U.S. Pharmacist

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Prevalence of Substance Abuse in the Adolescent Population

Timothy R. Ulbrich, PharmD
Assistant Professor of Pharmacy Practice
Northeastern Ohio University College of Pharmacy
Rootstown, Ohio



3/19/2010

 

US Pharm. 2010;35(3):31-37.

The National Survey on Drug Use and Health (NSDUH) and the Monitoring the Future (MTF) survey provide updated, long-term statistics about and insight into drug use across age, racial, ethnic, gender, and geographic groups, among others.1,2 Both surveys highlight the need for focused attention on combating prescription drug abuse in the adolescent population (age 12–17 years). The NSDUH (previously named the National Household Survey on Drug Abuse), which has been conducted since 1971, assesses a sample of individuals over the age of 12 years. The MTF survey, sponsored by the National Institute on Drug Abuse (NIDA), has been conducted by the University of Michigan Institute for Social Research since 1975 and focuses primarily on a sample of 8th-, 10th-, and 12th-graders.

Despite similar trends in both surveys regarding the prevalence of drug abuse, the NSDUH has traditionally reported lower rates of substance abuse among adolescents.1,2 While the MTF survey does not assess misuse of prescription medications across all adolescent age groups (e.g., narcotics other than cocaine are reported only in 12th-graders), it is useful for comparison with data reported by the NSDUH. This article will review survey data supporting an epidemic in drug misuse among adolescents, discuss commonly abused prescription and nonprescription medications, examine key components of educational programs, and provide available resources for educating the adolescent population.

Epidemiology

The explosive increase in the misuse of prescription and nonprescription medications has been referred to as “pharming.”3 The term Generation Rx has been used describe this increase in prescription-drug misuse among the current generation of youths.4 In 2007, 9.5% of adolescents aged 12 to 17 years indicated that they had used an illicit drug (marijuana, cocaine, heroin, hallucinogens, inhalants, or psychotherapeutics used nonmedically) within the past month. While marijuana was the most-used illicit drug (6.7%), past-month nonmedical use of psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) came in second (3.3%).1 Although past-month nonmedical use of prescription medications among adolescents declined slightly from 2002 to 2007 (4.0% and 3.3%, respectively), this should still be an area of great concern and attention in the medical community.1

It also is important to consider lifetime prevalence of drug use, since earlier onset of nonmedical use of prescription drugs is a predictor of subsequent drug abuse and dependence.5 While the reported lifetime use of amphetamines among 8th-, 10th-, and 12th-graders has decreased since 1991, the reported lifetime prevalence of narcotics other than heroin has doubled among 12th-graders, from 6.6% in 1991 to 13.2% in 2008.2 Additionally, the reported use of sedatives has increased slightly among 12th-graders—from 6.2% in 1991 to 8.5% in 2008—but has decreased since a peak of 10.5% in 2005.2

Factors that contribute to the misuse of prescription and nonprescription medications among adolescents should be incorporated into the development of educational programs to render them more effective. Several things to consider are the accessibility of products in the store or in the household medicine cabinet; ease of purchase OTC (for some products) or on the Internet; misconception of the risks associated with prescription medications; and lack of oversight by parents.3

With regard to access, the NSDUH reported that more than half of past-year nonmedical users of prescription medications over the age of 12 years obtained the medication from a friend or relative for free.1 The MTF survey echoes these results, noting that, among 12th-graders who reported nonmedical use of amphetamines, tranquilizers, or narcotics other than heroin within the last year, more than half were given the medication for free by a friend or relative (58.2%, 59.8%, and 50.5%, respectively).2 When 8th-, 10th-, and 12th-graders were asked about the difficulty of obtaining narcotics other than heroin, 12.1%, 20.3%, and 34.9%, respectively, said that these substances were “fairly easy” or “very easy” to get. The general upward trend from 8th grade to 12th grade also was seen for amphetamines, sedatives, and tranquilizers.2

With regard to perceived harmfulness, the MTF survey assessed this factor for prescription medications only among 12th-graders. When 12th-graders were asked, “How much do you think people risk harming themselves (physically or in other ways) if they take sedatives (barbiturates) regularly?” 50.2% responded that there was “great risk,” down from 70.2% in 1992.2 When asked the same question regarding amphetamines, 65.4% responded that there was “great risk,” down from 72.4% in 1992.2

