Nonmedical use of prescription medications among adolescents in the United States: a systematic review

Trends in the nonmedical misuse of benzodiazepines and Z-hypnotics among school-aged adolescents (2016-2021): gender differences and related factors

BACKGROUND

The misuse of psychotropic medication has increased during the past decade, especially among adolescents. The aim of our study was to describe the prevalence and patterns of the nonmedical use of benzodiazepines (BDZ) and Z-hypnotics among school-aged adolescents through the lens of sex. In addition, we sought to analyze the temporal evolution of the nonmedical use of these drugs during the period 2016-2021.

METHODS

The temporal evolution of the nonmedical use of these drugs was analyzed based on survey data collected in 2016, 2018 and 2021, which includes the first years of the COVID-19 pandemic. To assess the possible effect of the COVID-19 pandemic, the year at survey was conducted was introduced as a categorical variable. We used data from the Spanish State Survey on Drug Use in Secondary Education, which covers drug use among students aged 14-18 years. Using multivariate logistic regression models, we estimated the independent effect of different variables (sociodemographic data, use of other psychoactive substances, risk perception and availability) on the nonmedical use of BDZ and Z-hypnotics.

RESULTS

In total, survey data from 95,700 adolescents were included in our analysis. The nonmedical use of BDZ and Z-hypnotics increased among adolescents during the study period. The adjusted odds ratio (AOR) from 2016 to 2018 was 1.11 (95% CI 0.94-1.31) and from 2018 to 2021 the AOR was 1.26 (95% CI 1.08-1.46), using 2016 and 2018, respectively, as reference years. The nonmedical use of BDZ and Z-hypnotics was more likely in adolescent girls than boys (AOR = 2.11). The nonmedical use of prescription opioids (AOR = 3.44), novel psychoactive substances and other illicit psychoactive drugs (AOR = 4.10) were risk factors for the nonmedical use of BDZ and Z-hypnotics in both sexes. Use of cannabis (AOR = 1.38) was a predictor of nonmedical use in female adolescents only.

CONCLUSIONS

This study shows that the trend of the nonmedical use of BDZ and Z-hypnotics among school-aged adolescents in Spain increased between 2016 and 2021. Among adolescents aged 14 to 18, the probability of nonmedical use of these psychoactive substances was twice as high for female adolescents as for male adolescents.

Gone with the weed: incidents of adolescent marijuana use in the United States, 1976-2021

PURPOSE

This study sought to examine grouped and right-censored (GRC) counts of adolescent marijuana use and estimate its temporal trajectories and sociodemographic disparities over almost half a century.

METHODS

After compiling 46 waves of nationally representative data from the Monitoring the Future (MTF) study from 1976 to 2021 (sample size = 491,348), we utilized an innovative modified Poisson (mixture) approach to analyze past-year marijuana use quantified by GRC counts.

RESULTS

The overall reduction in incidence rates of marijuana use was attributable to an almost 40% reduction in the risk of marijuana use (with the proportion of at-risk adolescents at 51.36% in 1979 and 31.53% in 2021). Despite substantial changes over the study period, the recent incidence rates for at-risk individuals were similar to those in the early 1980s. Living in an intact family was a protective factor against adolescent marijuana use over time.

CONCLUSIONS

The incidence rates of marijuana use among at-risk students, especially those from disadvantaged families, remained high over the study period. The modified Poisson (mixture) approach serves as the preferred tool for modeling GRC responses. It is essential to distinguish among risk, at-risk incidence, and overall incidence when assessing substance use and other risky behaviors.

The prevalence of self-medication and its associated factors among college students: Cross-sectional study from Saudi Arabia

Background

Self-medication with OTC or prescription drugs is widespread, may impair health, and leads to microbial resistance. Self-medication treats symptoms without a prescription. Self-medication is common among students across disciplines. Thus, this study evaluates medical and non-medical students' self-medication prevalence, knowledge, and variables.

Methods

352 people completed a verified 25-item online questionnaire from September 5 to November 17, 2021. Self-medication and demographic characteristics such as gender, professional college, and family income were examined using a chi-square test of independence.

Results

210 (59.6 %) participants were from the College of Medicine, and 142 (40.34 %) were from other professional health colleges. Health professional students self-medicated 55.9 %. This research found substantial connections between self-medication knowledge, gender, and family income. With a p-value of 0.0001, 32 % of women agreed that self-medication is safe, compared to 15.8 % of men. Female students were more likely than boys (61.9 % vs 38.1 %, p-value = 0.0291) to self-medicate as their initial therapy. Family income was also related to self-medication; 69.6 % of low-income pupils self-medicated to reduce doctor visits, p-value = 0.0477.

Conclusion

Students of all majors self-medicate. Medical students were more informed about generic drug safety and administration. There were substantial unfavorable sentiments regarding self-medication, highlighting the need for educational health activities to raise student understanding of its risks.

Non-prescribed pharmaceutical stimulants use among adolescents: A way to self-care or peer success?

BACKGROUND

the use of pharmaceutical stimulants without a medical prescription (PSWMP) among adolescents is considered an established public health issue. The present study aimed to investigate the potential links between different patterns of non-medical use of pharmaceutical stimulants, psycho-social factors, and other risky behaviours (e.g. psychoactive substance use).

METHODS

For this purpose, data from a sample of 14,685 adolescents aged 15-19 participating in the ESPAD®Italia 2019 study were analysed by conducting descriptive analyses and multinomial logistic regressions.

RESULTS

The findings highlight the key role of psycho-social factors and engagement in other risky behaviours in either reducing or promoting the risk of PSWMP use. Particularly, being satisfied with peer relationships and with oneself is significantly associated with lower use of PSWMP. Conversely, the consumption of other psychoactive substances (both legal and illegal) and engagement in other risky behaviours (e.g., gambling and cyberbullying) may increase this phenomenon.

CONCLUSIONS

Considering their representativeness, the results of the present study could be used as groundwork for the development of effective and targeted prevention programs and interventions.

Onset of the Non-Medical Use of Prescription and Over-the-Counter Medications during Early Adolescence: Comparison with Alcohol, Tobacco, and Marijuana

This study examined the prevalence and psychosocial predictors of the non-medical use of prescription and over-the-counter (OTC) medications and compared these to cigarette, marijuana, and alcohol use in a cohort of early adolescents (N = 1887) aged 11 to 13, a critical risk period for the initiation of substance use. Participants were students attending 22 middle schools in the northeastern United States. Participants completed surveys in the classroom, the first in the sixth grade and a second in the seventh grade, and the rate of overall substance use more than doubled from 5.5% to 11.9% over this period. Predictors of the onset of non-medical prescription and over-the-counter drug misuse overlapped substantially with those for marijuana and other substances. The perception of friends' substance use and the belief that substance use can help you deal with problems predicted the onset of marijuana use, OTC medication misuse, and prescription drug misuse. Decision-making skills were protective for the onset of all substance use outcomes. The findings of this study have important implications for prevention and suggest that a single comprehensive approach may be sufficient for preventing multiple forms of substance use onset during early adolescence.

Prescription Drug Misuse with Alcohol Coingestion among US Adolescents: Youth Experiences, Health-related Factors, and Other Substance Use Behaviors

BACKGROUND

While alcohol use and prescription drug misuse (PDM) are common among adolescents, there is relatively little research on coingestion. This is disquieting as polysubstance use has become a major contributing factor in drug overdose deaths among young people in the United States.

METHODS

The current research uses multiple years of data from the National Survey on Drug Use and Health (2015-2019) to assess characteristics associated with coingestion among adolescents aged 12 to 17 years ( N = 57,352). Multinomial logistic regression analysis is used to identify characteristics associated with past 30-day PDM with and without alcohol coingestion. The primary objective is to determine how youth experiences with parents, involvement in conventional activities, religiosity, social support, and school status are associated with coingestion.

RESULTS

Among adolescents who report past 30-day PDM, 18.6% coingest with alcohol and 77.5% of adolescents who coingest report at least one substance use disorder. Several youth experiences were significantly associated with opioid coingestion including increased conflict with parents (relative risk ratio [RRR], 1.27; 95% confidence interval [CI], 1.07-1.48), lower levels of religiosity (RRR, 0.72; 95% CI, 0.52-0.98), less social support (RRR, 0.36; 95% CI, 0.18-0.69), and not being in school (RRR, 3.86; 95% CI, 1.33-11.17). In addition, emergency department visits, depression, and other substance use behaviors were also significantly associated with coingestion.

CONCLUSIONS

Findings demonstrate a strong connection between coingestion and substance use disorder among US adolescents. The findings from the current study can inform prevention and intervention efforts by identifying youth experiences and health-related factors that are associated with coingestion.

