Drug and Alcohol Dependence 143 (2014) 272–276
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Short communication
A survey of nonmedical use of tranquilizers, stimulants, and pain relievers among college students: Patterns of use among users and factors related to abstinence in non-users Sara A. Brandt a,1 , Elise C. Taverna b,1 , Robert M. Hallock b,∗,1 a b
Dept of psychology, Skidmore College, 815 N Broadway, Saratoga Springs NY, 12866 Neuroscience Program, Skidmore College, 815 N Broadway, Saratoga Springs NY 12866
a r t i c l e
i n f o
Article history: Received 10 December 2013 Received in revised form 14 July 2014 Accepted 21 July 2014 Available online 7 August 2014 Keywords: Non-medical prescription drug use Stimulant abuse Polydrug use
a b s t r a c t Background: This study examined lifetime non-medical prescription drug use among college students at a small liberal arts college in the Northeast. We assessed the motives, frequency of use, sources, and perceived emotional/physical risks of nonmedical prescription drugs. Specifically, we examined the nonmedical use of prescription pain relievers, stimulants, and anti-anxiety medication. Methods: We sent an internet-based survey to 1/3 of the student body and 303 students completed the survey. Results: We found that 36.8% of the sample reported using prescription drugs for non-medical purposes. First-year students were less likely to have used the drugs than those in other class years. Of those reporting use, 48% reported non-medical use of pain relievers, 72.8% reported using stimulants, and 39.8% reported using anti-anxiety medication. The most commonly used pain relievers were Vicodin (hydrocodone/acetaminophen), OxyContin (oxycodone), and codeine (acetaminophen/codeine). The most commonly used stimulants were Adderall (amphetamine/dextroamphetamine) and Ritalin (methylphenidate), while the most commonly used anti-anxiety medication was Xanax (alprazolam). When non-users were asked what factors influenced their choice not to abuse prescription drugs, 82% cited a lack of interest, 61% responded it was due to a fear of damaging their physical health, and 60.1% responded fear of damaging their mental health. Conclusion: This study supports recent findings that show widespread non-medical use of prescription drugs among college students. Our report brings a more detailed understanding of the patterns of drug usage, and the factors influencing both drug use in those who use them and abstinence in those who choose not to use them. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Many studies have looked at usage, motives, and risks of nonmedical prescription drug use among young adults, specifically undergraduates. The 2012 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2013) examined the use of psychotherapeutic drugs among 18–25 year olds, and past month usage was 5.1%. Studies show the rate of non-medical prescription drug use varies among college students (Garnier-Dykstra et al., 2012; McCabe, 2008; McCabe et al., 2005a,c; McCabe and Teter, 2007; Teter et al., 2006; White et al.,
∗ Corresponding author. Tel.: +1 518 580 5740; fax: +1 518 580 5319. E-mail address: [email protected] (R.M. Hallock). 1 All authors contributed equally. http://dx.doi.org/10.1016/j.drugalcdep.2014.07.034 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
2006). More research that quantifies non-medical use of prescription drugs on the college campus is necessary, especially given the reported epidemic rates of use/abuse. College students report using pain relievers, stimulants, and tranquilizers for various non-medical purposes. College students frequently use pain relievers (including hydrocodone products like Vicodin and codeine, and oxycodone products such as OxyContin and Percodan; Wu et al., 2008). Furthermore, stimulants are commonly used as study aids and to increase concentration (Burgard et al., 2013; Garnier-Dykstra et al., 2012; Hanson et al., 2013; Rozenbroeck and Rothstein, 2011; Teter et al., 2006). Lastly, tranquilizers are often used to amplify the high of another drug or offset its unfavorable effects (O’Brien, 2005). The current study examines use of non-medical prescription drugs among college students at Skidmore College, a small private liberal arts college in the Capital District of New York (190
S.A. Brandt et al. / Drug and Alcohol Dependence 143 (2014) 272–276
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Table 1 Sources of pain relievers, stimulants, and tranquilizers, and when they were used.
Source of drugs A friend gives them the drugs Own prescription Family member provides them Purchases them from a friend Purchases them from an acquaintance Reason for use Studying for final exams Studying for midterm exams Studying for regular exams Before attending class Socializing and partying Self-medication*
Pain relievers (%)
Stimulants (%)
Tranquilizers (%)
59.6
78.6
60.5
32.7 26.9
21.4 11.4
13.2 28.9
17.3
41.4
18.4
9.6
14.3
7.9
8.2
65.7
9.1
6.1
54.3
9.1
6.1
48.6
9.1
2.0 69.4
31.4 47.1
12.1 48.5
24
N/A
97
* Includes pain relievers used for self-medication of pain/sleep, and tranquilizers used for self-medication of anxiety and to aid in relaxation. Participants did not list any uses for stimulants that were for self-medication, rather, the principle reason for using stimulants was for studying purposes, as indicated above.
miles north of New York City). We sent nearly 900 undergraduates an online survey that assessed non-medical use of stimulants, pain relievers, and anti-anxiety medication (tranquilizers), including the frequency of and motivations for use, routes of administration, and perceived emotional/physical risks of use. We also assessed non-users’ perceptions of these drugs, why they abstain from use, and whether or not they perceive these drugs to be harmful to one’s physical and mental health. We also asked user and non-user groups about polydrug use. 2. Method 2.1. Participants Participants were students at Skidmore College (∼2600 undergraduates). A random sample of one third of students from each class year was contacted through email, and the survey was emailed a week before classes ended for the semester. A total of 303 students gave consent; 93 were male, 200 female, 2 other, and 8 did not indicate their gender. There were 74 first-years, 68 sophomores, 85 juniors, 67 seniors, and 9 who did not indicate their class year. 2.2. Survey The survey was created using Surveymonkey, an online survey manager. A link to the survey was emailed to randomly selected students. There was a statement of consent, and then participants were asked whether they had ever used prescription drugs non-medically. Participants who had used prescription drugs non-medically were directed to three sets of questions addressing prescription pain relievers, stimulants, and anti-anxiety medication. Users were asked which prescription drugs they had used non-medically. Prescription medications were identified by both their brand name and generic name in the survey. For example, Diazepam was presented as, ‘Valium (Diazepam)’. An exception was diet pills, which were defined as ‘Diet pills (Phentermine)’. They were also asked where they obtained these drugs. For example, “If you have used prescription anti-anxiety medication/tranquilizers without a current prescription and/or other than as directed by a doctor, how do you usually obtain them?” Selections included those presented in Table 1, plus ‘other’, where they could specify an alternate answer. One of the selections was ‘Had a prescription’, which was used to assess whether they had a prescription but were not using it as directed by a doctor. These data were used to calculate the percentage of users who had a prescription for each of the three categories of drugs. Reasons for using the drugs were assessed with the following statement: “I have used prescription stimulants without a current prescription, or other than directed by a doctor, for the following reasons”. Participants could then select responses that are included in Table 1, plus ‘other’, where they could specify an alternate answer. They were also asked about the route of administration. For example, they were asked “If you have used prescription anti-anxiety medication/tranquilizers without a current prescription and/or other than as directed by a doctor, how do you usually
Fig. 1. Recreational drug use between users and non-users of nonmedical prescription medications. Users were more likely to use all drugs except alcohol, which reached a ceiling in both groups.
