Abstract
The misuse of prescription medications has emerged as a national public health concern. Epidemiological studies suggest that college students are at an elevated risk to engage in nonmedical use of several medications, including stimulants and central nervous system depressants. Teachers can easily integrate material related to the nonmedical use of prescription drugs (NMUPD) into undergraduate psychology and statistics courses. Presenting this information provides an opportunity for teachers to address fundamental topics in ways that students tend to find interesting and personally relevant. We use this article to introduce a definition of NMUPD, present statistics on prevalence and a wide range of physical and psychological correlates among college students, and discuss risk and protective factors and motives for use. We also present a number of concrete examples of how teachers can use the material to illustrate basic concepts often included in statistics, research methods, and other psychology courses.
Decades of federal and state-funded longitudinal epidemiological research have consistently led to a simple conclusion: College students engage in relatively high levels of drug and alcohol use, and as a result, they are at risk of a range of negative consequences. The epidemiological research has led to prevention and intervention programs designed to limit use and negative consequences among adolescents, college students, and young adults. Thus, prior to or early in their college experience, many students learn about the potential implications of using alcohol, marijuana, and other illicit substances. Programs like drugs abuse resistance education (D.A.R.E.) are still common at the primary and high school levels, and web-based programs such as AlcoholEdu, Alcohol Wise, and Marijuana Wise have been implemented widely across higher education to inform incoming students about risks, norms, and institutional policies for college student drinking and drug use (Amaro et al., 2010; Nelson, Toomey, Lenk, Erickson, & Winters, 2010). There is less research, however, on the use of prescription drugs among high school and college students, and therefore prevention and intervention programs are not as common. As a result, students with prescriptions for a range of medications, along with students at risk of using medications without a prescription, may lack adequate information on the potential consequences of such use.
As we will establish later in this article, use and misuse of prescription drugs is fairly prevalent among college students, and such use can lead to a variety of severe public health consequences. Perhaps most evident has been the opioid crisis, which has garnered increased national attention and was recently named a public health emergency in the United States. Opioid-related deaths have increased by 591% since 1999, and prescription opioids have recently been linked to over 17,000 national deaths per year (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2018). Teaching about the misuse of prescription drugs raises issues that are relevant to the lives of students while simultaneously exposing them to psychological theories and methods. Some topics of interest addressed in this article include accurate definitions of problematic use, prevalence data, correlated and negative consequences, risk and protective factors, and motives for use.
Defining Nonmedical Use of Prescription Drugs (NMUPD)
In order to further an understanding of problematic substance use most effectively, including misuse of prescription drugs, it is important to provide accurate definitions that are consistent with psychological theory and research. NMUPD can be defined as using prescription drugs either (a) without a valid prescription or (b) in ways for which they were not intended (McCabe, West, Morales, Cranford, & Boyd, 2007). Consistent with research conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), commonly misused prescription drugs fall into four primary categories: stimulants, pain relievers, tranquilizers, and sedatives.
Stimulants are typically classified as amphetamines or methylphenidate, and individuals most often use them to enhance energy levels or attention; they are also a major tool in the treatment of attention deficit hyperactivity disorder (Center for Behavioral Health Statistics and Quality [CBHSQ], 2018b; Rozenbroek & Rothstein, 2011). Pain relievers reduce severe or chronic pain and include opioids or opioid analgesics. Tranquilizers, which are typically benzodiazepines, are most often used to treat anxiety-related concerns or muscle spasms through their effects on the central nervous system (CNS). Sedatives, most often barbiturates, but also including some benzodiazepines, also act as CNS depressants and typically address anxiety disorders or sleep concerns (CBHSQ, 2018a). Because both tranquilizers and sedatives act on the CNS and address similar concerns, some researchers combine them into a single group. Therefore, depending on cited research, the remainder of this article will either refer to tranquilizers and sedatives separately or as a combined “CNS depressants” group (for a more comprehensive list of commercial and slang names for the four drug classes, see Table 1).