Promoting Prescription Drug Safety Skills in School: Evaluating the Effectiveness of a Technology-Based Curriculum

Background

Prescription drug misuse among youth aged 12–18 remains high in the United States. Grounded in Social Norms Theory, school-based curricula have been shown to effectively challenge students’ misperceptions of peer norms and safety regarding prescription drug misuse (PDM).

Objective

The present study is a quasi-experimental evaluation of a brief, no cost, school-based prescription drug safety program.

Methods

Participants included 94 teachers and their students (n = 2325) in grades 8 through 12. Teachers (and their students) were assigned to experimental or control conditions. Using a pre-/post-survey design, we examined whether the curriculum promoted growth in five key student outcomes: Personal Responsibility, Social Norms, Knowledge, Future Actions, and Refusal Skills. Student demographic characteristics and prescription drug history were examined as moderators of growth. Within the experimental group, variation in implementation factors such as teachers’ prior experience with the program and perceptions of student engagement were examined as moderators of the effectiveness of the curriculum.

Results

Multilevel models demonstrated equitable growth in Personal Responsibility, Social Norms, Knowledge, Future Actions, and Refusal Skills across gender, race, and other demographic characteristics. Students’ prescription drug history was not associated with growth on the five key outcomes. Growth in Personal Responsibility, Social Norms, Knowledge, and Future Actions was maintained in a one-month follow-up survey. Teacher perceptions of student engagement were associated with lower growth in Social Norms.

Conclusions

The findings suggest promising implications for the scalability of an effective, brief, no cost, technology-based intervention targeting adolescent PDM.

Behavioral Intervention for Nonmedical Use of Prescription Drugs Among Adolescents and Young Adults: A Narrative Review

The nonmedical use of prescription drugs (NMUPD) is a public health crisis. In 2020, more Americans died of drug overdose than in any prior year, and the nonmedical use of opioids and other prescription drugs contributed significantly to that total. Young adults and adolescents report the highest rates of NMUPD, relative to other age groups. This article provides a narrative review of interventions for young adults and adolescents to prevent NMUPD, including interventions directed at the individual, family or other small group, and community. The interventions reviewed included those that were delivered in person and via technology.

Trajectories of prescription opioid and heroin use in adulthood

BACKGROUND AND OBJECTIVES

Due to a reduction in the availability of prescription opioids in the United States, the potential transition from prescription opioids to heroin is a public health concern. We assessed trajectories of both nonmedical prescription opioid (NMPO) and heroin use from adolescence (age 18) to adulthood (age 50) and how these trajectories were associated with substance use disorder (SUD) in adulthood (age 35-50).

METHODS

A national sample of 26,569 individuals from eleven cohorts of US high school seniors (1976-1986) who were followed until age 50 (2008-2018). The analysis focuses on respondents who engaged in past-year NMPO and heroin use. Outcomes included the endorsement of two or more SUD symptoms.

RESULTS

Among NMPO users, 7.5% had used heroin by the age of 50. The latent profile analyses assessing individuals who reported both NMPO and heroin use during the 32-year study period found four unique trajectory groups: (1) "age 18 concurrent use" (81.2%); (2) "mid-30s NMPO-to-heroin use transition" (10.7%); (3) age 19/20 NMPO-to-heroin use transition, followed by 40s heroin-to-NMPO use transition (4.3%); and (4) "mid-20s NMPO-to-heroin use transition" (3.7%). Respondents in the "mid-30s NMPO-to-heroin use transition" trajectory group had the highest odds of indicating two or more SUD symptoms between ages 35-50.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This is the first study to assess NMPO and heroin use trajectories among a national probability-based sample followed from age 18 to 50. The findings suggest that prescription opioid misuse is a risk factor in the development of SUDs and has a long-term impact.

Acceptability of a Game-Based Intervention to Prevent Adolescent Prescription Opioid Misuse

Objective: This study assessed the initial acceptability of SafeUse, a game-based opioid misuse prevention intervention for delivery via smartphone among adolescents. Evidence-based educational and refusal skills training materials were adapted, and game design elements were applied to clinically and scientifically informed scenarios in which opioids are typically introduced to adolescents using standard product development methods to create the SafeUse prototype. Materials and Methods: In a mixed-methods study, 14 adolescents were assessed on their knowledge and perceptions of opioids before and following 5-7 days of access to SafeUse. Participants provided feedback in focus groups on the acceptability, relevance, and understandability of SafeUse and made suggestions for its improvement. Feedback was coded and summarized as to playability, acceptability, appropriateness, content development, and knowledge transfer. Pre- and post-access quantitative data were analyzed using Wilcoxon matched pairs signed-rank tests. Results: Overall, participants liked SafeUse, its characters, graphics, and approach, finding it more appealing than lectures/reading materials and appropriate for school settings. They moderately to extremely "liked the game," "would like to play more game modules," "liked playing through the decisions," thought the game was realistic/relevant and fun, and they learned new information about opioids. Participants reported increased confidence to refuse opioids and decreased likelihood of accepting opioids from someone they know. Knowledge about opioids increased (P < 0.006), and adolescent perception that prescription drugs are safer than illegal drugs decreased (P < 0.003) after playing SafeUse. Conclusion: Findings suggest that SafeUse is acceptable and likely educational to adolescents and worthy of further development and research.

Nonmedical Prescription Drug Use Among Female Adolescents: The Relative Influence of Maternal Factors, Social Norms, and Perceptions of Risk and Availability

Increasing understanding of the risk and protective factors for adolescent nonmedical use of prescription drugs (NMUPD) could inform prevention efforts. Several correlates have been identified, including parental factors, perceptions about use and accessibility, social norms, and age. However, these constructs have rarely been simultaneously examined using paired data from parents and adolescents. We aimed to examine the relative influence of these correlates among dyads (N=349) of mothers and adolescent daughters. Using multiple logistic regression, daughters' past NMUPD and inclination for future NMUPD were regressed onto descriptive norms for friend use, perceived drug accessibility and risk of harm from use, daughter age, mothers' disapproval about use, mothers' past NMUPD and inclination for future NMUPD, and the mother-daughter relationship quality. Akaike weights and lasso regressions were also estimated to evaluate the relative importance of each correlate. Higher descriptive norms for friend use, older age, and mothers' inclination for NMUPD were risk factors for daughters' NMUPD, while a closer mother-daughter relationship and mothers' disapproving attitudes towards NMUPD were protective factors. The three analysis approaches were corroborative. Results suggest friend descriptive norms, mother-daughter relationship quality, and mothers' attitudes about NMUPD are important prevention targets.

Trajectories of Prescription Drug Misuse Among US Adults From Ages 18 to 50 Years

Importance

US adults born from 1965 to 1996 had high exposure to controlled medications, yet little is known about how this exposure has affected them over time. Prescription drug misuse (PDM) has increased among adults in the past 2 decades, with related increases in emergency department visits, overdoses, and deaths.

Objectives

To identify 32-year PDM trajectories involving opioids, stimulants, and sedatives or tranquilizers and to examine associations between these PDM trajectories and substance use disorder (SUD) symptoms in adulthood as well as between baseline characteristics and PDM trajectories.

Design, Setting, and Participants

This cohort study included 11 cohorts of adolescents who were followed up longitudinally from age 18 years (study start, 1976-1986) to age 50 years (2008-2018) in the Monitoring the Future (MTF) study, which included a national multistage random sample of US 12th grade students. Baseline surveys (modal age 18) were self-administered in classrooms. Ten follow-ups were conducted by mail. Data analysis was conducted from December 2020 to October 2021.

Main Outcomes and Measures

Sociodemographic variables were measured at baseline. PDM and SUD symptoms were measured at baseline and every follow-up. Latent profile analysis (LPA) was used to create PDM trajectory profiles. Associations between these PDM trajectories, SUD symptoms, and baseline sociodemographic characteristics were examined.