ingest them?” Possible responses included: ‘inhale’, ‘inject’, ‘snort’, ‘swallow’, or ‘other (please specify). There were two questions that assessed user’s perceptions of the drugs. First, “Do you consider using prescription stimulants without a current prescription or other than as directed by a doctor to be rewarding?” Second, “Do you consider prescription stimulants to be addictive?” These questions had yes/no answers and were asked for each of the three groups of prescription drugs. Users were also asked about polydrug use. Here, they were presented with the list of drugs in Fig. 1, along with a choice of ‘other (please specify)’, where they could enter in one or more additional drugs that they have used. Participants who had not used prescription drugs for non-medical reasons were asked about their reasons for abstaining as follows: “What factors have influenced your decision to avoid using prescription drugs (i.e., pain relievers, anti-anxiety medication, stimulants etc.) without a prescription?” Participants could select more than one response, and responses included ‘fear of damaging mental health’, ‘fear of damaging physical health’, ‘generally don’t do drugs’, ‘lack of interest’, ‘unable to acquire’, and ‘other’ where they could specify an additional answer. They were also asked if they considered each of the three categories of drugs to be addictive, as well as rewarding and damaging to physical/mental health. Further, they were further asked: “Do you believe that students who take ADHD/ADD drugs while studying for or taking exams have an unfair advantage over students who don’t?” Finally, they were asked about polydrug use with the same question and selections as the users, as described above. All participants were asked their gender, age, and class year. Some questions allowed participants to select more than one answer while some required only one answer, as described below. The survey concluded with instructions on clearing browser history and cache. This project was approved by the Skidmore College Institutional Review Board.
3. Results 3.1. Demographics A total of 303 students consented to participate in this survey. One hundred and ten students (36.8%) indicated that they had used prescription drugs non-medically. Of these, 58.6% were female and 41.4% were male. Ages ranged from 18 to 22; 11.7% were first-years, 24.3% sophomores, 34.2% juniors, and 29.7% seniors. There were 189 students (25.4% male, 73.4% female, and 1.2% other) who reported never using prescription drugs non-medically. Ages ranged from 18 to 23; 33.3% were first-years, 22.4% sophomores, 25.7% juniors, and 18.6% seniors. 3.2. Students who reported non-medical pain reliever use Of students who reported lifetime non-medical prescription drug use, 48.0% reported using prescription pain relievers, and 32.7% had a prescription. Also, 3.9% reported using in the past week, 11.8% in the past month, 28.9% in the past year, and 55.3% over a year ago. Vicodin (hydrocodone/acetaminophen) was the most commonly used drug (64.1%), followed by OxyContin
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(oxycodone) (42.6%), codeine (34.0%), morphine (10.6%), Percodan (aspirin/oxycodone) (8.5%), and Demerol (meperidine) (2.1%). These drugs were swallowed (92.6%) or snorted (24.1%). See Table 1 for data on how they were obtained and why they were used. Additionally, 31.3% reported mixing prescription pain relievers with other drugs: 80% with marijuana, 76.7% with alcohol, and 16.7% with cocaine. 3.3. Students who reported non-medical stimulant use Of students who reported lifetime non-medical prescription drug use, 72.8% reported lifetime non-medical stimulant use, and 21.4% had a prescription. Twenty-two students (27.8%) reported use during the past week, 24.1% within the past month, 26.6% within the past year, and 30.4% over a year ago. Of these, 81.2% reported using Adderall (amphetamine/ dextroamphetamine), 44.9% Ritalin (methylphenidate), 21.7% Concerta (methylphenidate), 10.1% Dexedrine (dextroamphetamine sulfate), 2.9% Methamphetamine, and 1.4% diet pills (phentermine). These drugs were swallowed (88.6%) or snorted (34.4%). See Table 1 for data on how they were obtained and why they were used. Of the stimulant users, 41.8% reported mixing them with other drugs: 86.8% with marijuana, 81.6% with alcohol, 10.5% with cocaine, 7.9% with ecstasy, and 5.3% with lysergic acid diethylamide (LSD). 3.4. Students who reported non-medical tranquilizer use Of students who reported lifetime non-medical prescription drug use, 39.8% reported lifetime non-medical tranquilizer use, and 13.2% had a prescription. Five users (8.3%) reported tranquilizer use in the past week, 15% in the past month, 30% in the past year, and 50% over a year ago. Xanax (alprazolam) (70.3%), Klonopin (clonazepam) (35.1%), Valium (diazepam) (35.1%), Ambien (zolpidem) (32.4%), and Ativan (lorazepam) (10.8%) were the most commonly used. These drugs were swallowed (89.7%) or snorted (10.3%). See Table 1 for data on how they were obtained and why they were used. Additionally, 26.3% of these participants mixed them with other drugs: 75% with marijuana, 65% with alcohol, 20% with ecstasy, 20% with LSD, and 10% with cocaine. 3.5. Students who abstained from prescription drug use When asked what factors influenced their choice not to abuse prescription drugs, 82.6% reported a lack of interest, 61.8% reported fear of damaging their physical health, 60.1% reported fear of damaging their mental health, 56.7% reported that they did not do drugs, and 10.1% indicated that they were unable to acquire the drugs. 3.6. Perceptions of users and non-users Users and non-users differed in the extent to which they perceived pain reliever use as harmful to one’s mental health, 2 (1, n = 277) = 7.23, p < 0.01, physical health, 2 (1, n = 279) = 4.04, p < 0.05, and whether they are addictive, 2 (1, n = 276) = 8.82, p < 0.01. Additional 2 analyses revealed similar differences in perceptions of stimulants and tranquilizers between users and non-users (p < 0.01 for each comparison). Within each category of drugs, non-users were more likely to state that the drugs were harmful and addictive. When users were asked if the drugs were rewarding (inducing pleasure), 24% indicated pain relievers were rewarding, 38% that tranquilizers were rewarding, and 52% that stimulants were rewarding. When asked about whether stimulant use leads to an unfair advantage on exams, 50% of non-users and 45.7% of users indicated that they felt it does. Lastly, there was a significant difference between users and non-users in terms of
other drugs they reported using, 2 (11, n = 934) = 144.08, p < 0.001 (see Fig. 1).
