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Medical use and misuse of psychoactive prescription medications among US youth and young adults
  1. Israel Agaku1,
  2. Satomi Odani2 and
  3. Jantel Nelson3
  1. 1Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts, USA
  2. 2Department of Social Medicine, University of Crete, Rethimno, Crete, Greece
  3. 3Great Life Counseling Center, Addison, Texas, USA
  1. Correspondence to Dr Israel Agaku; iagaku{at}post.harvard.edu

Abstract

Objective To investigate prevalence and correlates of medical use and misuse of psychoactive prescription medications among US youth and young adults.

Design Cross-sectional, self-reported surveys from the 2015–2018 National Survey of Drug Use and Health. Sampling was probabilistic and nationally representative.

Setting The target population included individuals from households, non-institutional group quarters (eg, college dormitories) and civilians living on military bases. Questionnaires were completed using computer-assisted self-interview methods.

Participants Our analytical sample included youth and young adults aged 12–25 years (n=110 556). Psychoactive prescription medication misuse was a report by the respondent that they had used psychoactive prescription medications in the past year in any way not directed or prescribed for them. Medical use was defined as past-year use without a report of misuse. Because certain variables were assessed only among adults, our multivariable analysis to identify correlates of misuse was restricted to young adults aged 18–25 years (n=55 690).

Results Among US youth aged 12–17 years, 25.0% reported use of any psychoactive prescription medication assessed, and 5.7% reported past-year use of at least two psychoactive prescription medications. Among youth who used any psychoactive prescription medications, 20.9% (1.3 million) reported misuse; 3.4% were classified as having substance use disorder. Past-year use of each psychoactive prescription medication was: opioids (19.0%), stimulants (7.2%), tranquillisers (4.3%) and sedatives (2.2%). Among users of each psychoactive prescription medication, the estimated percentage reporting misuse was as follows: opioids (17.6%, 0.8 million), stimulants (24.2%, 0.4 million), tranquillisers (40.1%, 0.4 million) and sedatives (14.2%, 80 000). Among users of each psychoactive prescription medication, the estimated percentage having substance use disorder was as follows: opioids 2.6%, stimulants 3.0%, tranquillisers 7.0% and sedatives 3.6%. Analyses among young adults aged 18–25 years revealed that, compared with never users of non-prescription substances (including alcohol, tobacco, marijuana, cocaine, heroin), opioid misuse increased with: more recent use of non-prescription substances (adjusted prevalence ratios (APRs)=8.26, 2.75 and 2.41 for past ≤30-day, ≤12-month and >12-month use, respectively); and a higher number of substances used (APRs=1.69, 3.44, 6.82, 10.60 and 20.60 for 1, 2, 3, 4 and 5+ substances, respectively) (all p<0.05). Similar patterns were seen for stimulants, tranquillisers and sedatives.

Conclusions It is important to monitor the diversity of medication misuse behaviours among youth and young adults, given their potential for abuse liability. Modifiable risk factors for prescription substance misuse, such as tobacco and other non-prescription substance use, underscore the need for comprehensive approaches towards health promotion among youth and young adults.

  • adolescent health
  • child health
  • family medicine
  • pediatrics
  • tobacco use cessation
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Key points

Question

  • What percentage of US youth and young adults aged 12-25 years reported medical use and misuse of psychoactive prescription medications during 2015–2018?

Findings

  • Past-year use of each psychoactive prescription medication among youth aged 12–17 years was: opioids (19.0%), stimulants (7.2%), tranquillisers (4.3%) and sedatives (2.2%). Among users of each psychoactive prescription medications, the estimated percentage reporting misuse was as follows: opioids (17.6%, 0.8 million), stimulants (24.2%, 0.4 million), tranquillisers (40,1%, 0.4 million) and sedatives (14.2%, 80 000). Multivariable analyses among young adults aged 18–25 years revealed strong associations between prescription and non-prescription substance use.

Meaning

  • It is important to monitor the diversity of medication misuse behaviours among youth and young adults, especially with their potential for abuse liability.