Results

The sample of 26 575 individuals was 50.8% (95% CI, 50.2%-51.4%) female and 79.3% (95% CI, 78.8%-79.8%) White. The baseline response rate ranged from 77% to 84%, and the 32-year retention rate was 53%. In adjusting for attrition, 45.7% (95% CI, 44.9%-46.4%) of the respondents reported past-year PDM at least once during the 32-year reporting period. Among those who reported PDM, the prevalence of poly-PDM was 40.3% (95% CI, 39.3%-41.3%). Based on LPA, the number of class-specific PDM trajectories ranged from 4 (prescription opioids) to 6 (prescription stimulants). For the class-combined analyses, we identified 8 PDM trajectories consisting of early peak trajectories (eg, age 18 years), later peak trajectories (eg, age 40 years), and a high-risk trajectory (eg, high frequency PDM at multiple ages). All PDM trajectories were associated with increased odds of developing SUD symptoms in middle adulthood, especially the later peak and high-risk trajectories compared with early peak trajectories (eg, peak at age 40 years: adjusted odds ratio [aOR], 5.17; 95% CI, 3.97-6.73; high-risk: aOR, 12.41; 95% CI, 8.47-18.24). Baseline characteristics associated with a high-risk trajectory were binge drinking (aOR, 1.69; 95% CI, 1.13-2.54), cigarette smoking (aOR, 2.30; 95% CI, 1.60-3.29), and marijuana use (aOR, 3.78; 95% CI, 2.38-6.01). More recent cohorts (eg, 1985-1986) had a higher risk of belonging to later peak PDM trajectories (ages 40 and 45 years) than the 1976-1978 cohort (age 40 years peak: aOR, 2.49; 95% CI, 1.69-3.68).

Conclusions and Relevance

In this cohort study, adults with later peak PDM trajectories were at increased risk of SUD symptoms in middle adulthood. These findings suggest the need to screen for PDM and SUD from adolescence through middle adulthood.

Nonmedical Opioid Use After Short-term Therapeutic Exposure in Children: A Systematic Review

CONTEXT

Opioid-related harms continue to rise for children and youth. Analgesic prescribing decisions are challenging because the risk for future nonmedical opioid use or disorder is unclear.

OBJECTIVE

To synthesize research examining the association between short-term therapeutic opioid exposure and future nonmedical opioid use or opioid use disorder and associated risk factors.

DATA SOURCES

We searched 11 electronic databases.

STUDY SELECTION

Two reviewers screened studies. Studies were included if: they were published in English or French, participants had short-term (≤14 days) or an unknown duration of therapeutic exposure to opioids before 18 years, and reported opioid use disorder or misuse.

DATA EXTRACTION

Data were extracted, and methodologic quality was assessed by 2 reviewers. Data were summarized narratively.

RESULTS

We included 21 observational studies (49 944 602 participants). One study demonstrated that short-term therapeutic exposure may be associated with opioid abuse; 4 showed an association between medical and nonmedical opioid use without specifying duration of exposure. Other studies reported on prevalence or incidence of nonmedical use after medical exposure to opioids. Risk factors were contradictory and remain unclear.

LIMITATIONS

Most studies did not specify duration of exposure and were of low methodologic quality, and participants might not have been opioid naïve.

CONCLUSIONS

Some studies suggest an association between lifetime therapeutic opioid use and nonmedical opioid use. Given the lack of clear evidence regarding short-term therapeutic exposure, health care providers should carefully evaluate pain management options and educate patients and caregivers about safe, judicious, and appropriate use of opioids and potential signs of misuse.

Race, Adolescent Socioeconomic Status, and Lifetime Non-Medical Use of Prescription Painkillers: Evidence from the National Longitudinal Study of Adolescent to Adult Health

The misuse of prescription painkillers is a major contributor to the ongoing drug overdose epidemic. This study investigated variability in non-medical use of prescription painkillers (NMUPP) by race and early-life socioeconomic status (SES) in a sample now at increased risk for opioid overdose. Data from two waves of the National Longitudinal Study of Adolescent to Adult Health (n = 11,602) were used to calculate prevalence of reported NMUPP by Wave 4 (2008; mean age 28), and to assess variation by race and by equivalized household family income at Wave 1 (1994/5). Predicted values for prevalence of NMUPP were modelled, adjusting for age, sex, parental education, and region. Race and SES in adolescence were associated with later reported NMUPP. A gradient was seen in prevalence by SES (adjusted: family income quartile 1 = 13.3%; quartile 2 = 13.8%; quartile 3 = 14.8%; quartile 4 = 16.0%; trend p-value = 0.007). Prevalence was higher among males. Racial/ethnic differences in prevalence were seen (non-Hispanic white (NHW) = 18.5%; non-Hispanic black (NHB) = 5.8%; Hispanic = 10.5%; Other = 10.0%). SES differences were less pronounced upon stratification, with trend tests significant only among females (p = 0.004), and marginally significant among Hispanic males (p = 0.06). Early-life SES was associated with reported lifetime NMUPP: the higher the family income in adolescence, the greater the likelihood of NMUPP by young adulthood. Variations in NMUPP by income paled in comparison with racial/ethnic differences. Results point to a possible long-enduring association between SES and NMUPP, and a need to examine underlying mechanisms.

Social-Ecological Predictors of Opioid Use Among Adolescents With Histories of Substance Use Disorders

Adolescent opioid misuse is a public health crisis, particularly among clinical populations of youth with substance misuse histories. Given the negative and often lethal consequences associated with opioid misuse among adolescents, it is essential to identify the risk and protective factors underlying early opioid misuse to inform targeted prevention efforts. Understanding the role of parental risk and protective factors is particularly paramount during the developmental stage of adolescence. Using a social-ecological framework, this study explored the associations between individual, peer, family, community, and school-level risk and protective factors and opioid use among adolescents with histories of substance use disorders (SUDs). Further, we explored the potential moderating role of poor parental monitoring in the associations between the aforementioned risk and protective factors and adolescent opioid use. Participants included 294 adolescents (M _age = 16 years; 45% female) who were recently discharged from substance use treatment, and their parents (n = 323). Results indicated that lifetime opioid use was significantly more likely among adolescents endorsing antisocial traits and those whose parents reported histories of substance abuse. Additionally, adolescents reporting more perceived availability of substances were significantly more likely to report lifetime opioid use compared to those reporting lower perceived availability of substances. Results did not indicate any significant moderation effects of parental monitoring on any associations between risk factors and lifetime opioid use. Findings generally did not support social-ecological indicators of opioid use in this high-risk population of adolescents, signaling that the social-ecological variables tested may not be salient risk factors among adolescents with SUD histories. We discuss these findings in terms of continuing care options for adolescents with SUD histories that target adolescents' antisocial traits, perceived availability of substances, and parent histories of substance abuse, including practical implications for working with families of adolescents with SUD histories.

Suicidal Behavior and Club Drugs in Young Adults

Psychoactive drugs play a significant role in suicidality when used for intentional overdose or, more frequently, when the intoxication leads to disinhibition and alterations in judgment, thereby making suicide more likely. In this study, we investigated suicidality prevalence among drug users and evaluated the differences in suicide ideation, taking into account the substance categories and the association of suicide ideation intensity with other psychiatric symptoms. Subjects admitted to the Can Misses Hospital's psychiatry ward in Ibiza were recruited during summer openings of local nightclubs for four consecutive years starting in 2015. The main inclusion criterium was an intake of psychoactive substances during the previous 24 h. The Columbia Suicide Severity Rating Scale (C-SSRS) was used to assess the suicide risk. Suicidality was present in 39% of the study cohort. Suicide Ideation Intensity overall and in the previous month was higher in users of opioids and in general of psychodepressors compared to psychostimulants or psychodysleptics. Suicidality was not correlated with alterations in any of the major psychopathological scales employed to assess the psychiatric background of the study subjects. The presence of high levels of suicidality did not specifically correlate with any major symptom indicative of previous or ongoing psychopathological alterations. These findings suggest that impulsivity and loss of self-control may be determinants of the increased suicidality irrespectively of any major ongoing psychiatric background.

The Effects of Early Onset Tranquilizers, Sedatives, and Sleeping Pills Use on Recent Consumption Among Adolescents

BACKGROUND

Adolescents' consumption of tranquilizers, sedatives, and sleeping pills (TSSp) has increased during the last few decades, and TSSp are currently among the substances with the lowest age-of-onset. We characterized current-use patterns of TSSp consumers by age when first taken.

METHODS

This study used individualized secondary data retrieved from the 2016 Spanish State Survey on Drug Use in Secondary Education (16-18-year-olds), and included all subjects who reported having taken TSSp at any point, but excluded those who had started during the previous year (n = 1502). Logistic regression models were used to obtain adjusted odds ratios (aOR) for associations between early TSSp consumption (<14 years) and current TSSp use patterns, adjusted for sociodemographic factors.

RESULTS

About 17.9% of respondents had taken TSSp (average age-of-onset = 13.7) and 45% of these without a prescription. TSSp consumption at <14 years was higher for males and nonrepeaters. Having begun to use TSSp < 14 years was associated with both higher probability of consumption in the last month (aOR = 1.41; 95%CI:1.12-1.77) and daily/almost daily consumption in the last month (aOR = 1.56; 95CI%:1.16-2.08).