4. Discussion We found that 36.8% of the 303 undergraduates in our survey reported lifetime use of prescription drugs for non-medical purposes, and that usage peaked during their junior year of college. Overall, we found that the most commonly used prescription drugs were stimulants, and the most commonly used stimulant was Adderall (amphetamine/dextroamphetamine). Stimulants were mostly used when studying for final exams, midterms, and regular exams. However, evidence of cognitive enhancement from stimulant use is far from conclusive. In fact, some reports demonstrated that stimulant use is inversely correlated with grade point averages (Egan et al., 2013; Shillington et al., 2006). Nevertheless, 7.3% of our total sample had used stimulants in the past week, potentially because our survey was administered a week before classes ended for the semester and these drugs are often used as study aids (Burgard et al., 2013; Garnier-Dykstra et al., 2012; Hanson et al., 2013; Rozenbroeck and Rothstein, 2011; Teter et al., 2006). Consistent with this, users perceived that stimulants were less harmful to their mental and physical health, less addictive, and more rewarding (pleasurable) than pain relievers and tranquilizers. Conversely, the other drugs in the survey were reported as more addictive and less rewarding. This dichotomy may be attributed to the fact that stimulants are typically used non-medically for study purposes. It is possible that they are perceived as being more rewarding because they are believed to enhance academic performance, but they are not seen as having high addiction potential by these users. Even though the reported lifetime use of methamphetamine was reported to be low (2.9%), this number could be inflated because this drug is available as both a prescribed and illicit drug, as discussed in Kroutil et al. (2006). Therefore, some of our reported prescription stimulant use may have actually reflected the use of street methamphetamine. Among our total sample, 16% reported lifetime non-medical use of pain relievers, while 7% used in the past year. Vicodin (hydrocodone/acetaminophen) was the most commonly used, followed by OxyContin (oxycodone), and codeine. These drugs were most commonly used for recreational purposes and selfmedication of pain. Interestingly, pain relievers were reported as more addictive (77%), more harmful to physical health (65%), and less rewarding (24%) than other prescription drugs. The perceived addictive qualities of these drugs may explain why they are used despite their perceived harm. These data indicate that it may be beneficial to target non-medical pain-reliever use in drug education programs on college campuses. Additionally, there was a 12.2% lifetime non-medical use of tranquilizers within our total sample, with Xanax (alprazolam) being the most commonly used. These rates are higher than the 7.8% reported by McCabe (2008). Tranquilizers were most often used for self-medication to aid in relaxation. Additionally, 23.5% of our participants who reported tranquilizer use commonly mixed tranquilizers with marijuana, alcohol, or cocaine, and less commonly with ecstasy or LSD. This is consistent with our finding that participants commonly used tranquilizers for recreational purposes. Furthermore, O’Brien (2005) reports that tranquilizers are often used to amplify the high of another drug or offset its unfavorable effects. In addition, we found high rates of co-ingestion with marijuana: 49.0% of non-medical pain reliever users, 47.1% of non-medical stimulant users, and 40.5% of tranquilizer users reported simultaneous use with marijuana. Previous studies have shown similar
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levels of co-ingestion of non-medical prescription drugs and marijuana (McCabe et al., 2012). In a study of a post-mortem database of oxycodone-related deaths, marijuana was one of the most commonly found co-ingested drugs according to toxicology reports (Cone et al., 2003). Reported motivations for the co-ingestion of marijuana with non-medical prescription pain relievers include to “come down” from the effects of the drugs, to accentuate the high of the pain relievers, and to accentuate the high of marijuana ˜ (Rigg and Ibanez, 2010). An ethnographic study of young female marijuana smokers revealed that many women received a prescription for pain relievers as a result of an injury, and later began to take the drugs recreationally and co-ingest them with marijuana (Bardhi et al., 2007). Our findings provide further evidence that marijuana is commonly co-ingested with non-medical prescription drugs. Our study was limited in that our response rate was approximately 30%. Also, females predominantly participated in the survey (66% of those who consented to the survey were female, compared to 61% of the college who were female). Additionally, all participants were from a private liberal arts college in the northeast United States. Research shows that colleges in the northeast United States have higher rates of non-medical prescription drug use, potentially due to the more competitive academic environment (McCabe et al., 2005a). It would be very interesting to administer our survey to both public and private institutions in a range of geographical areas. Despite these shortcomings, however, our data was consistent with other studies (Arria et al., 2008; Burgard et al., 2013; Garnier-Dykstra et al., 2012; Hanson et al., 2013; McCabe, 2008; McCabe and Teter, 2007; McCabe et al., 2005a,c; Rozenbroeck and Rothstein, 2011; Sepúlveda et al., 2011; Teter et al., 2006; Wu et al., 2008). Furthermore, we found higher use rates of tobacco, marijuana, LSD, hallucinogenic mushrooms, mescaline, dimethyltryptamine (DMT), salvia, cocaine, ecstasy and opioids among non-medical prescription drug users than non-users. Other studies also found that non-medical prescription drug users are more likely to report polydrug use than those who do not use prescription drugs (Hallock et al., 2013; McCabe, 2008; McCabe and Teter, 2007; McCabe et al., 2005a,b,c; Sepúlveda et al., 2011; Teter et al., 2005). Additionally, users engage in other risky behaviors (Garnier-Dykstra et al., 2012). These data suggest that there is a population of students who are more likely to use a range of illicit drugs. A predisposition to novelty and risk-taking behaviors may underlie this increased drug use. To help understand underlying differences between users and non-users, we assessed the perceptions of drugs between these two groups. We found that non-users were more likely to report that non-medical prescription drug use is harmful to mental and physical health than users. Specifically, 83% of non-users reported that stimulants were harmful to mental health, compared to 51% of users who believed this. Consistent with this, non-users cited damage to mental and physical health as primary reasons they abstained from using the drugs. In sum, non-medical prescription drug use is common among undergraduate college students. Stimulant use was most common, and 28% of our user sample reported using them for non-medical purposes during the last week of classes, principally for studying purposes. Conversely, pain relievers and tranquilizers were principally used for self-medication, socializing and partying. Future studies should focus on how to raise awareness of this issue and best curtail non-medical use among college students.