In terms of parental involvement, past-month use of illicit drugs, cigarettes, and alcohol was lower among teens aged 12 to 17 years who reported that their parents “always” or “sometimes” monitored their behavior, versus teens who reported “seldom” or “never.”1 While 9 in 10 parents reported discussing drugs with their child or teen within the past year, “drugs in general,” “cigarettes,” and “alcohol” topped the list of items discussed and “Rx medicines to get high” and “Non-Rx cough medicine to get high” fell into the bottom half.6

Analysis of differences in drug misuse among gender, ethnic, racial, and geographic groups, as well as of predictors of misuse, may provide valuable information in terms of early treatment by clinicians and development of successful educational programs. Among subjects aged 12 years and older, although males tended to have higher rates of illicit drug use, similar rates between males and females were reported for the nonmedical use of prescription medications.1 In addition, differences in illicit drug use among different races and ethnicities have been noted. Past-month illicit drug use was lowest among Asians (4.2%) and highest among American Indians and Alaskan Natives (12.6%); in between were adolescents of two or more races (11.8%), African Americans (9.5%), Caucasians (8.2%), and Hispanics (6.6%).1

In terms of geographic location, 34% of rural adolescents in one study reported lifetime nonmedical use of prescription medications; this is much higher than the national rate.7 While this was an isolated study of 849 rural high school students in Vermont with high reports of concomitant marijuana use, it is an important consideration for practitioners and educators located in rural settings, and further research is warranted to determine whether the findings are consistent among other rural populations.

Predictors of prescription medication misuse among adolescents include poor academic performance; past-year major depression; higher risk-taking levels; and past-year use of alcohol, cigarettes, marijuana, cocaine, or inhalants.8 Among adolescents reporting a past-year major depressive episode (MDE), 35.5% used illicit drugs during the episode, versus 17.2% among those who did not have a past-year MDE.1

Commonly Abused Prescription and OTC Medications

Both prescription and nonprescription medications are abused in the adolescent population.3 A list of commonly abused prescription and nonprescription medications, organized by medication class and including common street names, is given in TABLE 1.9 Commonly abused medications are painkillers (most commonly, opioid-containing products), stimulants, and central nervous system depressants (including sedatives and tranquilizers).9


One common nonprescription product with significant misuse potential is dextromethorphan.3,10 An ingredient in several OTC cough and cold products, dextromethorphan can produce mind-altering effects in larger doses; in excessive doses, it can cause dissociative effects similar to those of ketamine and phencyclidine by antagonizing the N-methyl-d-aspartate receptor.3,10 Dextromethorphan has been used clinically since the 1950s, but abuse of the pills (Romilar) led to removal of the product from the market in the 1960s.11 However, different formulations of the product later became available OTC, and a new surge in misuse occurred in the 1990s.11 The wide availability of OTC products containing dextromethorphan makes it a source of concern in terms of misuse by adolescents.

Another worry with regard to the nonprescription market has been the misuse of methamphetamine among adolescents. Methamphetamine is a stimulant that can be produced from products such as pseudoephedrine.12 Among youths aged 16 to 25 years, approximately 47% of methamphetamine misusers also reported misuse of a prescription stimulant.12 In addition, more than 90% of all young people who misused methamphetamine reported lifetime use of at least three different classes of illicit drugs.12

Educational Programs

Information about research-based drug-abuse prevention programs supported by the NIDA is available at www.drugabuse.gov/pdf/prevention/RedBook.pdf.13 This document, published by the NIDA, outlines 16 research-based principles that are important to the selection, construction, and delivery of drug-abuse prevention programs (TABLE 2).13 Among adolescents aged 12 to 17 years in 2007, 75.8% reported having seen or heard of drug or alcohol prevention messages at school.1 Among teens who reported exposure to a prevention message at school, 8.7% had used illicit drugs within the past month, compared with 12.0% of those who did not report exposure to a prevention message.1


Educational programs aimed at preventing the misuse of prescription medications among adolescents should take into account that there are differences in motivation for abuse across different classes of medications.14,15 In addition, differences in the source of the prescription medication, as well as differences in sex, ethnicity, and severity of misuse, should be considered.16 For example, in a study assessing data from the 2005–2006 NSDUH, adolescent females were found to be more likely to steal opioids or obtain them for free, whereas males were more likely to purchase opioid medication or obtain it from a physician.16

