus action plans to reduce nonmedical prescription stimulant use.



Have students re-think taking 18 credits per semester in the first year of college.



Consider options for enforcing sanctions against diversion.

Give students who don’t use a LOUDER voice

Monitoring the Future, not published.

Cognitively Strong

Interlocking Dimensions of Student Success

For more information and a list of publications, please visit: www.cls.umd.edu www.cyahd.umd.edu Thank you! Email Dr. Arria at aarria@umd.edu