Role of funding source Nothing declared.
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Contributors Author Robert M. Hallock administered the survey, compiled the data, revised multiple versions of sections from other authors and wrote remaining portions of the manuscript. Author Sara A. Brandt did initial literature review, designed portions of the survey, input portions of the survey into Surveymonkey, wrote the introduction and the discussion sections, and a portion of the results section. Author Elise C. Taverna did initial literature review, designed portions of the survey, input portions of the survey into Surveymonkey, conducted statistical analysis, wrote a portion of the results section and added portions to the introduction and discussion sections during revision. All authors have approved the final manuscript. Conflict of interest statement The authors report no conflicts of interest. Acknowledgement The authors sincerely thank Kris Banowetz for critical feedback that improved the quality of the paper. References Arria, A.M., Caldiera, K.M., Wish, E.D., 2008. Perceived harmfulness predicts nonmedical use of prescription drugs among college students: interactions with sensation seeking. Prev. Sci. 9, 191–201. Bardhi, F., Sifaneck, S.J., Johnson, B.D., Dunlap, E., 2007. Pills, thrills, and bellyaches: case studies of prescription pill use and misuse among marijuana/blunt smoking middle class young women. Contemp. Drug Probl. 34, 53–101. Burgard, D.A., Fuller, R., Becker, B., Ferrell, R., Dinglasan-Panlilio, M.J., 2013. Potential trends in attention deficit hyperactivity disorder (ADHD) drug use on a college campus: wastewater analysis of amphetamine and ritalinic acid. Sci. Total Environ. 450–451, 242–249. Cone, E.J., Fant, R.V., Rohay, J.M., Caplan, Y.H., Ballina, M., Reder, R.F., Spyker, D., Haddox, J.D., 2003. Oxycodone involvement in drug abuse deaths: a DAWN-based classification scheme applied to an oxycodone postmortem database containing over 1000 cases. J. Anal Toxicol. 27, 57–67. Egan, K.L., Reboussin, B.A., Blocker, J.N., Wolfson, M., Sutfin, E.L., 2013. Simultaneous use of non-medical ADHD prescription stimulants and alcohol among undergraduate students. Drug Alcohol Depend. 131, 71–77. 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. J. Am. Coll. Health 60, 226–234. Hallock, R.M., Dean, A., Knecht, Z.A., Spencer, J., Taverna, E.C., 2013. A survey of hallucinogenic mushroom use, factors related to usage, and perceptions of use among college students. Drug Alcohol Depend. 30, 245–248. Hanson, C.L., Burton, S.H., Giraud-Carrier, C., West, J.H., Barnes, M.D., Hansen, B., 2013. Tweaking and tweeting: exploring twitter for nonmedical use of a psychostimulant drug (Adderall) among college students. J. Med. Internet Res. 15, e62. Kroutil, L.A., Van Brunt, D.L., Herman-Stahl, M.A., Heller, D.C., Bray, R.M., Penne, M.A., 2006. Nonmedical use of prescription stimulants in the United States. Drug Alcohol Depend. 84, 135–143. McCabe, S.E., 2008. Misperceptions of non-medical prescription drug use: a web survey of college students. Addict. Behav. 33, 713–724. McCabe, S.E., Knight, J.R., Teter, C.J., Wechsler, H., 2005a. Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey. Addiction 100, 96–106. McCabe, S.E., Teter, C.J., 2007. Drug use related problems among nonmedical users of prescription stimulants: a web-based survey of college students from a midwestern university. Drug Alcohol Depend. 91, 69–76. McCabe, S.E., Teter, C.J., Boyd, C.J., 2005b. Illicit use of prescription pain medication among college students. Drug Alcohol Depend. 77, 37–47. McCabe, S.E., Teter, C.J., Boyd, C.J., Knight, J.R., Wechsler, H., 2005c. Nonmedical use of prescription opioids among college students: prevalence and correlates from a national survey. Addict. Behav. 30, 789–805. McCabe, S.E., West, B.T., Teter, C.J., Boyd, C.J., 2012. Co-ingestion of prescription opioids and other drugs among high school seniors: results from a national study. Drug Alcohol Depend. 126, 65–70. O’Brien, C.P., 2005. Benzodiazepines use, abuse, and dependence. J. Clin. Psychiatry 66, 28–33. ˜ Rigg, K.K., Ibanez, G.E., 2010. Motivations for non-medical prescription drug use: a mixed methods analysis. J. Subst. Abuse Treat. 39, 236–247. Rozenbroeck, K., Rothstein, W.G., 2011. Medical and nonmedical users of prescription drugs among college students. J. Am. Coll. Health 59, 358–363.