Introduction

National efforts to stem psychoactive prescription medication misuse in recent times have focused largely on the opioid epidemic, which kills nearly 50 000 Americans every year from overdose.1 For this paper, misuse is defined as the use of any prescription medicine that is not prescribed to the individual or taken as instructed by the prescribing doctor/nurse practitioner.2 The number of emergency room visits involving the misuse of prescription medication more than doubled between 2004 and 2008.3 Alarmingly, in the USA in 2017, drug overdose deaths were a leading cause of ‘unintentional injury death’.1 4 Most, but not all these drug overdose incidents involve opioid analgesics, making it imperative to monitor other ‘lesser known’ psychoactive prescription medication misuse behaviours, to prevent another epidemic. Boyd et al found that 12% of their respondents had engaged in non-medical use of opioid pain medications in the past year: 3% for sleeping, 2% as a sedative and/or for anxiety, and 2% as stimulants.5 In 2017, the occurrences of first-time misuse for stimulants, tranquillisers and sedatives combined (2.8 million), surpassed that for prescription opioids (2.0 million) among persons aged ≥12 years old.2 While evidence shows that stimulant medication therapy for attention-deficit hyperactivity disorder in early childhood does not increase subsequent risk for non-medical use of prescription stimulants or other substance use behaviours,6 7 there is basis for concern with misuse of prescription stimulants among youth.8 Prescription drug monitoring programmes can help identify chronic prescription medication ‘shoppers’ such as adults. Their utility in detecting misuse or diversion among adolescents may be somewhat limited though because most youth and young adults who misuse psychoactive prescription medications obtain them from family and friends.2 9 10 Other measures such as psychoactive drug education programmes, changes in the Centers for Disease Control and Prevention (CDC) and US Food and Drug Administration (FDA)’s guidelines for prescribing opioids, and alternative medication options have also aided in the decrease of prescribing opioids. Parents/caregivers/guardians, pharmacists and clinicians therefore need to be alert for behavioural markers of psychoactive prescription medication misuse. However, there are very little data on other psychoactive prescription medications besides opioids, for example, the extent of overlap in the behavioural characteristics of youth and young adults who misuse prescription opioids versus other psychoactive prescription medications, or those who misuse multiple psychoactive prescription medications simultaneously, is poorly understood.

While opioid-specific studies can still offer valuable clinical insights regarding misuse of psychoactive prescription medications in general, the populations from which several existing studies of youths and young adults were drawn may limit their generalisability. Two of the commonly analysed national surveillance systems in relation to psychoactive prescription medication misuse are school-based surveys, which are not generalisable to all school-aged youth and young adults. These surveys are, Monitoring the Future (eighth, tenth and twelfth graders),11 and the Youth Risk Behaviour Survey (eighth graders to twelfth graders).12 Besides non-inclusion of middle school students under eighth grade, these surveys also exclude groups (eg, school dropouts) or schools (eg, special education schools, alternative schools and Department of Defence operated schools) whose members may have elevated risk of substance use.12 Recent and generalisable data on youth and young adults are needed across the diversity of psychoactive prescription medications.

Using a nationally representative, household-based sample of US youth and young adults aged 12–25 years during 2015–2017, this study had two objectives: (1) assess prevalence and weighted population counts describing use, misuse, dependence and abuse for prescription opioids, sedatives, tranquillisers, stimulants, as well as at least two psychoactive prescription medications. (2) compare behavioural and demographic profiles of youth and young adults reporting medical use versus misuse of the different psychoactive prescription medications assessed.

Methods

Data source

Data were from the National Survey of Drug Use and Health (NSDUH). The survey participants were individuals from households, non-institutional group quarters (eg, college dormitories) and civilians living on military bases.13 To increase privacy, questionnaires are completed by the individuals themselves using audio, computer-assisted self-interview methods. The analyses in this report were restricted to youth aged 12–17 years and young adults aged 18–25 years. We pooled data across the 2015–2018 waves to increase sample size; pooled sample size was n=54 866 for youth aged 12–17 years and 55 690 for young adults aged 18–25 years, average response rate=67.4%.