CONCLUSIONS

The results of this study show there is a high proportion of 16 to 18 TSSp student consumers - both prescribed and nonprescribed; it also establishes that early onset-of-use is associated with higher levels of intensive use later on.

Nonmedical Use of Benzodiazepines among Immigrant and Native-Born Adolescents in Spain: National Trends and Related Factors

Background: the nonmedical use of prescribed medications among adolescents has increased significantly in recent years. We aimed to identify the patterns of benzodiazepine nonmedical use and its evolution during the decade 2006–2016 among immigrant and native-born adolescent populations. Methods: we used individualized secondary data retrieved from the 2006–2016 Spanish State Survey on Drug Use in Secondary Education (ESTUDES) of the school-aged population. Using logistic multivariate regression models, we estimated the independent effect of each of these variables on nonmedical use. Two models were generated: one for immigrant adolescents and one for native-born adolescents. Results: during the decade 2006–2016, 2.81% of native-born and 3.36% of immigrant adolescent students made nonmedical use of benzodiazepines. Gender and socioeconomic status were found to be related to the nonmedical use of benzodiazepines. Consumption of illegal psychoactive substances, other than marijuana, was the variable of greatest value (aOR = 6.00, 95% CI 3.89–9.27). Perceived risks and drug availability were found to be predictors for the nonmedical use of benzodiazepines in both immigrant and native-born adolescents. Conclusion: in Spain, patterns of benzodiazepine nonmedical use among immigrant and native-born adolescents are similar. The results of this study refute certain stereotypes related to consumption of substances among immigrant adolescents, identifying them as a risk group.

The impact of adverse childhood experiences on healthcare utilization in children

BACKGROUND

Adverse childhood experiences (ACEs) are related to long-term negative outcomes. The impact of these experiences on healthcare utilization in children has been understudied.

OBJECTIVE

To examine the impact of ACEs on children's healthcare utilization, medical diagnoses, and pharmacological treatment.

PARTICIPANTS AND SETTING

Children aged 6 months to 17 years who were screened for ACEs in the Behavioral Health Department or in primary care locations as part of an initial consultation visit and who had at least one subsequent healthcare visit during the study period were included in the study.

METHODS

Adverse childhood experiences were measured using the ACE screening questionnaire designed by Felitti et al. (1998). Data from the year following administration of the ACE screening tool were retrospectively extracted from the electronic health record.

RESULTS

Overall, 1,183 children met study inclusion criteria. Children with any reported ACEs were more likely to no show appointments (1-3 ACEs incidence rate ratio (IRR) [95 % confidence interval (CI)]: 1.40 [1.11-1.77]; 4+ ACEs IRR [95 % CI]: 1.41 [1.08-1.84]) and to use emergency services (1-3 ACEs IRR [95 % CI]: 1.24 [1.00-1.53]; 4+ ACEs: IRR [95 % CI]: 1.42 [1.11-1.81) than children with no ACEs. Those with 4+ ACEs used the telephone nurse advisor less frequently (1-3 ACEs IRR [95 % CI]: 0.67 [0.53-0.84]; 4+ ACEs IRR [95 % CI]: 0.69 [0.53-0.90]). Although ACE scores were associated with healthcare utilization, insurance status was more robustly associated with healthcare utilization than ACE score.

CONCLUSIONS

Healthcare systems may employ results from this study to adopt trauma-informed care initiatives. Ensuring that all patients have insurance may be a first step toward improving healthcare utilization.

Racial and Ethnic Differences in the Relationship Between Risk-Taking and the Effectiveness of Adolescents' Contraceptive Use

CONTEXT

Little is known about whether adolescents' risk-taking in areas other than sex is associated with the effectiveness of their contraceptive method use, or whether any such associations vary by race and ethnicity.

METHODS

Data from the 2011, 2013 and 2015 National Youth Risk Behavior Surveys were used to examine nonsexual risk behaviors and contraceptive method choice among 5,971 sexually active females aged 13-18. Risk-taking profiles for White, Black and Hispanic adolescents were identified using latent class analysis. Multinomial logistic regression was used to estimate the associations between these risk profiles and use of less- or more-effective contraceptive methods at last sexual intercourse.

RESULTS

Three distinct risk-taking profiles were identified for White and Hispanic adolescents and two for Black adolescents. Compared with their counterparts in the low-risk "abstainer" group, White adolescents in the "high substance use and violence" group were less likely to use condoms alone (relative risk, 0.4) or a prescription contraceptive paired with condoms (0.3) rather than no contraceptive at all, and more likely to use withdrawal or no method rather than condoms alone (2.4 each). However, higher risk-taking among Whites was positively associated with using prescription contraceptives rather than condoms (1.9). Among Black and Hispanic females, lower risk-taking was associated only with more condom use.

CONCLUSIONS

Future studies should examine whether interventions designed to reduce adolescent risk-taking improve the effectiveness of contraceptive use, particularly among White females. However, efforts to increase Black and Hispanic adolescents' use of more-effective contraceptives should target barriers other than risk-proneness. Perspectives on Sexual and Reproductive Health, 2020, 52(4):TK, doi:10.1363/psrh.12165.

Prescription opioid misuse and its correlates among veterans and military in the United States: A systematic literature review

BACKGROUND

Prescription opioid misuse (POM) has become a critical public health issue in the United States (US), with veteran and military population being especially vulnerable to POM. However, limited behavioral interventions have been developed for veterans and military to reduce POM risk due to the lack of an adequate understanding of POM andrelated factors among veterans and military. The current study aims to review and synthesize empirical findings regarding POM and its correlates among US veterans and military.

METHODS

We conducted a systematic review of 17 empirical studies (16 quantitative studies and one qualitative study) from 1980 to 2019 that reported POM statistics (e.g., prevalence) and examined correlates of POM in veterans and military.

RESULTS

The prevalence of POM in veterans and military ranged from 6.9%-77.9% varying by study samples, individual POM behaviors, and recalled time periods. Several factors were identified to be associated with POM in veterans and military. These factors included socio-demographic factors (age, race/ethnicity, education, relationship status, and military status), pain-related factors (pain symptoms, severity, interference, and cognitions), other physical factors (e.g., common illness), opioid-medication-related factors (receipt of opioid medications and quantity of opioid medications), behavioral factors (substance use disorder, alcohol use, cigarette use, and other prescription drug use), and psychological factors (psychiatric symptoms and cognitive factors).

CONCLUSIONS

POM was prevalent in veterans and military and could be potentially influenced by multiple psycho-behavioral factors. Future research guided by a theoretical framework is warranted to examine psycho-behavioral influences on POM and their mechanisms and to inform effective psychosocial POM interventions in veterans and military.

Opioid-related overdose deaths among African Americans: Implications for research, practice and policy

Opioid-related overdose deaths among African Americans have only recently received national attention despite evidence of increase in death rates among this population spanning the past decade. Numerous authors have highlighted how the 'opioid epidemic' has largely been portrayed as a problem mostly affecting White America. The purpose of this commentary is to provide a synthesis spotlighting the unique structural and cultural considerations involved in research, practice and policy related to opioid use and treatment for opioid use disorders among African Americans. The commentary concludes with considerations for future research and practice intended to reduce deaths among this group.

Predictors of Opioid Misuse During Emerging Adulthood: An Examination of Adolescent Individual, Family and Peer Factors

INTRODUCTION

Opioid misuse has reached epidemic proportions among emerging adults in the U.S. To inform prevention efforts, this study examined adolescent factors related to alcohol and marijuana (AM) use that are associated with a higher or lower risk for opioid misuse during emerging adulthood.

METHODS

We used 11 waves of survey data from a diverse California cohort (N = 6,509). Predictor variables from waves 1-7 (ages 11-17) included individual (resistance self-efficacy, positive expectancies) family (older sibling and important adult use), and peer (perceived norms, time spent with peers who use, peer approval) factors. Opioid misuse at wave 8 (mean age = 18.3) and wave 11 (mean age = 21.6) included heroin and nonmedical prescription drug use.

RESULTS

Initial latent growth models (LGMs) indicated that nearly all intercepts and slopes for individual, family, and peer AM factors predicted opioid misuse at waves 8 and 11. These associations were reduced to non-significance after adjusting for prior other substance use with the exception of three intercepts: positive expectancies, peer approval, and older sibling use predicted a higher probability of opioid misuse at wave 8.

CONCLUSIONS

Stronger AM positive expectancies, perceived peer approval of AM use, and older sibling AM use during adolescence are associated with a higher likelihood of opioid misuse during the transition to emerging adulthood. However, most adolescent factors were no longer associated with subsequent opioid misuse after adjusting for history of other substance use, highlighting the importance of considering the larger context of substance use in studies of opioid misuse among young people.