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Sepúlveda, D.R., Thomas, L.M., McCabe, S.E., Cranford, J.A., Boyd, C.J., Teter, C.J., 2011. Misuse of prescribed stimulant medication for ADHD and associated patterns of substance use: preliminary analysis among college students. J. Pharm. Pract. 24, 551–560. Shillington, A.M., Reed, M.B., Lange, J.E., Clapp, J.D., Henry, S., 2006. College undergraduate Ritalin abusers in the Southwestern United States: protective and risk factors. J. Drug Issues 36, 999–1014. Substance Abuse and Mental Health Services Administration, 2013. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Substance Abuse and Mental Health Services Administration, Rockville, MD.
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Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Short communication
A survey of nonmedical use of tranquilizers, stimulants, and pain relievers among college students: Patterns of use among users and factors related to abstinence in non-users Sara A. Brandt a,1 , Elise C. Taverna b,1 , Robert M. Hallock b,∗,1 a b
Dept of psychology, Skidmore College, 815 N Broadway, Saratoga Springs NY, 12866 Neuroscience Program, Skidmore College, 815 N Broadway, Saratoga Springs NY 12866
a r t i c l e
i n f o
Article history: Received 10 December 2013 Received in revised form 14 July 2014 Accepted 21 July 2014 Available online 7 August 2014 Keywords: Non-medical prescription drug use Stimulant abuse Polydrug use
a b s t r a c t Background: This study examined lifetime non-medical prescription drug use among college students at a small liberal arts college in the Northeast. We assessed the motives, frequency of use, sources, and perceived emotional/physical risks of nonmedical prescription drugs. Specifically, we examined the nonmedical use of prescription pain relievers, stimulants, and anti-anxiety medication. Methods: We sent an internet-based survey to 1/3 of the student body and 303 students completed the survey. Results: We found that 36.8% of the sample reported using prescription drugs for non-medical purposes. First-year students were less likely to have used the drugs than those in other class years. Of those reporting use, 48% reported non-medical use of pain relievers, 72.8% reported using stimulants, and 39.8% reported using anti-anxiety medication. The most commonly used pain relievers were Vicodin (hydrocodone/acetaminophen), OxyContin (oxycodone), and codeine (acetaminophen/codeine). The most commonly used stimulants were Adderall (amphetamine/dextroamphetamine) and Ritalin (methylphenidate), while the most commonly used anti-anxiety medication was Xanax (alprazolam). When non-users were asked what factors influenced their choice not to abuse prescription drugs, 82% cited a lack of interest, 61% responded it was due to a fear of damaging their physical health, and 60.1% responded fear of damaging their mental health. Conclusion: This study supports recent findings that show widespread non-medical use of prescription drugs among college students. Our report brings a more detailed understanding of the patterns of drug usage, and the factors influencing both drug use in those who use them and abstinence in those who choose not to use them. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Many studies have looked at usage, motives, and risks of nonmedical prescription drug use among young adults, specifically undergraduates. The 2012 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2013) examined the use of psychotherapeutic drugs among 18–25 year olds, and past month usage was 5.1%. Studies show the rate of non-medical prescription drug use varies among college students (Garnier-Dykstra et al., 2012; McCabe, 2008; McCabe et al., 2005a,c; McCabe and Teter, 2007; Teter et al., 2006; White et al.,
∗ Corresponding author. Tel.: +1 518 580 5740; fax: +1 518 580 5319. E-mail address: [email protected] (R.M. Hallock). 1 All authors contributed equally. http://dx.doi.org/10.1016/j.drugalcdep.2014.07.034 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
2006). More research that quantifies non-medical use of prescription drugs on the college campus is necessary, especially given the reported epidemic rates of use/abuse. College students report using pain relievers, stimulants, and tranquilizers for various non-medical purposes. College students frequently use pain relievers (including hydrocodone products like Vicodin and codeine, and oxycodone products such as OxyContin and Percodan; Wu et al., 2008). Furthermore, stimulants are commonly used as study aids and to increase concentration (Burgard et al., 2013; Garnier-Dykstra et al., 2012; Hanson et al., 2013; Rozenbroeck and Rothstein, 2011; Teter et al., 2006). Lastly, tranquilizers are often used to amplify the high of another drug or offset its unfavorable effects (O’Brien, 2005). The current study examines use of non-medical prescription drugs among college students at Skidmore College, a small private liberal arts college in the Capital District of New York (190
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Table 1 Sources of pain relievers, stimulants, and tranquilizers, and when they were used.
Source of drugs A friend gives them the drugs Own prescription Family member provides them Purchases them from a friend Purchases them from an acquaintance Reason for use Studying for final exams Studying for midterm exams Studying for regular exams Before attending class Socializing and partying Self-medication*
Pain relievers (%)
Stimulants (%)
Tranquilizers (%)
59.6
78.6
60.5
32.7 26.9
21.4 11.4
13.2 28.9
17.3
41.4
18.4
9.6
14.3
7.9
8.2
65.7
9.1
6.1
54.3
9.1
6.1
48.6
9.1
2.0 69.4
31.4 47.1
12.1 48.5
24
N/A
97
* Includes pain relievers used for self-medication of pain/sleep, and tranquilizers used for self-medication of anxiety and to aid in relaxation. Participants did not list any uses for stimulants that were for self-medication, rather, the principle reason for using stimulants was for studying purposes, as indicated above.
