Youth who use prescription medications recreationally may access them through peers at school who obtain them through legal prescriptions for legitimate reasons including the treatment of ADHD. This study examined risk factors for the nonmedical use of prescription stimulants in high school students.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Schools are common points of access for substance use among youth. For example, in 2019, 22% of US students reported that someone had offered, sold, or given them an illegal drug on school property in the previous year. The likelihood of adolescents having opportunities to obtain substances in school may be even higher, as there are also legal, prescription drugs, that can be used for nonmedical purposes.
Although prescription drugs are used by students for legitimate purposes, e.g., stimulant prescriptions to address ADHD symptoms or sedative prescriptions (e.g., benzodiazepines) to reduce anxiety or improve sleep, there are concerns when others get and use them outside of doctor’s advice and monitoring (termed nonmedical use, abuse, or misuse of prescription drugs). That is, although these drugs can support health and well-being when prescribed by a doctor and used as intended, they can have the opposite effect when used for other reasons. As well, use of these drugs outside of a doctor’s advice and monitoring can lead to substance use problems, including developing a substance use disorder, especially among adolescents. Diversion of prescription medication – giving or selling medication to others who have not been prescribed it – is the primary way that others can use medication outside of a doctor’s advice and experience negative outcomes. This diversion may also reduce the health benefits experienced by the person who received the prescription.
This study examined the prevalence of medical and nonmedical use of prescription stimulants among high school students to better understand risk factors for the nonmedical use of prescription stimulants among adolescents. The authors focused on whether having more prescription drug use in a school community (due to legitimate medical need) may also signal a greater amount of nonmedical prescription drug use (through, for example, diversion of that medication between students).
HOW WAS THIS STUDY CONDUCTED?
This study pooled 16 years of cross-sectional survey data collected between 2005 and 2020 as part of the longstanding Monitoring the Future study. These are data collected annually from students in the United States by self-report. It is a nationally representative sample of 3284 US secondary schools. This study used a sample of 231,141 students enrolled in public and private schools who participated in the Monitoring the Future study.
To measure prescription stimulant medication use, participants were asked if they had ever taken stimulant medications for ADHD under a physician’s or health professional’s supervision (prescribed stimulant medication use). Participants were first told stimulant medications are prescribed for people with ADHD who have problems concentrating on one task at a time, or with being too active or too disruptive, or both. They were given a list of generic and brand name stimulant medications (e.g., amphetamine, methylphenidate, Ritalin, Adderall). To measure nonmedical use of prescription stimulants the participants were asked “On how many occasions (if any) have you taken amphetamines or other prescription stimulant drugs on your own—that is, without a doctor telling you to take them?”
The authors used these responses to first examine the school-level prevalence of prescribed stimulant drugs for the condition of ADHD as well as the nonmedical use of prescription stimulants among students. They then evaluated the association between the school-level prevalence of stimulant therapy for ADHD and nonmedical use of prescription stimulants by accounting for students attending the same schools. They accounted for other school-level factors (i.e., public vs. private school, urbanicity, US census region, grade level sampled, school size, percent female, percent with 1 parent who had at least a college degree, percent white, and cohort year of data collection, percent engaged in recent substance use) and individual-level factors (i.e., sex, race, ethnicity, parental education, grade point average, binge drinking, cigarette smoking, and marijuana use) when examining the unique association between prevalence of students receiving stimulant medication for ADHD and nonmedical stimulant use.
Of the sample of 231,141 students across 3284 public and private schools in the United States, approximately 51% were female, 12% were Black, 16% were Hispanic, 53% were white, and 19% were another race/ethnicity. The majority (83%) were enrolled in a public school at the time of the study and the schools were nearly equally distributed across city, suburban, and rural areas.
WHAT DID THIS STUDY FIND?
Average use of prescription stimulants was 6-8% among high school students.
Across all schools, 8% of students received prescription stimulants for ADHD while 6% reported nonmedical use of prescription stimulants. Yet, there was wide variation in the nonmedical use of prescription stimulants in the past year. That is, 1706 schools had 0% nonmedical use of prescription stimulants, while 58 schools had 25% or more students indicate nonmedical use of prescription stimulants.
Prescription stimulant medication for ADHD associated with nonmedical use of prescription stimulant drugs.
When accounting for individual- and school-level factors, an individual was more likely to engage in past-year nonmedical use of prescription stimulants at high schools with higher proportions of students who reported using prescription stimulant medications for ADHD. Students attending schools with the highest rates of prescription stimulant therapy for ADHD (12% or higher) had 36% increased odds of past-year nonmedical use of prescription stimulants compared with students attending schools with no medical use of prescription stimulants.
There were also several school-level risk factors for nonmedical use of prescription stimulants. Participants from more recent study cohorts (5 recent years of data), schools with higher proportions of parents with higher levels of education, schools outside the Northeast, schools in suburban areas, schools with higher proportions of White students, and schools with medium levels of binge drinking had increased risk of nonmedical stimulant use. Further, participants who engaged in marijuana use in the past 30 days were 4 times more likely to engage in past-year nonmedical use of prescription stimulants when compared with participants who did not use marijuana. Participants who reported either current or past medical use of prescription stimulants were also more likely to report engaging in nonmedical use of prescription stimulants in the past year when compared with peers who never used stimulants to treat ADHD.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
In this study of over 200,000 high school students in the United States, the researchers found that the rates of prescription stimulant use for ADHD were widely variable across schools. Yet, schools with greater proportions of students who were using prescription stimulants to address their ADHD also had more students who were using prescription stimulants outside the advice and monitoring of a doctor. The findings suggest the possibility of diversion of medication and indicates an increased potential for youth experimentation with prescription drugs and associated consequences, including an increased risk of substance use disorder, multi-substance use, cognitive dysfunction, depressed mood, and lower graduation rates. As well, given that youth, on average, who had ever been prescribed stimulant medication were more likely to engage in nonmedical use of prescription stimulants, the findings highlight the need for identification of which youth may be most at risk for such additional non-medical use and to understand the reasons for such additional use (e.g., whether it’s due to self-medication of symptoms due to inadequate prescribed dosing or for recreational use etc.).
Administrators, school officials, and public health departments should be aware that this is a potential threat to student safety and will likely need to work across sectors to educate and support students on medication storage and safety. Ensuring all students receive a universal prevention intervention such as Life Skills Training may help reduce the initiation of nonmedical use of prescription stimulant drugs. Schools may also need to be prepared to identify and screen students for substance use, especially at schools where there are students using prescription stimulants (or other medications) to address behavioral and mental health challenges.
The risks for youth to engage in nonmedical prescription drug use may be greater in some communities than others. At the community level, risk factors such as being from certain geographic regions and schools with students more likely to engage in heavy alcohol use (binge drinking), suggest there are likely different key regional, sub-cultural, or other contextual elements that may drive some patterns of nonmedical prescription drug use. At the individual level, this study found that youth who also engaged in heavy marijuana use were more likely to engage in nonmedical use of prescription drugs, suggesting some problematic patterns of substance co-use that could lead to increased risks for developing a substance use disorder. Having multiple and appropriate channels to identify and screen students at risk is vital to preventing the consequences associated with substance use among youth.