Commonly Misused Prescription Drugs: Summary of Brand Names, Slang Terms, and Effects.
Note. ADHD = attention deficit hyperactivity disorder; CNS = central nervous system.
Prevalence
Data on patterns of use can be an important way of determining the scope and severity of problematic use within given populations. The data from federally funded epidemiology studies like Monitoring the Future (www.monitoringthefuture.org) and the National Survey on Drug Use and Health (nsduhweb.rti.org) are publicly available. As such, teachers in statistics and research methods courses can easily incorporate data on NMUPD into lectures and assignments.
Among young adults aged 18–25 years, 44% reported medical or nonmedical use of prescription medications within the past year. Furthermore, 14.4% of 18- to 25-year-olds reported NMUPD within the past year; endorsement of NMUPD was higher for adults aged 18–25 than all other age groups (CBHSQ, 2018b). Due to these relatively high general prevalence rates, we consider college students to be a particularly important group to study when examining NMUPD.
Stimulants represent the class of drugs most commonly misused by college students. Indeed, stimulants are the only prescription drug type with higher rates of misuse among college-enrolled students than among unenrolled peers of the same age (McCabe, Teter, Boyd, Wilens, & Schepis, 2018). Since 2000, studies estimating prevalence rates for nonmedical use of prescription stimulants (NMUPS) have indicated that anywhere from 8% to 43% of college students have engaged in stimulant misuse (Advokat, Guidry, & Martino, 2008; McCabe, Teter, & Boyd, 2006). Benson, Flory, Humphreys, and Lee (2015) conducted a meta-analysis to provide more accurate prevalence rates of NMUPS among college students and found that 17% of students have misused prescription stimulants while enrolled in college. Recent estimates have indicated lifetime and annual rates of NMUPS of 12.6% and 8.6%, respectively, among college students (Schulenberg et al., 2018).
Compared to stimulants, use of pain relievers and CNS depressants is less frequent among college students. Lifetime rates of misuse were 6.8%, 6.7%, and 3.9% for pain relievers, tranquilizers, and sedatives, respectively, whereas annual rates of misuse were 3.1%, 3.6%, and 1.9% (Schulenberg et al., 2018). However, due to the scope and severity of problematic outcomes (e.g., fatal overdoses) related to opioid and CNS depressant misuse, use of these drugs among college students and other populations represents a major public health issue.
Negative Outcomes and Correlates
Informing students about common use-related consequences can provide the rationale for further research and intervention efforts. Students may be personally interested and perhaps surprised about negative outcomes and correlates related to NMUPD, and many of them will have direct or indirect experience. Discussing correlates, antecedents, and consequences of NMUPD can lead to several discussions regarding research methods. Students typically enjoy discussing the ethics of conducting research on substance use. For example, what is the most appropriate way to ask participants about their use? Or when is it safe, legal, and ethical to conduct drug administration studies? Research on the consequences of drug use can also lead to excellent discussions on the types of inferences that researchers can draw from various research designs (e.g., case studies; cross-sectional, longitudinal, and experimental studies).
Health-Related Concerns
The first set of potential negative consequences in substance-use research includes physical risks and health effects. Common side effects among individuals who regularly take stimulants include sleeplessness and weight loss (Pillow, Naylor, & Malone, 2014). A significant number of students who endorsed NMUPS also reported experiencing headaches, stomachaches, and dizziness or lightheadedness (Rabiner et al., 2009). In addition, stimulant users with cardiovascular problems may be at greater risk of use-related heart problems including heart failure; for such reasons, the Food and Drug Administration suggested that doctors should screen patients for heart concerns prior to prescribing stimulants (Vetter et al., 2008).