miles north of New York City). We sent nearly 900 undergraduates an online survey that assessed non-medical use of stimulants, pain relievers, and anti-anxiety medication (tranquilizers), including the frequency of and motivations for use, routes of administration, and perceived emotional/physical risks of use. We also assessed non-users’ perceptions of these drugs, why they abstain from use, and whether or not they perceive these drugs to be harmful to one’s physical and mental health. We also asked user and non-user groups about polydrug use. 2. Method 2.1. Participants Participants were students at Skidmore College (∼2600 undergraduates). A random sample of one third of students from each class year was contacted through email, and the survey was emailed a week before classes ended for the semester. A total of 303 students gave consent; 93 were male, 200 female, 2 other, and 8 did not indicate their gender. There were 74 first-years, 68 sophomores, 85 juniors, 67 seniors, and 9 who did not indicate their class year. 2.2. Survey The survey was created using Surveymonkey, an online survey manager. A link to the survey was emailed to randomly selected students. There was a statement of consent, and then participants were asked whether they had ever used prescription drugs non-medically. Participants who had used prescription drugs non-medically were directed to three sets of questions addressing prescription pain relievers, stimulants, and anti-anxiety medication. Users were asked which prescription drugs they had used non-medically. Prescription medications were identified by both their brand name and generic name in the survey. For example, Diazepam was presented as, ‘Valium (Diazepam)’. An exception was diet pills, which were defined as ‘Diet pills (Phentermine)’. They were also asked where they obtained these drugs. For example, “If you have used prescription anti-anxiety medication/tranquilizers without a current prescription and/or other than as directed by a doctor, how do you usually obtain them?” Selections included those presented in Table 1, plus ‘other’, where they could specify an alternate answer. One of the selections was ‘Had a prescription’, which was used to assess whether they had a prescription but were not using it as directed by a doctor. These data were used to calculate the percentage of users who had a prescription for each of the three categories of drugs. Reasons for using the drugs were assessed with the following statement: “I have used prescription stimulants without a current prescription, or other than directed by a doctor, for the following reasons”. Participants could then select responses that are included in Table 1, plus ‘other’, where they could specify an alternate answer. They were also asked about the route of administration. For example, they were asked “If you have used prescription anti-anxiety medication/tranquilizers without a current prescription and/or other than as directed by a doctor, how do you usually
Fig. 1. Recreational drug use between users and non-users of nonmedical prescription medications. Users were more likely to use all drugs except alcohol, which reached a ceiling in both groups.
ingest them?” Possible responses included: ‘inhale’, ‘inject’, ‘snort’, ‘swallow’, or ‘other (please specify). There were two questions that assessed user’s perceptions of the drugs. First, “Do you consider using prescription stimulants without a current prescription or other than as directed by a doctor to be rewarding?” Second, “Do you consider prescription stimulants to be addictive?” These questions had yes/no answers and were asked for each of the three groups of prescription drugs. Users were also asked about polydrug use. Here, they were presented with the list of drugs in Fig. 1, along with a choice of ‘other (please specify)’, where they could enter in one or more additional drugs that they have used. Participants who had not used prescription drugs for non-medical reasons were asked about their reasons for abstaining as follows: “What factors have influenced your decision to avoid using prescription drugs (i.e., pain relievers, anti-anxiety medication, stimulants etc.) without a prescription?” Participants could select more than one response, and responses included ‘fear of damaging mental health’, ‘fear of damaging physical health’, ‘generally don’t do drugs’, ‘lack of interest’, ‘unable to acquire’, and ‘other’ where they could specify an additional answer. They were also asked if they considered each of the three categories of drugs to be addictive, as well as rewarding and damaging to physical/mental health. Further, they were further asked: “Do you believe that students who take ADHD/ADD drugs while studying for or taking exams have an unfair advantage over students who don’t?” Finally, they were asked about polydrug use with the same question and selections as the users, as described above. All participants were asked their gender, age, and class year. Some questions allowed participants to select more than one answer while some required only one answer, as described below. The survey concluded with instructions on clearing browser history and cache. This project was approved by the Skidmore College Institutional Review Board.
3. Results 3.1. Demographics A total of 303 students consented to participate in this survey. One hundred and ten students (36.8%) indicated that they had used prescription drugs non-medically. Of these, 58.6% were female and 41.4% were male. Ages ranged from 18 to 22; 11.7% were first-years, 24.3% sophomores, 34.2% juniors, and 29.7% seniors. There were 189 students (25.4% male, 73.4% female, and 1.2% other) who reported never using prescription drugs non-medically. Ages ranged from 18 to 23; 33.3% were first-years, 22.4% sophomores, 25.7% juniors, and 18.6% seniors. 3.2. Students who reported non-medical pain reliever use Of students who reported lifetime non-medical prescription drug use, 48.0% reported using prescription pain relievers, and 32.7% had a prescription. Also, 3.9% reported using in the past week, 11.8% in the past month, 28.9% in the past year, and 55.3% over a year ago. Vicodin (hydrocodone/acetaminophen) was the most commonly used drug (64.1%), followed by OxyContin
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(oxycodone) (42.6%), codeine (34.0%), morphine (10.6%), Percodan (aspirin/oxycodone) (8.5%), and Demerol (meperidine) (2.1%). These drugs were swallowed (92.6%) or snorted (24.1%). See Table 1 for data on how they were obtained and why they were used. Additionally, 31.3% reported mixing prescription pain relievers with other drugs: 80% with marijuana, 76.7% with alcohol, and 16.7% with cocaine. 3.3. Students who reported non-medical stimulant use Of students who reported lifetime non-medical prescription drug use, 72.8% reported lifetime non-medical stimulant use, and 21.4% had a prescription. Twenty-two students (27.8%) reported use during the past week, 24.1% within the past month, 26.6% within the past year, and 30.4% over a year ago. Of these, 81.2% reported using Adderall (amphetamine/ dextroamphetamine), 44.9% Ritalin (methylphenidate), 21.7% Concerta (methylphenidate), 10.1% Dexedrine (dextroamphetamine sulfate), 2.9% Methamphetamine, and 1.4% diet pills (phentermine). These drugs were swallowed (88.6%) or snorted (34.4%). See Table 1 for data on how they were obtained and why they were used. Of the stimulant users, 41.8% reported mixing them with other drugs: 86.8% with marijuana, 81.6% with alcohol, 10.5% with cocaine, 7.9% with ecstasy, and 5.3% with lysergic acid diethylamide (LSD). 3.4. Students who reported non-medical tranquilizer use Of students who reported lifetime non-medical prescription drug use, 39.8% reported lifetime non-medical tranquilizer use, and 13.2% had a prescription. Five users (8.3%) reported tranquilizer use in the past week, 15% in the past month, 30% in the past year, and 50% over a year ago. Xanax (alprazolam) (70.3%), Klonopin (clonazepam) (35.1%), Valium (diazepam) (35.1%), Ambien (zolpidem) (32.4%), and Ativan (lorazepam) (10.8%) were the most commonly used. These drugs were swallowed (89.7%) or snorted (10.3%). See Table 1 for data on how they were obtained and why they were used. Additionally, 26.3% of these participants mixed them with other drugs: 75% with marijuana, 65% with alcohol, 20% with ecstasy, 20% with LSD, and 10% with cocaine. 3.5. Students who abstained from prescription drug use When asked what factors influenced their choice not to abuse prescription drugs, 82.6% reported a lack of interest, 61.8% reported fear of damaging their physical health, 60.1% reported fear of damaging their mental health, 56.7% reported that they did not do drugs, and 10.1% indicated that they were unable to acquire the drugs. 3.6. Perceptions of users and non-users Users and non-users differed in the extent to which they perceived pain reliever use as harmful to one’s mental health, 2 (1, n = 277) = 7.23, p < 0.01, physical health, 2 (1, n = 279) = 4.04, p < 0.05, and whether they are addictive, 2 (1, n = 276) = 8.82, p < 0.01. Additional 2 analyses revealed similar differences in perceptions of stimulants and tranquilizers between users and non-users (p < 0.01 for each comparison). Within each category of drugs, non-users were more likely to state that the drugs were harmful and addictive. When users were asked if the drugs were rewarding (inducing pleasure), 24% indicated pain relievers were rewarding, 38% that tranquilizers were rewarding, and 52% that stimulants were rewarding. When asked about whether stimulant use leads to an unfair advantage on exams, 50% of non-users and 45.7% of users indicated that they felt it does. Lastly, there was a significant difference between users and non-users in terms of
other drugs they reported using, 2 (11, n = 934) = 144.08, p < 0.001 (see Fig. 1).