Parental perceptions linked to opioid misuse among justice-involved children

Justice-involved children (JIC) are a subset of at-risk youth highly susceptible to the ill-consequences of opioid misuse (OM), especially for younger JIC. Parental practices and attitudes towards delinquency are known to influence a child's behavior, however the relationship between parental attitudes towards youth delinquent behavior and odds of OM has yet to be investigated. The current study used a sample from the Florida Department of Juvenile Justice (age 10-18; M=14; n=79,960) to investigate how parental attitudes towards youth delinquent behavior influence the likelihood JIC meet criteria for past-30 day (P30D) OM. P30D OM was verified utilizing urinalysis. Youth with parents expressing proud or accepting attitudes towards youth delinquent behavior were roughly twice as likely to meet criteria for P30D OM as those with parents expressing disapproving attitudes. This relationship varied by age, with younger ages experiencing the greatest risk. These findings support early intervention efforts to develop prosocial attitudes in youth and their parents.

Clinical characteristics distinguishing tramadol-using adolescents from other substance-using adolescents in an out-patient treatment setting

BACKGROUND

Non-medical Prescription Opioid Use (NMPOU) has increased worldwide during the last decades, and specifically, tramadol misuse may represent a novel pattern of substance use among adolescents. The present study aims to analyze characteristics distinguishing tramadol-using adolescents from other substance-using adolescents seeking out-patient treatment.

METHODS

This is a cross-sectional study of treatment-seeking patients between 13 and 24 years of age in an out-patient facility for substance use problems in Malmö, Sweden. A total of 526 treatment-seeking adolescents at an out-patient treatment center were included. Data on substance use, treatment history and socio-demographic variables were extracted through a semi-structured interview method aimed specifically for adolescents with alcohol or drug problems (Ung-DOK). Lifetime tramadol users were compared to non-users, and also, primary tramadol users were compared to remaining subjects.

RESULTS

Thirty-one percent (n = 162) were tramadol users (lifetime prevalence). In logistic regression, the tramadol group showed a significantly increased risk of tobacco use, problematic lifetime cocaine, benzodiazepine and amphetamine use, and were more likely to report contacts with the judicial system, and less likely to report contacts with child or adult psychiatry, and more likely to have parents born outside the Scandinavian countries. In logistic regression, primary tramadol use was negatively associated with frequent cannabis use.

CONCLUSIONS

Tramadol use appears to be a novel pattern among treatment-seeking adolescents. They showed a significantly increased risk of initiation of other illicit drugs and criminal behaviour, despite less contact with psychiatric care. More attention may be needed to this relatively novel pattern of opioid use.

Prevalence and Health Characteristics of Prescription Opioid Use, Misuse, and Use Disorders Among U.S. Adolescents

PURPOSE

The prevalence of past-year prescription opioid use (POU), nonmedical POU (NMPOU), and POU disorder (POUD) and their correlates were examined in a national sample of American adolescents (N = 41,579).

METHODS

This study used data from the public-use files of the 2015, 2016, and 2017 National Surveys on Drug Use and Health, which captured substance use and mental health problems among noninstitutionalized individuals. Prevalence and specific types of prescription opioids and other substances used and misused in the past year were examined among adolescents. Logistic regression analyses were conducted to determine correlates (demographics, other substances used, past-year major depressive episode, school enrollment, two-parent household, number of lifetime medical conditions, and survey year) of POU, NMPOU, and POUD.

RESULTS

Multiple substance use was common within the past year. The most frequently used prescription opioids were hydrocodone, codeine, oxycodone, and other opioids among adolescents. Cannabis use disorder and alcohol use disorder were comparatively prevalent among opioid misusers. Several correlates (demographics, other substances used, lifetime medical conditions, major depressive episode, and survey year) of POU, NMPOU, and POUD were found.

CONCLUSIONS

In this national sample, multiple substance use was common among adolescents with past-year POU and NMPOU. Clinical screening for opioid use problems, assessment, and treatment expansion for POUD can focus on persons with substance use, mental health, and/or behavioral problems. Longitudinal studies are needed to better elucidate temporal associations between POU and NMPOU/POUD among adolescents, and more prevention and treatment research on rural residents and minority groups is needed.

Prescription Opioid Misuse and Risky Adolescent Behavior

OBJECTIVES

Misuse of opioid medications (ie, using opioids differently than how a doctor prescribed the medication) is common among US adolescents and associated with preventable health consequences (eg, severe respiratory depression, seizures, heart failure, and death).¹ New guidelines and recommendations have made providers more attuned to overprescribing and more vigilant about screening for opioid misuse.² We hypothesized that youth who misused prescription opioids were more likely to report engaging in a broad range of other risky behaviors.

METHODS

We used the Centers for Disease Control and Prevention's 2017 Youth Risk Behavior Surveillance Survey (n = 14 765), a cross-sectional, nationally representative survey of high school students. Students were sampled by using a 3-stage random cluster design. We conducted weighted logistic regressions to determine the strength of the association between our independent variable, ever misusing prescription opioids, and 22 dependent variables in the following categories: risky driving behaviors (4 variables), violent behaviors (3 variables), risky sexual behaviors (4 variables), substance use (10 variables), and suicide attempt (1 variable).

RESULTS

In 2017, 14% of US adolescents reported ever misusing opioids. Those who misused prescription opioids were significantly more likely to have engaged in all 22 risky behaviors (adjusted odds ratios ranged from 2.0 to 22.3; P < .0001 for all tests) compared with other adolescents.

CONCLUSIONS

Adolescents reporting ever misusing prescription opioids were more likely to have engaged in a broad range of risky behaviors. Health care providers screening for prescription opioid misuse may be ideally positioned to identify these high-risk youth and initiate early interventions.

Educational attainment and prescription drug misuse: The importance of push and pull factors for dropping out

PURPOSE

Young adults who do not complete high school are at increased risk for substance use and offending behavior. A limitation of this research is that dropouts are often treated as a homogeneous group, which ignores the various push (e.g., academic failure or disciplinary problems) and pull (e.g., family responsibility or economic need) factors for leaving school.

METHODS

The current study relies on multiple years of data from the National Survey on Drug Use and Health (2009-2014) and examines several dependent variables, including prevalence of prescription drug misuse, frequent prescription drug misuse, and prescription drug-related substance use disorder symptoms. We assess the importance of push and pull factors for dropping out, and compare dropouts to respondents who completed school.

RESULTS

Multivariable logistic regression analyses produce two important findings. First, push factors increase the risk of various types of prescription drug misuse compared to pull factors. Additionally, respondents who attend college are at a decreased risk for various types of prescription opioid and sedative/tranquilizer misuse and disorder.

DISCUSSION

The current research identifies important differences in prescription drug misuse and disorders among dropouts based on the reason they left school. Additionally, college attendance appears to be a strong protective factor.

Prescription Drug Misuse in "Clubbers" and Disco Goers in Ibiza

Background: Prescription drug misuse and its related risks are considered a worldwide public health issue. Current trends show that the extent of such phenomenon may not be limited to subjects with psychiatric disorders, as it also spreads to dance party and nightclub attendees, who often consume prescription drugs in combination with alcohol and psychoactive substances. This study aims to report the sociodemographic data and the psychiatric and clinical features of a sample of clubbers reporting prescription drugs use. Methods: Patients admitted to the psychiatry ward of the Can Misses Hospital in Ibiza were recruited for the study during a span of four consecutive years (2015-2018). The inclusion criteria were age 18-75 years old and the intake of psychoactive substances or more than five alcohol units during the previous 24 h. Substance use habits, psychopathological features, and use of unprescribed pharmaceuticals were investigated. Urine samples were collected and analyzed using gas chromatography/mass spectrometry. Results: A total of 110 subjects with psychoactive substance intoxication were recruited for the study. Among these, 37 (40%) disclosed the use of prescription drugs without medical supervision. The most common compounds were benzodiazepines (66%), antiepileptic drugs (8%), antidepressants (6%), opioids (6%), antipsychotics (6%), stimulants (6%), and non-steroidal anti-inflammatory drugs (NSAIDs, 2%). Prescription drug misuse was negatively associated with the use of psychodysleptics (two-tailed Fisher's exact test p = 0.018, ρ = -0.262). Conclusions: The use of prescription drugs is also common among clubbers, usually characterized by low propensity to be prescribed benzodiazepines, antipsychotics, or antidepressants. Prescription drugs may be an alternative to classic and novel psychoactive compounds or may be used to tamper and self-medicate the effects determined by the use of substances. Party goers should be adequately informed about possible risks of co-intake of psychoactive substances and prescription drugs to prevent serious medical and psychiatric consequences.