Perhaps more noticeable and severe are negative health outcomes related to pain reliever misuse and CNS depressant misuse. From a public health perspective, the most salient problematic outcome for NMUPD is the risk of fatal overdose, which has risen dramatically over the last two decades, from 3,422 in 1999 to 17,029 in 2017, a 498% increase (Centers for Disease Control and Prevention [CDC], 2017). Among adolescents and young adults, prescription opioids account for more than 1,100 deaths annually, and with regard to sedatives, over 8,000 people died in 2015 due to misuse, including over 1,000 adolescents and young adults (CDC, 2017). Other nonfatal health-related consequences for sedatives include respiratory difficulties, seizures, dangerous heart rate elevations, and impaired motor control (Weaver, 2015). Other health-related risks of tranquilizer misuse include seizures, nausea, and increased likelihood for developing tinnitus (Salzman, 1991).
Psychological and Cognitive Correlates
One obvious risk associated with NMUPD is addiction, often understood and referred to as “dependence.” As substance-use research and interventions have developed over time, these concerns are now conceptualized as substance-use disorders (SUDs; American Psychiatric Association [APA], 2013). An SUD, as defined in Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5; APA, 2013), is manifested by a “cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-use related problems” (p. 483). Impairments from SUDs fall into four main categories: (a) impaired control, (b) social impairment, (c) risky use, and (d) pharmacological indicators (i.e., tolerance and withdrawal; for a comprehensive list of SUD criteria, see Table 2). It is worth pointing out that only a portion of students who engage in NMUPD meet the criteria for an SUD. Nevertheless, the ideal time for prevention and intervention is before an individual meets the criteria. In addition, negative consequences of use, including overdose, can occur to users regardless of their diagnostic status.
DSM-5 Diagnostic Criteria for Substance Use Disorder.
Note. Material adapted from Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5; APA, 2013).
a These criteria are not considered to be met for individuals taking the substance under medical supervision.
Research has also shown that NMUPD is significantly correlated with depression. Whereas studies have previously linked NMUPD to depressive symptoms (Poulin, 2007), more recent studies have extended this research by identifying specific types of stimulant misuse that might be especially problematic. For example, in a study evaluating administration route and frequency of misuse, researchers found that both increased NMUPS frequency and nonoral routes of administration (e.g., snorting, smoking, inhaling) were linked to depression; individuals who reported these behaviors experienced significantly more depressive symptoms than individuals who engaged in NMUPS less frequently or strictly through oral routes of administration (Teter, Falone, Cranford, Boyd, & McCabe, 2010).
Similar to NMUPS, individuals who misused sedatives were at higher risk of depression than individuals who did not use sedatives or who used sedatives with a valid prescription (Goodwin & Hasin, 2002). Regarding pain relievers, Martins et al. (2012) conducted a longitudinal study and found that lifetime nonmedical use of prescription opioids predicted a variety of psychological disorders including major depressive disorder, bipolar disorder, general anxiety disorder, social anxiety disorder, and panic disorder. These findings suggest that misuse of prescription opioids puts individuals at increased risk of not only at overdose and death but also serious mental disorders that are linked to lower quality of life and suicidal ideation (Furr, Westefeld, McConnell, & Jenkins, 2001). But, as noted above, discussing other variables and risk factors that might also account for increased rates of disorders among those who misuse pain relievers would be an interesting way for teachers to incorporate a discussion of research methods into their courses.
Researchers have also observed strong relations between NMUPD and other substance use–related concerns. Among young adults, NMUPD has been linked to a variety of problematic drinking behaviors including driving under the influence and alcohol-related legal concerns, interpersonal problems, and physical injury (Hermos, Winter, Heeren, & Hingson, 2009). More specifically, individuals who endorsed NMUPS were at increased risk of more negative alcohol-related consequences; this was especially true for students who engaged in NMUPS and alcohol co-ingestion (Messina et al., 2014). College students who reported nonmedical use of tranquilizers were over 10 times more likely to report use of cocaine, ecstasy, and other NMUPD over the past month; such individuals were also significantly more likely to engage in binge drinking and driving while intoxicated (McCabe, 2005). Similarly, opioid misuse has been linked to binge drinking and to use of cigarettes, marijuana, cocaine, and other illicit drugs (McCabe, Teter, & Boyd, 2005).