Measures

Psychoactive prescription medications

Past-year use of four psychoactive prescription medications was assessed: opioids, stimulants, tranquillisers and sedatives. Respondents were asked to answer when they used the respective medications last time. We used recoded dichotomous variables provided in NSDUH to assess past-year use. We also created an aggregate measure of any (ie, at least one) and multiple (ie, at least two) use of psychoactive prescription medications.

Medical use and misuse of psychoactive prescription medications

Past-year medical use and misuse were defined as to be mutually exclusive within our analyses. Misuse was defined as a report by the respondent that they had used the psychoactive prescription medications in the past year in any way not directed or prescribed, including (1) use without a prescription of the respondent’s own; (2) use in greater amounts, more often, or longer than the respondent was told to take them; or (3) use in any other way a doctor did not direct the respondent to use them. Respondents were classified as having an indication of medical use if they reported using the psychoactive prescription medications in the past year but reported no misuse for that specific medication. It should be noted that NSDUH did not distinguish between intentional misuse (eg, diversion, with overdose) versus non-intentional misuse (eg, medication errors). Some misclassification may therefore exist.

Substance use disorder of psychoactive prescription medications

Within our analysis, substance use disorder was defined as having symptoms of abuse and/or dependence on the psychoactive prescription medications in the past year. The questions were asked based on the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) criteria.13 14 To be classified as having dependence, at least three criteria had to be met from the following: (1) spent a lot of time engaged in activities related to drug use, (2) used drug in greater amounts or for longer period than intended, (3) developed tolerance, (4) unsuccessfully tried to cut down, (5) continued drug use despite physical or emotional problems associated with use, (6) reduced or stopped participating in other activities because of drug use, and (7) had withdrawal symptoms after reducing or stopping drug use. Individuals were classified as having abuse if they did not meet the dependence criteria for that drug and reported at least one of the following: (1) experienced problems at work/home/school because of drug use; (2) engaged in something physically dangerous following regular drug use; (3) had repeated trouble with the law because of drug use; and (4) continued drug use despite problems with family/friends.

Non-prescription substance use

Past-30-day and past-year use was assessed for the following non-prescription substances: alcohol; tobacco (cigarettes and cigars); marijuana; cocaine; heroin; inhalants; and hallucinogens. Variables describing recency of use for each substance were created with the following four categories: never user, last used within the past 30 days (≤30 days), 31 days to 12 months (≤12 months) or used more than 12 months ago (>12 months). An aggregate measure was also created, with never users defined as persons who had never used any of the assessed substances; classification into other categories (≤30 days, ≤12 months, >12 months) was based on using at least one substance within the specified time window, conditional on not meeting the criteria for a more recent period. We also created two separate variables that tallied total number of non-prescription substances used for either the past 30 days or the past 12 months.

Other covariates

Demographic variables assessed were sex, age, race/ethnicity, educational attainment, poverty status, health insurance and metro status (whether the respondent lived in a metropolitan statistical area delineated by the Office of Management and Budget). We also assessed presence of serious psychological distress in the past year among young adults.15 This information was available only for adult respondents aged ≥18 years and measured using the Kessler-6 Psychological Distress Scale (range 0–24). As recommended by previous assessment, scores 13 or above were classified as having serious psychological distress in NSDUH.

Statistical analyses

Since data were being pooled across 3 years, we recalibrated the weights by dividing by three to generate accurate weighted population counts. Among those who reported past-year use, we calculated the weighted percentages of those reporting misuse: group differences were tested with χ2 tests. Prevalence estimates with relative standard errors >40% were suppressed because of imprecision. Conceivably, older adolescents and younger adults have more access to medications and less parental oversight than preteens or early adolescents; we therefore analysed age as a tabulation variable, within the categories of 12–13; 14–15; 16–17; 18–20; or 21–25 years (which were the smallest age classification available in NSDUH). As part of descriptive analyses, we calculated three specific estimates for each psychoactive prescription medication assessed: (1) any use, regardless of whether it was medical or non-medical use (2) medical use (3) misuse use; the last two measures were mutually exclusive of each other and were the main focus of this paper. For each of the four psychoactive prescription medications, exploratory Poisson regression analyses were performed to compute prevalence ratios and compare characteristics of individuals reporting medical use versus misuse. Variables assessed included sex, race/ethnicity, education, poverty status, health insurance, metro status, psychological distress and recency of any non-prescription substance use. Separate Poisson regression models were further fitted to measure the relationships between psychoactive prescription medication misuse and recency of each non-prescription substance use and number of non-prescription substances used, adjusting for sex, age, race/ethnicity, education, poverty status, health insurance, metro status and psychological distress. We compared the performance of the past-30-day tally versus the past-year tally as a behavioural marker of psychoactive prescription medication misuse. Variance inflation factors (VIFs) were computed to examine multicollinearity for each of the models fitted, and confirmed VIF for each independent variable did not exceed 5. Poisson regression analyses were restricted to respondents aged 18–25 years as psychological distress was assessed for this age group only. All data were weighted and analysed with R V.3.5.3.

