By: Israel Agaku, PhD
Harvard School of Dental Medicine, Boston MA
iagaku@post.harvard.edu

Our interest in the issue of prescription medication misuse¹ is underpinned by the large number of preventable deaths each year from drug overdose; in 2018, there were 67,367 drug overdose deaths in the United States, making this, along with other unintentional injuries such as poisonings, motor vehicle traffic accidents, and unintentional falls, the third leading cause of death in the United States.² Were it to be placed in its own separate category, drug overdose would still remain one of the 10 leading causes of death in the country.² Opioids contribute a large share of this overdose crisis. Two out of three drug overdose deaths in 2018 involved an opioid – be it prescription opioids, heroin, or synthetic opioids.³ To respond to this crisis, the U.S. Department of Health and Human Services declared a public health emergency in 2017 and announced a 5-Point Strategy to Combat the Opioid Crisis,⁴ the Surgeon General also released a Spotlight on Opioids.⁵ Health professions that were significant contributors to opioid prescriptions, including dentistry, heeded these calls to action and adjusted their prescription practices.⁶ As a result of these and many other actions, the death toll from opioid overdose fell by more than 4% between 2017 and 2018.⁷

The same degree of focus has not been paid to misuse of other prescription medications which also have high abuse potential among youth, including medications such as prescription stimulants, tranquilizers, and sedatives. Prescription stimulants deserve particular attention because of the silent epidemic of prescription stimulant misuse among youth in school, especially those in college.⁸ College-enrolled youth are more likely to be away from home, further from parental supervision and closer to peer influences, when compared to those still in middle or high school. Part of the definition for “misuse” is using someone else’s prescription,¹ which could be easily facilitated in social circles where there is some measure of social acceptability of the behavior. The proximity to campus health clinics may also afford college students greater accessibility to healthcare providers for prescription medications such as stimulants which could end up being misused. Youth in college also report a higher prevalence of other behaviors that may be associated with misuse of prescription medications, including marijuana use.⁹

To highlight the issue of misuse of various prescription medications, not just opioids, we therefore conducted this study to quantify and compare the extent of misuse for prescription opioids, stimulants, tranquilizers, and sedatives among a nationally representative sample of U.S. youth and young adults aged 12-25 years old.¹ This age range was selected to cover both youth who might still be enrolled in middle/high school, as well as college-aged youth. Consequently, analyses were stratified by ages 12-17 years, and 18-25 years to examine differential patterns in misuse. We used nationally representative data from the National Survey on Drug Use and Health. Participants in this survey include residents of households and non-institutional group quarters such as college dormitories. Selected participants completed the survey in their homes or dwellings through audio, computer-assisted self-interview methods, which increases privacy and improves self-report of sensitive behaviors such as those assessed in our study (i.e., misuse of prescription medications). Misusing the drug was defined as taking a prescription in larger quantities than prescribed, more frequently than prescribed, for longer than prescribed or in any way that was not specified by their health care provider.¹ Someone taking a drug that was not prescribed to them was also considered misuse. As a secondary objective of this study, we also measured how use of non-prescription substances (e.g., tobacco, alcohol) was associated with misuse of prescription substances. ¹

The purpose of this article is not to denigrate youth (or their parents) for whom these medications are truly needed for medical reasons. Rather, it is to draw attention to the potential for misuse for nonmedical reasons. The basis for concern regarding misuse of prescription medications is because misuse of these drugs can result in drug overdoses, chemical dependency, and even death. The health risks may even be higher when these prescription medications are laced with other substances to increase their bulk weight or alter their psychoactive effects. Besides the risks to an individual, there are also population-level harms from normalizing certain harmful behaviors (e.g., the misuse of so-called “study drugs”, or prescription stimulants, on college campuses). It is imperative for policy makers, school administrators, healthcare professionals, and parents to become aware of these emerging dangers and take appropriate steps, like what has been done for the opioid epidemic. Collectively, we need to recognize that the problem of prescription medication misuse extends far beyond opioids, especially among the youth population.  This should consequently inform the development of cross-cutting comprehensive strategies rather than focusing on a single substance.

There is no golden bullet to solve the problem of substance misuse; multiple evidence-based measures are needed simultaneously. Stricter prescription guidelines can help reduce the extent of diverted prescriptions. We also need to expand barrier-free access to mental health services, including behavioral interventions. Efforts to restrict improper access to prescription medications within clinical settings should be combined with interventions that change social norms. For healthcare providers, there should be a recognition that holistic care involves more than just prescribing medications. Increased quality of patient-provider communication, including offering behavioral counseling when needed, may avert unnecessary prescriptions. Parents and other family members who are prescribed these medications should be encouraged to take more responsibility to keep them locked and out of the hands of youth and young adults.  Parents, caregivers, educators, pharmacists, and clinicians all need to be alert for behavioral markers of prescription medication misuse among youth.

References

1. Agaku I, Odani S, Nelson J. Medical use and misuse of psychoactive prescription medications among US youth and young adults. Fam Med Community Health. 2021 Jan;9(1):e000374. doi: 10.1136/fmch-2020-000374.

2. Drug Overdose Deaths in the United States, 1999–2018. Available at https://www.cdc.gov/nchs/products/databriefs/db356.htm. Accessed 02/05/2021

3. The Drug Overdose Epidemic: Behind the Numbers. Available at https://www.cdc.gov/drugoverdose/data/index.html. Accessed 02/05/2021

4. S. Department of Health and Human Services. 5-Point Strategy To Combat the Opioid Crisis. Available at https://www.hhs.gov/opioids/about-the-epidemic/hhs-response/index.html. Accessed 02/05/2021.

5. S. Department of Health and Human Services. Facing Addiction in America: The Surgeon General’s Spotlight on Opioids. Available at https://addiction.surgeongeneral.gov/. Accessed 02/05/2021.

6. The American Dental Association. The Opioid Crisis. Available at https://www.ada.org/en/advocacy/advocacy-issues/opioid-crisis. Accessed 02/05/2020.

7. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2018. NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.

8. Arria AM, DuPont RL. Nonmedical prescription stimulant use among college students: why we need to do something and what we need to do. J Addict Dis. 2010 Oct;29(4):417-26. doi: 10.1080/10550887.2010.509273. PMID: 20924877; PMCID: PMC2951617.

9. Odani S, Soura BD, Tynan MA, Lavinghouze R, King BA, Agaku I. Tobacco and Marijuana Use Among US College and Noncollege Young Adults, 2002-2016. Pediatrics. 2019 Dec;144(6):e20191372. doi: 10.1542/peds.2019-1372.