With regard to potential cognitive effects of NMUPD, several studies have examined the degree to which misuse may yield either positive or negative cognitive outcomes. Although many students report NMUPS for cognitive enhancement or improved academic performance (e.g., Teter, McCabe, Cranford, Boyd, & Guthrie, 2005), research suggests that NMUPS may not result in desired cognitive and academic benefits. More specifically, a recent comprehensive review of the literature suggested that students who engage in NMUPS may not actually see intended improvements in either cognitive functioning or academic performance, thus putting students at risk of negative outcomes in the absence of intended benefits (Weyandt et al., 2013). Furthermore, long-term CNS depressant use has been linked to overall decreases in cognitive functioning (Barker, Greenwood, Jackson, & Crowe, 2004). Individuals who engage in misuse of prescription CNS depressants are unlikely to receive adequate instruction and monitoring from licensed physicians who can monitor long-term cognitive risks, therefore placing such misusers at increased risk of a variety of cognitive impairments.
Legal and Ethical Concerns
In our experience, and as documented in research, many students are unaware of the potential legal consequences of prescription misuse and diversion (defined as selling, sharing, or giving away prescription medications; DeSantis, Webb, & Noar, 2008). Despite such limited awareness, several states maintain that possession or diversion of a Schedule II drug (several stimulants and pain relievers and some sedatives) is a felony (Smith & Farah, 2011). As such, possessing or giving away medications can lead to significant fines, jail sentences, loss of student loans, and other legal consequences. Furthermore, various U.S. colleges (e.g., Duke University) have begun to label NMUPS as “cheating” in their school honor codes. Many students may be unaware of their school’s honor code policies, and discussing local and national trends on the inclusion of NMUPS in such codes can lead to lively classroom debate. Moreover, Reisinger, Rutledge, and Conklin (2016) found that students who believed their school honor code addressed NMUPS were less likely to engage in misuse. These findings suggest that further education efforts may be useful in preventing diversion and NMUPD among college students.
Prescription diversion rates among college students are particularly high. Estimates from studies with prescribed stimulant users have indicated that at least 43% of such individuals have provided peers with their medications within their lifetime (Gallucci, Martin, & Usdan, 2015; McCabe, West, Teter, & Boyd, 2014; Schultz, Silvestri, & Correia, 2017). Over 26% of students with opioid prescriptions and over 19% of students with CNS depressant prescriptions also reported lifetime diversion (McCabe et al., 2014). Furthermore, individuals seeking medication often approach diverters, with over 11% of stimulant diverters reporting that they have been asked for their medication over 40 times (Schultz et al., 2017). One factor that has been linked to diversion is the perception of peer beliefs and behaviors also referred to as normative beliefs. Diverters are more likely to perceive friends as being more likely to approve of frequent NMUPS (Schultz et al., 2017). Similarly, Holt, Marut, and Schepis (2018) found that overestimating the number of peers who use prescription stimulants was linked to higher likelihood of diversion. From a prevention standpoint, these data underscore the importance of making sure students have accurate information about NMUPS and diversion, as individuals with inflated perceptions of the frequency of these behaviors may be at increased risk.
Risk and Protective Factors
Although evaluating prevalence and negative outcomes for problematic substance use can provide useful information to support continued research, understanding various risk and protective factors for problematic use has several benefits as well. Identifying individuals and behaviors that are associated with increased or decreased likelihood for problematic use can be especially useful in developing specific, targeted prevention efforts. For NMUPD, there are various demographic, behavioral, and personality-related factors that make individuals more likely either to engage in NMUPD or to experience problematic outcomes from use.