Results

Prevalence of use, misuse and substance use disorder of psychoactive prescription medications among youth aged 12–17 years

Among US youth aged 12–17 years, 25.0% reported use of any psychoactive prescription medication assessed, and 5.7% reported using at least two psychoactive prescription medications in the past year (table 1). Among those who used any psychoactive prescription medication, 20.9% (1.3 million) reported misuse; 3.4% were classified as having substance use disorder. Among those who used at least two psychoactive prescription medications in the past year, 46.1% reported misuse of any psychoactive prescription medication and 62.1% reported concurrent use of a non-prescription substance (data not shown in table).

Table 1

Demographic characteristics and usage patterns of any psychoactive prescription medications among US youth aged 12–17 years, National Survey of Drug Use and Health, 2015–2018

Past-year use of each psychoactive prescription medication was as follows: opioids (19.0%), stimulants (7.2%), tranquillisers (4.3%) and sedatives (2.2%) (table 2). Among users of each psychoactive prescription medication, the estimated percentage reporting misuse was as follows: opioids (17.6%, 0.8 million), stimulants (24.2%, 0.4 million), tranquillisers (40,1%, 0.4 million) and sedatives (14.2%, 80 000). Among users of each psychoactive prescription medication, the estimated percentage having substance use disorder was as follows: opioids 2.6%, stimulants 3.0%, tranquillisers 7.0% and sedatives 3.6% (data not shown in table). Stratified estimates of past-year use, misuse and at least two product use are presented in tables 1 and 2 for some demographic characteristics.

Table 2

Prevalence of use and percentage of misuse by medication and demographic characteristics among US youth aged 12–17 years, National Survey of Drug Use and Health, 2015–2018

Prevalence of use, misuse and substance use disorder of psychoactive prescription medications among young adults

Among US young adults aged 18–25 years, 41.0% reported use of any psychoactive prescription medication assessed, and 13.4% reported using at least two psychoactive prescription medications in the past year (table 3). Among those who used any psychoactive prescription medication, 34.7% (4.9 million) reported misuse; 4.2% were classified as having substance use disorder. Among those who used at least two psychoactive prescription medications in the past year, 60.7% reported misuse of any psychoactive prescription medication and 93.6% reported concurrent use of a non-prescription substance (data not shown in table).

Table 3

Demographic characteristics and usage patterns of any psychoactive prescription medications among US young adults aged 18–25 years, National Survey of Drug Use and Health, 2015–2018

Past-year use of each psychoactive prescription medication was as follows: opioids (30.2%), stimulants (14.1%), tranquillisers (11.5%) and sedatives (3.5%) (table 4). Among users of each psychoactive prescription medication, the estimated percentage reporting misuse was as follows: opioids (23.3%, 2.4 million), stimulants (51.3%, 2.5 million), tranquillisers (45.1%, 1.8 million) and sedatives (19.0%, 0.2 million). Among users of each psychoactive prescription medication, the estimated percentage having substance use disorder was as follows: opioids 3.0%, stimulants 3.7%, tranquillisers 5.6% and sedatives 1.6% (data not shown in table).