Correlates of nonmedical use of prescription opioids among a cohort of adolescents in Ontario, Canada

INTRODUCTION

Mortality and morbidity rates related to prescription opioid analgesics have been rising in North America and may be a gateway to the nonmedical use of prescription opioids (NUPO). The purpose of this study was to explore correlates of NUPO in the adolescent population given the scarce literature in this area.

METHODS

Cross-sectional data from 10,163 middle- and high-school students (15.1 ± 1.8 years old; 57.0% female; 55.6% White ethnic background) in Ontario were derived from the 2017 Ontario Student Drug Use and Health Survey. Potential correlates of NUPO in the past year included sociodemographic, behavioral, parental, and school characteristics.

RESULTS

Overall prevalence of NUPO was 10.7%. In the final multivariable model, NUPO was significantly associated with 8 of the 21 correlates examined. Students who used prescription opioids nonmedically were of black, South Asian, and "other" ethnic backgrounds (OR 2.83, OR 1.77, and OR 1.67, respectively); reported a lower subjective socioeconomic status (OR 0.92), lower parental support (OR 0.90), and lower academic performance (OR 0.86); met physical activity recommendations (OR 1.48); consumed energy drinks (OR 1.42); smoked tobacco cigarettes (OR 2.33); and used cannabis (OR 1.84).

CONCLUSIONS

Findings from this study show a wide variety of correlates of NUPO among Canadian adolescents, and highlight the need for further research and the value in targeted prevention and multi-level intervention programs for NUPO in this population.

Using machine learning to predict opioid misuse among U.S. adolescents

This study evaluated prediction performance of three different machine learning (ML) techniques in predicting opioid misuse among U.S. adolescents. Data were drawn from the 2015-2017 National Survey on Drug Use and Health (N = 41,579 adolescents, ages 12-17 years) and analyzed in 2019. Prediction models were developed using three ML algorithms, including artificial neural networks, distributed random forest, and gradient boosting machine. The performance of the ML prediction models was compared with performance of the penalized logistic regression. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used as metrics of prediction performance. We used the AUPRC as the primary measure of prediction performance given that it is considered more informative for assessing binary classifiers on imbalanced outcome variable than AUROC. The overall rate of opioid misuse among U.S. adolescents was 3.7% (n = 1521). Prediction performance was similar across the four models (AUROC values range from 0.809 to 0.815). In terms of the AUPRC, the distributed random forest showed the best performance in prediction (0.172) followed by penalized logistic regression (0.162), gradient boosting machine (0.160), and artificial neural networks (0.157). Findings suggest that machine learning techniques can be a promising technique especially in the prediction of outcomes with rare cases (i.e., when the binary outcome variable is heavily lopsided) such as adolescent opioid misuse.

Sex differences in nonmedical prescription tranquilizer and stimulant use trends among secondary school students in Argentina, Chile, and Uruguay

BACKGROUND

Little is known about recent nonmedical prescription tranquilizer and stimulant use trends in Latin America. We tested whether recent trends among students in three South American countries differed by sex over time.

METHODS

Three countries independently collected National School Students Survey on Drugs. Students in 8th, 10th, and 12th grades were sampled in Argentina (2007-2014, N = 328,202), Chile (2007-2015, N = 136,379), and Uruguay (2007-2016, N = 32,371). Weighted linear regression models predicted the prevalences and trends over time of past-year nonmedical tranquilizer and stimulant use by country, and tested whether trends differed by sex, adjusting for school type and grade.

RESULTS

In Argentina from 2007 to 2014, past-year nonmedical prescription tranquilizer (girls: 2.8 to 2.6%, boys: 2.5 to 2.3%) and stimulant (girls: 1.7 to 1.3%, boys: 1.9 to 1.5%) use trends did not differ by sex. In Chile from 2007 to 2015, nonmedical prescription tranquilizer use trends significantly differed comparing girls (3.9 to 10%) with boys (3.2 to 6.9%); stimulant use trends did not differ comparing girls (1.6 to 2.0%) with boys (2.0 to 1.3%). In Uruguay from 2007 to 2014 and 2014-2016, past-year nonmedical prescription tranquilizer (girls: 5.1 to 6.6%; boys: 2.8 to 4.2%) and stimulant (girls: 1.8 to 0.7%; boys: 1.8 to 0.7%) use trends did not differ by sex.

CONCLUSIONS

Trends of nonmedical prescription tranquilizer use recently increased in Chile and Uruguay, widening by sex over time in Chile only. The drivers of increasing tranquilizer use among girls in Chile and Uruguay merit further investigation.

Opioid prescribing patterns in emergency departments and future opioid use in adolescent patients

OBJECTIVE

Evidence suggests that exposure to opioids in adolescence increases risk of future opioid use. We evaluate if exposure to high versus low intensity opioid prescribers in the Emergency Department (ED) influences the risk of future opioid use in adolescents.

METHODS

Retrospective study of opioid-naïve patients 10 to 17 years seen in one of 14 EDs between January 2013 and December 2014. We categorized ED providers into quartiles according to the proportion of encounters resulting in opioid prescriptions. Primary outcome was use of opioids in the subsequent 12 months. Analysis adjusted for patient characteristics and compared future use of opioids for patients seen by the lowest versus the highest prescribing quartiles.

RESULTS

We included 9,688 patient encounters evaluated by the lowest opioid prescribing physician quartile versus 9,467 in the highest. The highest quartile gave opioid prescriptions to 14.9% of their patients compared to 2.8% for the lowest quartile. No association with future opioid use was found for patients evaluated by low versus high prescriber quartiles (OR 0.99, 95% CI 0.90-1.08). Patients with increasing age (OR 2.15, 95% CI 1.92-2.42) and white versus Hispanic ethnicity (OR 1.55, 95% CI 1.33-1.80) were associated with recurrent opioid use.

CONCLUSION

We found no association between high intensity opioid prescribers and recurrent 12 month use of opioids in opioid-naïve adolescents seen in the ED. This likely reflects various factors that put adolescents at risk for recurrent opioid use and may indicate the importance of the second prescription from primary care after initial exposure to opioids.

Opioid Seeking Behaviors and Diversion in Hospitalized Pediatric Patients: A Case Series

All nurses have a responsibility for monitoring their patients for signs of substance misuse or substance use disorder. Adolescents and young adults are at risk for substance use. Prescription medications may be used by adolescents for non-medical reasons such as to feel high, to assist with sleep, to avoid negative feelings or thoughts or to avoid withdrawal symptoms after chronic use. Some adolescents with legally prescribed medications have been asked to divert those medications by giving them to someone else. Drug diversion by employees is often reported in healthcare settings, but diversion of medications done by patients is far less commonly reported. This paper is a report of two patients with complex medical issues and chronic pain who diverted opioid medications while hospitalized. Hiring clinical staff, such as nurses, working in Drug Diversion Prevention positions will provide knowledge and expertise to facilitate investigations and to help reduce risks for diversion in healthcare settings. In addition, nurses with concerns about patient diversion should discuss these concerns with the care team. Organizational leaders need to support their teams by providing education and resources so staff feel comfortable addressing these challenging situations.

Gender differences in the nonmedical use of psychoactive medications in the school population- national trends and related factors

BACKGROUND

The nonmedical use of prescribed medicines among adolescents has increased significantly in recent years. Our study was designed to describe the prevalence of the nonmedical use of tranquilizers, sedatives, and sleeping pills (TSSp) among the school-age population residing in Spain from a gender perspective, and to identify factors associated with such use.

METHODS

Nationwide, epidemiological, cross-sectional study on the nonmedical use during the previous 30 days, of TSSp by the Spanish school population. We used individualized secondary data retrieved from the 2004, 2006, 2008, 2010, 2012 and 2014 Spanish state survey on Drug Use in Secondary Education and a total of 179,114 surveys from respondents aged 14 to 18 years. Using logistic multivariate regression models, we estimated the independent effect of each of these variables on the nonmedical use of medicines. Two models were generated- one for females and one for males.

RESULTS

2.86% (5116) of the Spanish school population of both sexes made nonmedical use of TSSp. Prevalence was greater among girls than among boys for all the study years. Patterns of nonmedical use among female adolescents were related to alcohol, tobacco and marijuana use. Consumption of illegal psychoactive substances, other than marijuana, was the variable showing the greatest value among male teenagers (aOR 6.21 (95% CI 4.97-7.77).