Resources

Pharmacists can play an integral role in the attempt to stem adolescent drug misuse by increasing awareness among consumers, participating in community events and presentations, and encouraging the proper disposal of prescription medications through programs such as SMARxT Disposal (www.smarxtdisposal.net). Proper disposal of medications may prevent outdated or unnecessary medications from being accessible to the adolescent population. In addition, many resources are available for parents and providers who want to learn more about drug abuse and for individuals who are interested in educating adolescents in their community. The Web sites of the National Institute on Drug Abuse (www.nida.nih.gov), the Partnership for a Drug-Free America (www.drugfree.org), and the Generation Rx Initiative at The Ohio State University (http://pharmacy.osu.edu/outreach/generation-rx) all include valuable resources. In addition, material for parents to educate their children, such as the Substance Abuse and Mental Health Services Administration (SAMHSA) Family Guide (www.family.samhsa.gov/default.aspx) and the Talking to Your Kids About Prescription Drug Abuse brochure developed by the National Council on Patient Information and Education and SAMHSA (www.talkaboutrx.org/documents/samhsa_parent_brochure.pdf), may be useful.

Conclusion

Both the prevalence of and potential factors contributing to drug misuse among adolescents are sources of concern. Educational efforts in the home, community, or school may be beneficial, and research-based principles should be implemented to develop programs that are specific, timely, and comprehensive.

REFERENCES

1. Substance Abuse and Mental Health Services Administration (SAMHSA). Results From the 2008 National Survey on Drug Use and Health: National Findings. NSDUH Series H-36, HHS Publication No. SMA 09-4434. Rockville, MD: SAMHSA Office of Applied Studies; 2009.
2. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Results on Adolescent Drug Use. Overview of Key Findings, 2008. NIH Publication No. 09-7401. Bethesda, MD: National Institute on Drug Abuse; 2009.
3. Levine DA. ‘Pharming’: the abuse of prescription and over-the-counter drugs in teens. Curr Opin Pediatr. 2007;19:270-274.
4. Partnership for a Drug-Free America. Generation Rx: national study reveals new category of substance abuse emerging: teens abusing Rx and OTC medications intentionally to get high. www.drugfree.org/General/Articles/article.aspx?id=df07cc48-88e2-4fc5-abdf-c83c0e22e943&Site=Print&PrintPage=true. Accessed February 12, 2010.
5. McCabe SE, West BT, Morales M, et al. Does early onset of non-medical use of prescription drugs predict subsequent prescription drug abuse and dependence? Results from a national study. Addiction.
6. Partnership for a Drug-Free America and MetLife Foundation. 2008 parents attitude tracking study. May 2009. www.drugfree.org/Files/Full_Report_2008. Accessed November 29, 2009.
7. Levine SB, Coupey SM. Nonmedical use of prescription medications: an emerging risk behavior among rural adolescents. J Adolesc Health. 2009;44:407-409.
8. Schepis TS, Krishnan-Sarin S. Characterizing adolescent prescription misusers: a population-based study. J Am Acad Child Adolesc Psychiatry. 2008;47:745-754.
9. National Institute on Drug Abuse. Selected prescription drugs with potential for abuse. www.nida.nih.gov/PDF/PrescriptionDrugs.pdf. September 2002 (rev April 2005). Accessed November 17, 2009.
10. National Institute on Drug Abuse. NIDA InfoFacts: prescription and over-the-counter medications. www.nida.nih.gov/infofacts/PainMed.html. Accessed November 29, 2009.
11. Schwartz RH. Adolescent abuse of dextromethorphan. Clin Pediatr (Phila). 2005;44:565-568.
12. Wu LT, Pilowsky DJ, Schlenger WE, Galvin DM. Misuse of methamphetamine and prescription stimulants among youths and young adults in the community. Drug Alcohol Depend. 2007;89:195-205.
13. National Institute on Drug Abuse. Preventing Drug Use Among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders. 2nd ed. NIH Publication No. 04-4212A. Bethesda, MD: NIDA; 2003.
14. Boyd CJ, McCabe SE, Cranford JA, Young A. Adolescents’ motivations to abuse prescription medications. Pediatrics. 2006;118:2472-2480.
15. Twombly EC, Holtz KD. Teens and the misuse of prescription drugs: evidence-based recommendations to curb a growing societal problem. J Prim Prev. 2008;29:503-516.
16. Schepis TS, Krishnan-Sarin S. Sources of prescriptions for misuse by adolescents: differences in sex, ethnicity, and severity of misuse in a population-based study. J Am Acad Child Adolesc Psychiatry. 2009;48:828-836.

To comment on this article, contact rdavidson@uspharmacist.com.

 

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