Table 4

Prevalence of use and percentage of misuse by medication and demographic characteristics among US young adults aged 18–25 years, National Survey of Drug Use and Health, 2015–2018

Contrasting demographic profiles associated with medical versus non-medical use (misuse)

Among young adults aged 18–25 years, psychological distress and recency of any non-prescription substance use was strongly associated with both medical use and misuse of psychoactive prescription medications (table 5). Those who had serious psychological distress constantly showed increased likelihood of medical use, ranging from adjusted prevalence ratio (APR) =1.12 for opioids to APR=2.89 for sedatives; and misuse, ranging from APR=1.60 for stimulants to APR=3.06 for sedatives. Association between recency of non-prescription substance use and misuse is further discussed in a later section.

Table 5

Correlates of medical use and misuse of psychoactive prescription medications among US young adults aged 18–25 years, National Survey of Drug Use and Health, 2015–2018

For opioids, men had lower likelihood of opioid medical use (APR=0.70, 95% CI 0.67 to 0.73), but greater likelihood for reporting misuse than women (APR=1.22, 95% CI 1.13 to 1.32) (table 5). Compared with whites, Asians and Hispanics had lower likelihood for both medical use and misuse of opioids: blacks did not differ from whites for medical use but had lower likelihood for misuse (APR=0.82, 95% CI 0.73 to 0.93). Although Medicaid insurees and Medicare insurees had higher likelihood of reporting opioid medical use compared with uninsured persons (APR=1.32 and 1.45, respectively), they did not differ significantly for misuse.

For stimulants, both medical use and misuse were higher among men than women (APR=1.23 and 1.30, respectively). Likelihood of medical use and misuse of stimulants were both significantly lower among all non-white race/ethnic groups compared with whites. Whereas poverty status was not associated with medical use, it was however associated with misuse, with lower likelihood of misusing stimulants seen among individuals living above the poverty line. Compared with those living in poverty, adjusted prevalence of medical use of stimulants was lower by 29% (APR=0.71) among those living at up to twice the poverty level, and by 22% (APR=0.78) among those living at more than twice the poverty level. Individuals with private insurance had significantly higher likelihood of medical use (APR=1.37, 95% CI 1.18 to 1.58) and misuse (APR=1.44, 95% CI 1.25 to 1.67) relative to those uninsured. The likelihood of medical use and misuse were both significantly lower among those in non-metropolitan than metropolitan areas (APR=0.88 and 0.80, respectively).

For tranquillisers, men were less likely to report medical use (APR=0.66, 95% CI 0.60 to 0.72), but more likely to report misuse (APR=1.15, 95% CI 1.05 to 1.26). Compared with whites, the likelihood of both medical use and misuse of tranquilliser were lower among non-white groups, except non-Hispanic other race for misuse that showed no significant difference. Whereas no difference in metropolitan status was observed for medical use of stimulants, the likelihood of misuse was significantly lower among those in non-metro than metropolitan areas (APR=0.87, 95% CI 0.76 to 0.99).

For sedatives, the likelihood of medical use was lower among: men than women (APR=0.84, 95% CI 0.73 to 0.96); blacks (APR=0.55, 95% CI 0.44 to 0.69), Asians (APR=0.35, 95% CI 0.23 to 0.54), Hispanics (APR=0.61, 95% CI 0.50 to 0.74); and non-metropolitan than metropolitan dwellers (APR=0.80, 95% CI 0.68 to 0.95). These groups did not differ from their referent categories for misuse of sedative, except non-Hispanic blacks and Hispanics for which the likelihood of misuse was also significantly lower than whites (APR=0.39 and 0,63, respectively).

Factors associated with concurrent use of multiple prescription medications

The likelihood of using at least two psychotherapeutics was lower among: men than women (APR=0.95, 95% CI 0.90 to 0.99), each race/ethnic group compared with whites, and non-metropolitan than metropolitan dwellers (APR=0.93, 95% CI 0.86 to 0.99) (table 5). The likelihood of using at least two psychoactive prescription medications was higher among Medicaid insurees than uninsured persons (APR=1.15, 95% CI 1.04 to 1.27). Individuals with serious psychological distress had over twice the adjusted prevalence of using at least two psychotherapeutics than those without the condition (APR=2.01, 95% CI 1.90 to 2.12). Those who reported use of non-prescription substances also had higher likelihood of using at least two psychotherapeutics than those who did not (APR=4.55, 1.92 and 1.76 among past ≤30-day, ≤12-month and >12-month users, respectively).