CONCLUSIONS

The prevalence of the nonmedical use of TSSp is higher in girls than in boys. The influence of legal and illegal psychoactive substances leads to a higher likelihood of nonmedical use of TSSp in high-school students in Spain.

Trajectories of prescription drug misuse during the transition from late adolescence into adulthood in the USA: a national longitudinal multicohort study

BACKGROUND

Prescription drug misuse is most prevalent during young adulthood (ages 18-25 years). We aimed to identify prescription drug misuse trajectories for three drug classes (opioids, stimulants, and sedatives or tranquilisers) from adolescence into adulthood, assess the extent to which different trajectories are associated with symptoms of substance use disorder, and identity factors associated with high-risk prescription drug misuse trajectories.

METHODS

For this longitudinal multicohort study, nationally representative probability samples of 51 223 adolescents in the USA were followed up across eight waves from age 18 years (cohorts 1976-96) to age 35 years. Data were collected via self-administered paper questionnaires.

FINDINGS

Five prescription drug misuse trajectories were identified and the defining characteristic that differentiated the five trajectories was the age when past-year prescription drug misuse high frequency peaked: rare or no misuse at any age, peak at age 18 years, peak at ages 19-20 years, peak at age 23-24 years, and peak at ages 27-28 years. Similar prescription drug misuse trajectories were identified for each prescription drug class. The later peak misuse trajectory for sedatives and tranquilisers crested at an older age (35 years) than that for the other drug classes. Prescription drug misuse trajectories were all associated with significantly greater odds of having two or more substance use disorder symptoms at age 35 years, especially the later peak trajectories. In controlled analyses, risk factors associated with the high-risk latest peak prescription drug misuse trajectory included high school heavy drinking, cigarette smoking, marijuana use, poly-prescription drug misuse, white race, and not completing a 4-year university degree.

INTERPRETATION

Prescription drug misuse trajectories are heterogeneous, and any high-frequency prescription drug misuse is a strong risk factor for development of substance use disorders during adulthood, especially later-peak prescription drug misuse trajectories. These findings might help practitioners identify individuals at greatest risk for substance use disorders and target intervention strategies.

FUNDING

National Institute on Drug Abuse, National Institutes of Health.

Alleviation of diazepam-induced conditioned place preference and its withdrawal-associated neurobehavioral deficits following pre-exposure to enriched environment in rats

Diazepam is one of the widely prescribed sedative drugs for the treatment of anxiety and sleep disorders. However, its continuous use can induce addiction, tolerance, and withdrawal symptoms and, therefore, the pharmacological use of diazepam is restricted. Exposure to enriched environment can reduce the addiction to stimulants including amphetamine, cocaine, and nicotine. However, the protective effect of enriched environment against preference of sedative drugs is not yet investigated. This study, therefore, determined the effects of enriched environment to prevent diazepam-preference using conditioned place preference (CPP) paradigm. Adult rats were reared in social (n = 12) or physically (n = 12) enriched environment for four weeks. Each group was then sub-divided into two groups and were administered either saline (Control; n = 6) or diazepam (1 mg/kg; n = 6) on alternate days for thirteen days. During the administration of diazepam, the CPP was conducted to monitor drug preference on 5th, 9th and 13th day of experiment. It was observed that the diazepam administration significantly (p < .01) induced preference in rats. Neurobehavioral deficits including hypolocomotor activity, depression-like behavior, impaired learning and memory functions were also observed after 24 h of drug abstinence. Exposure to enriched environment significantly reduced diazepam-preference and other neurobehavioral deficits. This study provides preliminary evidence to highlight the importance of enriched environment in the attenuation of diazepam-preference.

Heavy Drinking and Non-Medical Use of Prescription Drugs among University Students: A 9-Year Follow-Up

Purpose: Investigations suggest non-medical use of prescription drugs (NMUPD) is associated with heavy drinking and polydrug use among university students. Our aim is to determine the prevalence of NMUPD among university students and to analyze its association with alcohol, tobacco, and cannabis use, and to study the role of the age of drinking onset. Methods: Cohort study among university Spanish students (n = 1382). Heavy drinking (HED) and risky consumption (RC) were measured with the Alcohol Use Disorders Identification Test. Questions related to tobacco and cannabis consumption were also formulated. NMUPD refers to sedative, anxiety, or pain medication intake within the last 15 days without medical prescription. All variables were measured at 18, 20, and 27 years. Multilevel logistic regression for repeated measures was used to obtain adjusted OR (odds ratios). We analyzed the results from a gender perspective. Results: Prevalence of NMUPD were higher in students who already partook in NMUPD at the beginning of the study. NMUPD in women at 27 is 3 times higher than at 18, while in men it is twice. Among females, RC (OR = 1.43) and cannabis consumption (OR = 1.33) are risk factors for NMUPD, while later onset of alcohol use (OR = 0.66) constitutes a protective factor. No significant differences were found for males. Conclusions: NMUPD is prevalent among university students. RC and early onset of alcohol use were associated with higher prevalence of NMUPD in females. The prevalence of NMUPD increased with age in both sexes. Strategies for reducing risky drinking and delaying onset of drinking should be provided for university students. Pharmacists and parents should be alerted to the risk of NMUPD.

Prevalence and Correlates of Depressive Symptomology among Young Adults Who Use Prescription Opioids Non-medically

Non-medical prescription opioid (NMPO) use and depression frequently co-occur and are mutually reinforcing in adults, yet NMPO use and depression in younger populations has been under-studied. We examined the prevalence and correlates of depressive symptomology among NMPO-using young adults. The Rhode Island Young Adult Prescription Drug Study (RAPiDS) recruited young adults in Rhode Island who reported past 30-day NMPO use. We administered the Center for Epidemiologic Studies Short Depression Scale (CES-D 10), and used modified Poisson regression to identify the independent correlates of depressive symptomology (CES-D 10 score ≥10). Over half (59.8%, n = 119) screened positive for depressive symptomology. In modified Poisson regression analysis, diagnostic history of depressive disorder and childhood verbal abuse were associated with depressive symptomology. Participants with depressive symptomology were more likely to report using prescription opioids non-medically to feel less depressed or anxious, to avoid withdrawal symptoms, and as a substitute when other drugs are not available. Among young adult NMPO users, depressive symptomology is prevalent and associated with distinct motivations for engaging in NMPO use and represents a potential subgroup for intervention. Improving guidelines with tools such as screening for depressive symptomology among young adult NMPO users may help prevent NMPO-related harms.

Adolescent and Parent Management of Controlled Prescription Medications

Background: Most adolescents who misuse controlled prescription medications acquire them from home settings. However, little is known regarding household management (storage, administration, and disposal) of these medications. Objective: To describe household management of controlled medications. Methods: This was a cross-sectional study with paired data using brief, online, confidential surveys of adolescents and parents via an adolescent medicine clinic associated with a large academic center. Eligible adolescents were 12-18 years with at least one controlled prescription medication in the home. Six core safe management strategies for controlled medications were identified based on current recommendations. Data were collected and analyzed in 2017. Results: Of the 243 adolescent-parent dyads, 78.2% (n = 190) dyads store medication out of sight, 68.7% (n = 167) lock up medications, 78.2% (n = 190) do not store pills besides a school nurse's office or a parent's place of work, 43.6% (n = 106) provide periodic parental monitoring, 64.6% (n = 157) frequently dispose of unused controlled medications (at least every 3-4 months), and 80.2% (n = 195) dispose of controlled medications in a prescription drug take-back program or by flushing. Families with an adolescent prescription for a controlled medication were more likely to use several core management strategies (periodic parental monitoring, frequent disposal, and appropriate disposal location). Families with a household pain reliever were 8.7 times (95% CI 3.3, 23.3) as likely to not keep spare pills in inappropriate locations. Conclusions/Importance: Most families do not practice all recommended safe management strategies for controlled medications. Healthcare professionals should promote safe management to reduce controlled prescription medication misuse.

Heroin Overdose-Related Child and Adolescent Hospitalizations: Insight on Comorbid Psychiatric and Substance Use Disorders

OBJECTIVE

To evaluate the association between psychiatric comorbidities, substance use disorders and heroin overdose-related hospitalizations (HOD). Next, to understand the demographic trend of HOD hospitalizations and comorbidities.

METHODS

Using the Nationwide Inpatient Sample (NIS), we included 27,442,808 child and adolescent hospitalizations, and 1432 inpatients (0.005%) were managed primarily for HOD. The odds ratio (OR) of the association of variables in HOD inpatients were measured using a logistic regression model.