4. Discussion We found that 36.8% of the 303 undergraduates in our survey reported lifetime use of prescription drugs for non-medical purposes, and that usage peaked during their junior year of college. Overall, we found that the most commonly used prescription drugs were stimulants, and the most commonly used stimulant was Adderall (amphetamine/dextroamphetamine). Stimulants were mostly used when studying for final exams, midterms, and regular exams. However, evidence of cognitive enhancement from stimulant use is far from conclusive. In fact, some reports demonstrated that stimulant use is inversely correlated with grade point averages (Egan et al., 2013; Shillington et al., 2006). Nevertheless, 7.3% of our total sample had used stimulants in the past week, potentially because our survey was administered a week before classes ended for the semester and these drugs are often used as study aids (Burgard et al., 2013; Garnier-Dykstra et al., 2012; Hanson et al., 2013; Rozenbroeck and Rothstein, 2011; Teter et al., 2006). Consistent with this, users perceived that stimulants were less harmful to their mental and physical health, less addictive, and more rewarding (pleasurable) than pain relievers and tranquilizers. Conversely, the other drugs in the survey were reported as more addictive and less rewarding. This dichotomy may be attributed to the fact that stimulants are typically used non-medically for study purposes. It is possible that they are perceived as being more rewarding because they are believed to enhance academic performance, but they are not seen as having high addiction potential by these users. Even though the reported lifetime use of methamphetamine was reported to be low (2.9%), this number could be inflated because this drug is available as both a prescribed and illicit drug, as discussed in Kroutil et al. (2006). Therefore, some of our reported prescription stimulant use may have actually reflected the use of street methamphetamine. Among our total sample, 16% reported lifetime non-medical use of pain relievers, while 7% used in the past year. Vicodin (hydrocodone/acetaminophen) was the most commonly used, followed by OxyContin (oxycodone), and codeine. These drugs were most commonly used for recreational purposes and selfmedication of pain. Interestingly, pain relievers were reported as more addictive (77%), more harmful to physical health (65%), and less rewarding (24%) than other prescription drugs. The perceived addictive qualities of these drugs may explain why they are used despite their perceived harm. These data indicate that it may be beneficial to target non-medical pain-reliever use in drug education programs on college campuses. Additionally, there was a 12.2% lifetime non-medical use of tranquilizers within our total sample, with Xanax (alprazolam) being the most commonly used. These rates are higher than the 7.8% reported by McCabe (2008). Tranquilizers were most often used for self-medication to aid in relaxation. Additionally, 23.5% of our participants who reported tranquilizer use commonly mixed tranquilizers with marijuana, alcohol, or cocaine, and less commonly with ecstasy or LSD. This is consistent with our finding that participants commonly used tranquilizers for recreational purposes. Furthermore, O’Brien (2005) reports that tranquilizers are often used to amplify the high of another drug or offset its unfavorable effects. In addition, we found high rates of co-ingestion with marijuana: 49.0% of non-medical pain reliever users, 47.1% of non-medical stimulant users, and 40.5% of tranquilizer users reported simultaneous use with marijuana. Previous studies have shown similar
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levels of co-ingestion of non-medical prescription drugs and marijuana (McCabe et al., 2012). In a study of a post-mortem database of oxycodone-related deaths, marijuana was one of the most commonly found co-ingested drugs according to toxicology reports (Cone et al., 2003). Reported motivations for the co-ingestion of marijuana with non-medical prescription pain relievers include to “come down” from the effects of the drugs, to accentuate the high of the pain relievers, and to accentuate the high of marijuana ˜ (Rigg and Ibanez, 2010). An ethnographic study of young female marijuana smokers revealed that many women received a prescription for pain relievers as a result of an injury, and later began to take the drugs recreationally and co-ingest them with marijuana (Bardhi et al., 2007). Our findings provide further evidence that marijuana is commonly co-ingested with non-medical prescription drugs. Our study was limited in that our response rate was approximately 30%. Also, females predominantly participated in the survey (66% of those who consented to the survey were female, compared to 61% of the college who were female). Additionally, all participants were from a private liberal arts college in the northeast United States. Research shows that colleges in the northeast United States have higher rates of non-medical prescription drug use, potentially due to the more competitive academic environment (McCabe et al., 2005a). It would be very interesting to administer our survey to both public and private institutions in a range of geographical areas. Despite these shortcomings, however, our data was consistent with other studies (Arria et al., 2008; Burgard et al., 2013; Garnier-Dykstra et al., 2012; Hanson et al., 2013; McCabe, 2008; McCabe and Teter, 2007; McCabe et al., 2005a,c; Rozenbroeck and Rothstein, 2011; Sepúlveda et al., 2011; Teter et al., 2006; Wu et al., 2008). Furthermore, we found higher use rates of tobacco, marijuana, LSD, hallucinogenic mushrooms, mescaline, dimethyltryptamine (DMT), salvia, cocaine, ecstasy and opioids among non-medical prescription drug users than non-users. Other studies also found that non-medical prescription drug users are more likely to report polydrug use than those who do not use prescription drugs (Hallock et al., 2013; McCabe, 2008; McCabe and Teter, 2007; McCabe et al., 2005a,b,c; Sepúlveda et al., 2011; Teter et al., 2005). Additionally, users engage in other risky behaviors (Garnier-Dykstra et al., 2012). These data suggest that there is a population of students who are more likely to use a range of illicit drugs. A predisposition to novelty and risk-taking behaviors may underlie this increased drug use. To help understand underlying differences between users and non-users, we assessed the perceptions of drugs between these two groups. We found that non-users were more likely to report that non-medical prescription drug use is harmful to mental and physical health than users. Specifically, 83% of non-users reported that stimulants were harmful to mental health, compared to 51% of users who believed this. Consistent with this, non-users cited damage to mental and physical health as primary reasons they abstained from using the drugs. In sum, non-medical prescription drug use is common among undergraduate college students. Stimulant use was most common, and 28% of our user sample reported using them for non-medical purposes during the last week of classes, principally for studying purposes. Conversely, pain relievers and tranquilizers were principally used for self-medication, socializing and partying. Future studies should focus on how to raise awareness of this issue and best curtail non-medical use among college students.