Non-prescription substance use as a behavioural marker for misuse of psychoactive prescription medications

Measures of recency (never, ≤30 days, ≤12 months or >12 months) of non-prescription substance use and the number of substances used (none, 1,2, 3, 4 or 5+) both were strongly associated with misuse of psychoactive prescription medications. Compared with never users of any non-prescription substance, corresponding prevalence ratios for past ≤30 days, ≤12 months, >12 months were as follows for misuse of opioids (APRs=8.26, 2.75 and 2.41 (all statistically significant)), stimulants (APRs=34.42, 6.11 and 1.83 (first two statistically significant, last not significant)), tranquillisers (APRs=27.42, 5.66 and 2.93 (all statistically significant)) and sedatives (APRs=5.79, 1.62 and 1.52 (first statistically significant, last two not significant)) (table 5). When examined by individual substances and adjusting for all other assessed products, the strongest determinant of prescription opioid misuse was heroin use (APRs=6.17, 7.21 and 1.48) (table 6). Marijuana use had the strongest association with every other psychoactive prescription medication misuse, including stimulants (APRs=5.37, 5.10 and 2.74), tranquillisers (APRs=5.81, 4.61 and 2.75) and sedatives (APRs=5.25, 3.14 and 2.85).

Table 6

Associations between misuse of prescription medications and use of non-prescription substances among US young adults aged 18–25 years, National Survey of Drug Use and Health, 2015–2018

The number of non-prescription substances used was also a significant determinant of psychoactive prescription medication misuse, regardless of whether tallied within the past 30 days or 12 months. By a past-30-day tally, compared with non-users, likelihood of psychoactive prescription medication misuse among those who used 1, 2, 3, 4 or 5+ non-prescription substances was as follows: opioid misuse (APRs=1.69, 3.44, 6.82, 10.60 and 20.60), stimulants (APRs=4.87, 16.97, 31.44, 58.15 and 104.25), tranquilliser misuse (APRs=2.72, 7.90, 19.25, 35.75 and 80,98) and sedatives (APR=1.20, 2.24, 5.41, 9.04 and 23.03 (first not statistically significant, last four significant)). Similar results were obtained for a past-year tally.

Discussion

Overall, 35.1% of persons aged 12–25 years reported past-year use of a psychoactive prescription medication, and of these, 31.0% reported misusing it. Possible consequences of such misuse, especially when co-occurring with multiple psychoactive prescription medications or other non-prescription substances include altered brain development, substance/medication-induced mental disorders, a potential for lifelong addiction, a ‘downward drift’ (ie, a descending social migration and/or loss of social status) and various substance-related diseases.16 Individuals with mood and anxiety disorders may engage in drug use to self-medicate or as a mechanism to cope with their mental health disorder.17 Misuse of psychoactive prescription medications may however make youth and young adults more susceptible to other substance use problems, a phenomenon called the ‘gateway’ effect.18–20 It is however also possible that individuals are taking psychoactive prescription medications to manage their anxiety and depression and for some this falls into use and for others into misuse as they actively manage their symptoms rather than strictly sticking to the duration, frequency and quantity as prescribed.

While reported past-year use was highest for prescription opioids, the estimated percentage reporting misuse was highest for stimulants (44.8%) and tranquillisers (44.4%). The largely overlapping population demographics for medical use versus misuse for each psychoactive prescription medication indicate the high abuse liability of these substances. Over 1 in 10 youth and young adults used at least two psychoactive prescription medications, with a majority of those misusing a psychoactive prescription medication (57.7%) and a non-prescription substance (86.7%). Individuals with co-occurring substance use disorders have been shown to be more likely to have major depressive episodes in comparison to those with a single substance use disorder.21 22 Use of multiple substances may also make youth and young adults more dependent, and more difficult for them to quit.23 24