Demographics
For overall prevalence of NMUPD, male students, Caucasian students, and members of Greek organizations are more likely to report misuse than female students, ethnic minorities, and students who are not Greek affiliated (McCabe et al., 2014). For stimulant misuse specifically, findings from Benson et al.’s (2015) comprehensive review of college NMUPS indicated that a majority of studies found significant differences in misuse based on ethnicity, with Caucasian students showing higher rates of misuse than all other ethnicities. In contrast, Benson et al.’s review found limited and mixed results when considering religion, socioeconomic status, and year in college. Several studies have also found that college men are more likely than women to engage in nonmedical use of stimulants (Dussault & Weyandt, 2013; Hartung et al., 2013; McCabe et al., 2014). However, further exploration has indicated that male college students are offered prescription stimulants more than female college students, and this difference may account for the overall difference in male and female stimulant misuse (Garnier-Dykstra, Caldeira, Vincent, O’Grady, & Arria, 2012). Such findings suggest that the frequency with which students are offered prescription medications may be a useful risk factor and should be a focus in the development of prevention efforts.
Regarding tranquilizers, some findings have suggested that male college students are more likely than female students to engage in misuse (McCabe, 2005). However, more recent exploration of demographic variables suggests that misuse among female students has increased, and gender might no longer represent a noticeable risk factor for tranquilizer and sedative misuse (Blanchard, Stevens, Littlefield, Talley, & Brown, 2017). Similar trends are also present for prescription pain reliever misuse among college students (Blanchard et al., 2017; McCabe et al., 2005). Gender effects among college students may vary slightly from those in the general population. Specifically, male adults tend to endorse higher rates of past-year stimulant, painkiller, and tranquilizer misuse than female adults, with no gender differences observed for sedative misuse (CBHSQ, 2018b).
Behavioral and Personality Factors
Although demographic variables may represent the most readily available and noticeable risk and protective factors for substance use, evaluating other behavioral and personality-related factors is also important. One behavioral indicator of substance-use frequency and use-related problems involves individual differences in expectancies for use. For example, Leigh and Stacy (1993) developed a scale to account for positive (i.e., social facilitation, fun, sex, and tension reduction) and negative (i.e., social, emotional, physical, and cognitive/performance) alcohol outcome expectancies, and research has suggested that endorsement of different expectations may predict various use-related outcomes. Although expectancies for using prescription drugs in college may be different than alcohol expectancies, they still represent an important factor to consider for nonmedical use. In a sample of undergraduate students, Arria, Caldeira, Vincent, O’Grady, and Wish (2008) examined the perceived risk of using both stimulants and opioids nonmedically. Arria et al. found that over 25% of students reported that they perceived great risk of nonmedical use. But importantly, individuals who expected potential harm were significantly less likely to engage in NMUPD, suggesting that awareness of such potential harms may represent an important protective factor for college student NMUPD. Conversely, students who expect cognitive enhancement effects are more likely to engage in NMUPS (Looby, Beyer, & Zimmerman, 2015). Given that NMUPS and grade point average (GPA) are negatively correlated (Weyandt et al., 2009), this indicates one area to consider for targeted prevention efforts with college students.
In addition to outcome expectancies, impulsivity is one of the most useful personality-related predictors of NMUPD. Similar to findings related to other substances (e.g., DeWit, 2009), the broad construct of impulsivity has been associated with increased NMUPD among college students (Chinneck et al., 2018; Messina et al., 2014). Students with high levels of sensation seeking and lack of premeditation engage in more NMUPS (Lookatch, Dunne, & Katz, 2012). With regard to other prescription drug classes, impulsivity-related correlates have varied by gender, as sensation seeking has been linked to pain reliever misuse among female students only and increased tranquilizer misuse among male students only (Blanchard et al., 2017). Although gender differences may exist when it comes to impulsivity and NMUPD, tailored prevention efforts to account generally for students with impulsive patterns of behavior may be warranted.