Role of funding source Nothing declared.
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Contributors Author Robert M. Hallock administered the survey, compiled the data, revised multiple versions of sections from other authors and wrote remaining portions of the manuscript. Author Sara A. Brandt did initial literature review, designed portions of the survey, input portions of the survey into Surveymonkey, wrote the introduction and the discussion sections, and a portion of the results section. Author Elise C. Taverna did initial literature review, designed portions of the survey, input portions of the survey into Surveymonkey, conducted statistical analysis, wrote a portion of the results section and added portions to the introduction and discussion sections during revision. All authors have approved the final manuscript. Conflict of interest statement The authors report no conflicts of interest. Acknowledgement The authors sincerely thank Kris Banowetz for critical feedback that improved the quality of the paper. References Arria, A.M., Caldiera, K.M., Wish, E.D., 2008. Perceived harmfulness predicts nonmedical use of prescription drugs among college students: interactions with sensation seeking. Prev. Sci. 9, 191–201. Bardhi, F., Sifaneck, S.J., Johnson, B.D., Dunlap, E., 2007. Pills, thrills, and bellyaches: case studies of prescription pill use and misuse among marijuana/blunt smoking middle class young women. Contemp. Drug Probl. 34, 53–101. Burgard, D.A., Fuller, R., Becker, B., Ferrell, R., Dinglasan-Panlilio, M.J., 2013. Potential trends in attention deficit hyperactivity disorder (ADHD) drug use on a college campus: wastewater analysis of amphetamine and ritalinic acid. Sci. Total Environ. 450–451, 242–249. Cone, E.J., Fant, R.V., Rohay, J.M., Caplan, Y.H., Ballina, M., Reder, R.F., Spyker, D., Haddox, J.D., 2003. Oxycodone involvement in drug abuse deaths: a DAWN-based classification scheme applied to an oxycodone postmortem database containing over 1000 cases. J. Anal Toxicol. 27, 57–67. Egan, K.L., Reboussin, B.A., Blocker, J.N., Wolfson, M., Sutfin, E.L., 2013. Simultaneous use of non-medical ADHD prescription stimulants and alcohol among undergraduate students. Drug Alcohol Depend. 131, 71–77. 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. J. Am. Coll. Health 60, 226–234. Hallock, R.M., Dean, A., Knecht, Z.A., Spencer, J., Taverna, E.C., 2013. A survey of hallucinogenic mushroom use, factors related to usage, and perceptions of use among college students. Drug Alcohol Depend. 30, 245–248. Hanson, C.L., Burton, S.H., Giraud-Carrier, C., West, J.H., Barnes, M.D., Hansen, B., 2013. Tweaking and tweeting: exploring twitter for nonmedical use of a psychostimulant drug (Adderall) among college students. J. Med. Internet Res. 15, e62. Kroutil, L.A., Van Brunt, D.L., Herman-Stahl, M.A., Heller, D.C., Bray, R.M., Penne, M.A., 2006. Nonmedical use of prescription stimulants in the United States. Drug Alcohol Depend. 84, 135–143. McCabe, S.E., 2008. Misperceptions of non-medical prescription drug use: a web survey of college students. Addict. Behav. 33, 713–724. McCabe, S.E., Knight, J.R., Teter, C.J., Wechsler, H., 2005a. Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey. Addiction 100, 96–106. McCabe, S.E., Teter, C.J., 2007. Drug use related problems among nonmedical users of prescription stimulants: a web-based survey of college students from a midwestern university. Drug Alcohol Depend. 91, 69–76. McCabe, S.E., Teter, C.J., Boyd, C.J., 2005b. Illicit use of prescription pain medication among college students. Drug Alcohol Depend. 77, 37–47. McCabe, S.E., Teter, C.J., Boyd, C.J., Knight, J.R., Wechsler, H., 2005c. Nonmedical use of prescription opioids among college students: prevalence and correlates from a national survey. Addict. Behav. 30, 789–805. McCabe, S.E., West, B.T., Teter, C.J., Boyd, C.J., 2012. Co-ingestion of prescription opioids and other drugs among high school seniors: results from a national study. Drug Alcohol Depend. 126, 65–70. O’Brien, C.P., 2005. Benzodiazepines use, abuse, and dependence. J. Clin. Psychiatry 66, 28–33. ˜ Rigg, K.K., Ibanez, G.E., 2010. Motivations for non-medical prescription drug use: a mixed methods analysis. J. Subst. Abuse Treat. 39, 236–247. Rozenbroeck, K., Rothstein, W.G., 2011. Medical and nonmedical users of prescription drugs among college students. J. Am. Coll. Health 59, 358–363.
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