The potential accessibility and affordability of these or similar substances are serious public health issues. In our study, with only a few exceptions, the likelihood of using psychoactive prescription medications and using multiple psychoactive prescription medications was not different by educational attainment and poverty status; or not different among those uninsured versus those with private insurance, suggesting wide accessibility and affordability of psychoactive prescription medications among the public. Recent studies also indicate that youth and young adults could access psychoactive prescription medications without a prescription: during 2017, over half (53.1%) of those who misused prescription opioids obtained them from a friend or relative.2 9 10 Taken together with this, efforts to restrict access to prescription medications within clinical settings should be combined with interventions that change social norms, and the perceived acceptability of substance misuse. Such interventions aimed at the entire population, not just youth and young adults, may benefit public health given that most youth and young adults access abuse substances from social contacts, including family members and friends. Consequently, both the youth and young adults who have access and the family members/friends who provide access (regardless of whether they are aware that they are providing access) could benefit from such a social norms intervention. For example, older patients who are prescribed these medications could be encouraged to take more responsibility to keep them locked and out of the hands of youth and young adults.

Our finding that the total number of distinct non-prescription substances used correlated stronger with misuse of psychoactive prescription medications than any individual non-prescription substance use behaviour, could be used as a behavioural marker to identify at-risk youth and young adults. Rather than asking only about cigarette smoking, paediatric practitioners should screen for different commonly used substances, including ‘social use’. Specifically asking youth and young adults if they have used certain substances, including occasional use, is important as those who use such substances infrequently or only occasionally may not self-identify as users if asked in generic terms.25

There is urgent need to address psychological distress among youth and young adults. In our study, 11.5% of persons aged 18–25 years reported having serious psychological distress, and this was a strong determinant of misuse of every prescription substance assessed. Increasing patient motivation and establishing a strong collaborative treatment team are key. Previous research suggests need for integrated treatment (social workers, psychologists, psychiatrists, medical doctors) and treatment plans being individually tailored to simultaneously addressing substance use and mental health symptoms, since the two conditions interact with each other.26 27 Possible psychological treatment options include behavioural interventions, establishing and identifying social support, utilisation of assessment tools, increase in self-advocacy training, and counselling services (individual, group, family and conjoint) addressing psychoeducation and coping skills.19 28 Being released after detoxification without ongoing care was found to put patients at an increased risk of relapse and overdose.29 In addition to clinical interventions, there is also need for approaches that change social perceptions (including stigma) regarding substance use treatment.19 28 Due to a lack of substance use education in schools, there are growing misconceptions about substance use, one of the largest being that substance use problems are a result of moral problems and not behavioural problems.30 This view places the entirety of the blame on the individual when there could be other extenuating factors.

The findings in this study are subject to certain limitations. First, the cross-sectional design and self-reported measures limit inferences to only associations. Second, while accurate, the term misuse is very broad. Those categorised as misusing may be using a psychoactive prescription medication for legitimate reasons (slight variations from how a psychoactive prescription medication was prescribed) rather than to get high. Third, there was some discrepancy in the time frame for which certain variables were measured. For example, psychological distress was only reported over the last 30 days whereas certain substance use behaviours were measured within the past year. This leads to issues of temporal order in the concurrent associations (ie, depression could have occurred in the past 30 days but psychoactive prescription medication use 11 months ago).

Conclusion

Over 1 in 10 youth and young adults aged 12–25 years used two or more psychoactive prescription medications concurrently. While reported past-year use was highest for prescription opioids, the estimated percentage of users who reported misuse was highest for stimulants (44.8%) and tranquillisers (44.4%). The largely overlapping population profiles for medical use versus misuse indicates the high abuse liability of these prescription substances. Having serious psychological distress was consistently associated with misuse of every assessed psychoactive prescription medication. Mental health and medical providers would benefit from using a team approach and having open communication with other healthcare providers to ensure evidence-based guidelines are used when assessing for and treating mental health and substance use difficulties.

References

Footnotes

  • Contributors IA conceptualised and designed the study and drafted the initial manuscript. SO and JN helped conceptualise the study, assisted in the statistical analyses, and critically reviewed and revised the manuscript. All authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding This survey is sponsored by the Substance Abuse and Mental Health Services Administration.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. Publicly available secondary data came from the National Survey on Drug Use and Health. All data files are publicly and freely available for download at their website at https://www.datafiles.samhsa.gov/study-series/national-survey-drug-use-and-health-nsduh-nid13517.

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