RESULTS

Adolescents had 56 times higher odds (95% CI 43.36-73.30) for HOD-related hospitalizations compared to 4.6% children under 11 years. About three-fifth of the HOD inpatients were male, and they had 1.5-fold higher odds (95% CI 1.30-1.64) compared to 43% females in the study population. Whites were considerably higher in proportion (81%) than other race/ethnicities. A greater portion of HOD inpatients (40%) were from high-income families. Most common comorbid psychiatric disorders were mood (43.8%) and anxiety (20.4%). The prevalent comorbid substance use disorders were opioid (62.4%), tobacco (36.8%) and cannabis (28.5%) use disorders.

CONCLUSION

HOD-related hospitalizations were predominant in males, White and older adolescents (12-18 years). Prescription opioids are the bridge to heroin abuse, thereby increasing the vulnerability to other substance abuse. This requires more surveillance and should be explored to help reduce the heroin epidemic in children.

Cross-sectional study on influence of the family environment on the lifetime non-medical use of prescription drugs among Chinese adolescents in Guangdong: an analysis of sex differences

OBJECTIVES

This study aimed to assess if adolescents had used any prescription drugs non-medically, to explore the associations between the family environment and non-medical use of prescription drugs (NMUPD) and to investigate whether there are any sex differences in the aforementioned associations.

DESIGN

A population-based cross-sectional study.

SETTING

A secondary analysis of the cross-sectional data collected from high school students in Guangdong who were sampled using a multistage, stratified-cluster, random-sampling method in the 2015 School-based Chinese Adolescents Health Survey.

PARTICIPANTS

A total of 21 774 students aged 12-20 years.

DATA ANALYSIS

Multilevel logistic regression models were used to explore the univariable and multivariable relationship between family environment and NMUPD among adolescents. Adjusted ORs and corresponding 95% CI were calculated.

OUTCOME MEASURES

Questions regarding to adolescent' NMUPD (including sedative, opioid and stimulant) were surveyed in the study.

RESULTS

A total of 6.3% students reported lifetime NMUPD in this study. The most commonly used drugs were opioids (3.9%), followed by sedatives (3.2%) and stimulants (2.5%). Multilevel analyses indicated that living arrangements, family economic status, parental relationships, parental education levels, monthly pocket money, parental drinking and drug problems were significantly correlated to the NMUPD among all students. Among boys, living arrangements, family economic status, maternal education levels, monthly pocket money, parental drinking and drug problems were significantly related to different types of NMUPD. The same factors were related to girls' NMUPD, except for maternal education levels. Parental relationships and paternal education levels were also associated with girls' NMUPD.

CONCLUSION

The family environment exerts an important influence on adolescents' NMUPD. Interventions targeted at families are highly recommended considering the negative effects of NMUPD. In addition, the child's sex might be taken into consideration when developing and implementing preventive strategies.

Nonmedical prescription drug use of analgesics and sedatives/hypnotics in Taiwan: Results from the 2014 National Survey of Substance Use

Nonmedical prescription drug use (NMPDU) has become a major public health issue but little is known in Asian populations. This study aimed to investigate the prevalence and correlates of NMPDU in Taiwan. Participants from the 2014 national survey of 17,837 individuals, aged 12 to 64 year, completed anonymously a computer-assisted self-interview. Past-year prescription drug use was divided into medical use only (MUO) and nonmedical use (NMU), defined as using the drug without a prescription, or more frequently, or in larger doses than prescribed. Problematic alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT), problematic drug use using the 20-item Drug Abuse Screening Test (DAST), and depressive symptoms using the Center for Epidemiological Study-Depression (CES-D). The prevalence of past-year NMU was 3.02% for analgesics, 0.71% for sedatives/hypnotics, and 3.66% for either drug, with a very small overlap of NMU between analgesics and sedatives/hypnotics (0.07%). When individuals with NMU were compared to those without NMU (Non-NMU) and those with MUO, respectively, some correlates consistently identified, including young adulthood, tobacco smoking, alcohol drinking, and greater AUDIT's scores for analgesics, as well as hard drug use and greater DAST's scores for sedatives/hypnotics. NMU was associated with greater CES-D's scores for both analgesics and sedatives/hypnotics when compared to Non-NMU but not to MUO. Robust correlates of NMPDU could offer implications for development of prevention strategies of NMPDU.

•

A 3.66% of Taiwanese aged 12 to 64 had past-year nonmedical prescription drug use.

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Nonmedical use of analgesics correlated with tobacco use and problematic alcohol use.

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Nonmedical use of sedatives/hypnotics correlated with problematic drug use.

•

The correlates of nonmedical drug use offer useful clues for prevention strategies.

Medical marijuana legalization and associated illicit drug use and prescription medication misuse among adolescents in the U.S

BACKGROUND

Use of illicit drugs and misuse of prescription medications among U.S. adolescents have been major public health issues. As over half of the states have implemented medical marijuana laws (MMLs), it is unclear if MML implementation is associated with use of illicit drugs and misuse of prescription medications among adolescents.

METHODS

This study used data from the 2013-2014 National Survey of Drug Use and Health and included adolescents aged 12-18 with a total of 26,826 participants after the propensity-score matching used to reduce selection bias between states that had and had not implemented MML. Seven logistic regressions were conducted to examine MML implementation and associated use of illicit drugs (including cocaine/crack, heroin, hallucinogens, and inhalants) and misuse of prescription medications (including pain relievers, tranquilizers/sedatives, and stimulants), controlling for sociodemographics and use of cigarettes, alcohol, and marijuana.

RESULTS

Adolescents residing in the states that had legalized medical marijuana were more likely to use cocaine/crack and heroin in the past 12 months (OR = 1.63, 2.61, respectively; both ps < 0.05). However, MML implementation was not associated with the likelihood of using other illicit drugs or misusing prescription medications.

CONCLUSIONS

The study findings suggest that for the states that have implemented MML, policy and educational interventions should as well be implemented to prevent not only marijuana use but also use of other harder drugs such as cocaine/crack and heroin among adolescents. States that have yet implemented MML should consider the possible associations between MML implementation and use of other illicit drugs when legislating MML.

The Association Between Ethnic Identity and Non-Medical Prescription Drug Use Among A Sample of College Students: Does a Sense of Ethnic Belonging Matter?

BACKGROUND

National data demonstrate significant differences in non-medical prescription drug (NMPD) use, with Whites seeming to be more likely to use compared to non-Whites. College students also appear to be at an increased risk for NMPD use.

OBJECTIVES

This study examines NMPD use using a component of social identity theory. We propose that a stronger sense of ethnic identity may reduce the likelihood of NMPD use among college students due to ethnic identity's ties to self-esteem and self-efficacy. We also propose that the protective power of ethnic identity may vary according to one's race.

METHODS

Data for this study were collected from a survey of undergraduate students at a Midwestern university (N = 530). Poisson regression analyses were used to test the relationship between ethnic identity and NMPD use. Of our sample, 135 participants (25.5%) indicated NMPD use over the past year. This percentage is high compared to findings from national college data.

RESULTS

Results indicate that a stronger sense of ethnic identity reduced the frequency of NMPD use among young adults. The findings also reveal that the relationship between ethnic identity and NMPD use is moderated by race. Ethnic identity was found to be a protective factor for non-White participants only.

CONCLUSIONS

This study suggests that ethnic belonging may act as a protective factor against NMPD use among non-White young adults. These findings build upon our understanding of the relationship between ethnic identity and substance use. We conclude with a discussion of directions for future research and intervention programs.

Opioid Prescribing Practices for Pediatric Headache

OBJECTIVES

To characterize the frequency of opioid prescribing for pediatric headache in both ambulatory and emergency department (ED) settings, including prescribing rates by provider type.

STUDY DESIGN

A retrospective cohort study of Washington State Medicaid beneficiaries, aged 7-17 years, with an ambulatory care or ED visit for headache between January 1, 2012, and September 30, 2015. The primary outcome was any opioid prescribed within 1 day of the visit.

RESULTS

A total of 51 720 visits were included, 83% outpatient and 17% ED. There was a predominance of female (63.2%) and adolescent (59.4%) patients, and 30.5% of encounters involved a pediatrician. An opioid was prescribed in 3.9% of ED and 1.0% of ambulatory care visits (P < .001). Pediatricians were less likely to prescribe opioids in both ED (-2.70 percentage point; 95% CI, -3.53 to -1.88) and ambulatory settings (-0.31 percentage point; 95% CI, -0.54 to -0.08; P < .001).

CONCLUSIONS

Opioid prescribing rates for pediatric headache were low, but significant variation was observed by setting and provider specialty. We identified opioid prescribing by nonpediatricians as a potential target for quality improvement efforts.