Another important predictor of substance use in college students relates to individuals’ perceptions of their peers’ use. Many students tend to overestimate how much alcohol an average student at their campus consumes; along with this, overestimating peers’ alcohol consumption has been associated with more frequent and heavier drinking patterns (Perkins & Wechsler, 1996). McCabe (2008) observed similar patterns for NMUPD: 70.2% of college students overestimated peer stimulant misuse, and 69.9% overestimated prescription opioid misuse, with overestimation predicting increased likelihood for NMUPD. More recent estimates have also indicated that students who overestimate the percentage of campus peers who engage in NMUPS are more likely to engage in NMUPS themselves (Blevins, Stephens, & Abrantes, 2017).
Motives for Use
One area of substance-use research that many students find interesting and relevant relates to why individuals tend to use various drugs. The motives-based model has been useful in furthering an understanding of substance use and use-related consequences. For example, Cooper’s (1994) drinking motives model highlights four main motives for alcohol consumption: coping (i.e., to reduce negative affect), enhancement (i.e., to increase positive affect), social (i.e., to enhance social interactions), and conformity (i.e., to reduce feelings of social rejection). Researchers have studied motives extensively and found that endorsement of specific motives predicts increased use and problematic outcomes (e.g., Carey & Correia, 1997; Kuntsche, Knibbe, Gmel, & Engels, 2005). Research on alcohol and marijuana use, for example, has found an association between coping motives and problematic use-related consequences (e.g., Cary & Correia, 1997; Simons, Correia, Carey, & Borsari, 1998). With coping motives traditionally indicating a salient risk factor for problematic substance use, questions remain regarding the impact of coping motives in NMUPD. More specifically, several prescription medications (e.g., tranquilizers) have been specifically developed and are typically prescribed to assist in reducing negative affect (Rozenbroek & Rothstein, 2011). Therefore, identifying problematic motives that account for appropriate and inappropriate coping for NMUPD may require new means of assessment and evaluation.
Seminal research on motives for NMUPD identified two primary reasons for use: self-treatment (i.e., to receive illicit benefits for which the drug was intended) and recreation (i.e., to experience effects for which the drug was not originally intended; McCabe, Boyd, & Teter, 2009). More recent efforts to evaluate motives for different drug types have identified specific self-treatment and recreational motives for stimulants, pain relievers, and CNS depressants (Messina et al., 2016). Self-treatment motives are linked to the typically intended purpose for each class of drug, whereas recreational motives for all drug types have included counteracting the effects of other drugs, experimentation, safety relative to other street drugs, and experiencing a high. Given the limited research on motives for NUMPD, students may enjoy discussing what types of studies are most warranted. Initial prompts may include developing a full taxonomy of reasons for use, constructing psychometrically sound measures of motives for use, establishing the risk and protective factors associated with various motives, and developing prevention and intervention strategies tailored to specific motives.
Making Referrals
It is not unusual for discussion of substance use and psychopathology to touch on the personal lives of students. We have also found it fairly common for students to ask about treatment options they can use or to which they can refer family members or friends. Thus, we recommend that course instructors should be aware of local treatment options and be prepared to share them with interested individuals or with their entire class. Contact information on student counseling or medical services offered by a specific college or university is usually available online. Moreover, SAMHSA offers an online “behavioral health treatment services locator” tool that typically provides a range of options (https://findtreatment.samhsa.gov/). The SAMHSA page also provides contact information for national suicide prevention and treatment helplines.
Conclusion
NMUPD is relatively common among college students and is linked to many personal and public health consequences. Students often find material on substance use interesting and relevant, and we offer a number of suggestions for how teachers can integrate such material into a range of undergraduate psychology courses. As mentioned throughout this review, inclusion of material on NMUPD can be helpful in facilitating discussion on research methods and ethics as well as common questions addressed in both basic and applied psychology courses. Although much of the literature covered in this article may offer information that could inform prevention and intervention efforts, implementation of such efforts is noticeably lacking (Palmer, McMahon, Moreggi, Rounsaville, & Ball, 2012). Actively discussing gaps in the literature can be useful in exploring the link between research and practice and provide a vehicle for critical thinking.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.