What Parents Can Do

April 10-12, 2012 Walt Disney World Swan Resort

Accepted Learning Objectives: 1. Compare mixed-method studies that focus on behavioral factors related to drug use and abuse, especially among youth and adolescents. 2. Outline proven comprehensive strategies for combating prescription drug abuse through the development of community partnerships. 3. Express the impact of prescription drug abuse on families and communities through anecdotal personal stories.

Disclosure Statement

•  All presenters for this session, Dr. Carol J. Boyd, Dr. Gary Martin, and Karen Perry, have disclosed no relevant, real or apparent personal or professional financial relationships.

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Nonmedical Use of Controlled Medications among Teens

Carol J Boyd, PhD, MSN, FAAN Deborah J Oakley Professor, Nursing Research Professor, UM Substance

Abuse Research Center Co-Director, SHARP Center

April 2012

Purpose To meet the objectives, I will:

•  Review the various ways in which the nonmedical use of controlled medications manifests itself in the adolescent population in the United States.

•  Present definitions and case examples in order to highlight the complexity of this form of substance abuse.

•  Using Problem Behavior Theory as a framework, we will focus on the behavioral and social problems that often accompany some forms of nonmedical use of controlled medications.

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Prescription Drug Abuse

•  Medical misuse of controlled medications (drugs): –  use of a controlled medication by the person (and for the purpose)

intended by the prescribing clinician; however, the medication is:

•  NOT used in the prescribed dose and/or not taken within a prescribed time interval. It may also a different route of administration.

•  Nonmedical use of controlled medications (drugs): –  use of a controlled medication to “get high”/create an altered state or –  for reasons other than what the prescribing clinician intended.

•  Diversion of prescription medications (drugs): –  exchange of prescription medications that leads to the use of these drugs:

•  by people other than whom the prescribing clinician intended or •  under conditions associated with “doctor shopping”/

misrepresentation •  by theft or drug dealing.

Differences among nonmedical users

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Subtypes of Nonmedical Users

Non-medical use of Controlled Medications

Sensation- Seekers (No Rx)

Self-Treaters (No Rx)

Sensation- Seekers (With own Rx)

Self-Treaters (With own Rx)

Medication Misuse Diverted

CASE EXAMPLES

What do these subtypes look like?

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CASE  EXAMPLES  

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Case Example #1

A student is prescribed an SSRI and an anxiolytic (benzodiazepine) for Generalized Anxiety Disorder. He has been taking these medications for two years. During his junior year, the young man doubled his dose of the benzodiazepines (without physician knowledge) in order to reduce his anxiety; his symptoms were perceived as intolerable and he was seeking relief.

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Case Example #1: Behavior and Attributes

BEHAVIOR:

The intentional change in the dosing of a prescribed, scheduled medication for the purpose of relieving the symptoms for which the medication was originally prescribed.

ATTRIBUTES:

•  Has his/her own prescription;

•  Aware of the correct dosing instructions;

•  Motive is to reduce symptoms from a medical disorder.

Self-treatment w/ own Rx

 A young man is prescribed a stimulant for his ADHD and to assist with concentration. He takes the medication as prescribed during the week; on the weekend he often snorts his medicine and goes out drinking with friends.

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Case Example #2

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Case Example #2: Behavior and Attributes  

BEHAVIOR:

The incorrect use of a prescribed medication by a patient with a prescription.    

ATTRIBUTES:

•  Administered in ways other than prescribed; •  Used in higher doses either by increasing the dosage or by decreasing the time-interval between doses; •  Motive is to enhance the medication’s effect in order to get high, experience an altered state or increase performance.

Sensation-seeking w/ own rx

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Case Example #3 On a Friday afternoon, a 16 year old teen, an honor student, is planning to attend “Homecoming” with her new boyfriend. Four hours before the event, she develops a severe migraine and is nauseated and dizzy. In tears, she asks her mother for help. Her mother gives her two hydrocodone tablets (left over from her own surgery). The teen went to the event and “had a great time.”

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Case Example #3: Behavior and Attributes

BEHAVIOR:

The intentional use of someone else’s prescription medication for the purpose of alleviating symptoms that may be related to a health problem.

ATTRIBUTES:

•  No prescription; •  Perceived barriers to

medical care (a prescription is not available);

•  Motive to relieve a condition for which the medication, when prescribed, is generally intended.    

Self-treatment w/o legal rx

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Case Example #4

A girl with a history of alcohol abuse is given an oxycodone tablet by a friend; she wants to experiment to see “what it does”. She crushes and snorts the pill. The girl continues to buy “Oxy” from friends when she wants to party.

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Case Example #3: Behavior and Attributes

DEFINITION:

The use of a controlled medication to experiment, to get high or to create an altered state.

ATTRIBUTES: •  No prescription; •  May involve using in

combination with other drugs

•  May involve delivering the medication in a wrongful manner (e.g. IV, skin-popping, snorting, smoking).

•  Motive is to experiment, get high or to alleviate withdrawal symptoms

Sensation-seeking w/o legal rx

 Should it Matter? Our PRELIMINARY work showed:

–  Increased risk with some motivations – When respondents report using their

scheduled medications correctly, there is no greater risk for using illicit drugs than non-users.

– When respondents divert their medications, they are more likely to engage in other forms of substance use.

–  Sharing/selling and taking/borrowing/buying involve differential health and social consequences.

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Person does not possess legal prescription

Person does possess legal prescription

Sensation-seeking: get high, experiment, or create altered state (w/ someone else’s meds)

Sensation-seeking: get high, experiment, or create altered state (w/ own meds)

Self-treating: self-treat symptoms of actual or perceived health condition (w/ someone else’s meds)

Self-treating: self-treat symptoms of actual or perceived health condition (w/ own meds)

Prescription Drug Misusers & Abusers: Subtypes

Boyd CJ, McCabe SE. Subst Abuse Treat Prev Policy. 2008,3:22.

IS THIS CONCEPTUALIZATION SUPPORTED BY DATA?

Do subtypes matter

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Background

•  In the past, our team has published on motivations, diversion and problem behaviors associated with the nonmedical use of scheduled medications by adolescents.

•  Our procedures and measures have been described previously in great detail.

NIH GRANT R01 DA024678

•  Boyd, C.J., McCabe, S.E., & Teter, C.J. (2006). Medical and Nonmedical Use of Prescription Pain Medication by Youth in a Detroit-Area Public School District. Drug and Alcohol Dependence, 81(1): 37-45.

•  Boyd, C.J., McCabe, S.E., Cranford, J.A., & Young, A.M. (2006). Adolescents’ Motivations to Abuse Prescription Medications. Pediatrics, 118:2472-2480.

•  Boyd, C.J., McCabe, S.E., Cranford, J.A., & Young, A.M. (2007). Gender Differences in Prescription Drug Abuse and Diversion among Adolescents in a Southeast Michigan School-District. Archives of Adolescent and Pediatric Medicine, 161: 276-281.

•  McCabe, S.E., Boyd, C.J., Young, A.M. (2007) Medical and Nonmedical Use of Prescription Drugs among Secondary School Students. Journal of Adolescent Health, 40: 76-83.

•  Boyd, C.J., Young, A.M., Grey, M., & McCabe, S.E. (2009). Adolescents’ nonmedical use of prescription medications and other problem behaviors. Journal of Adolescent Health. 45, 543-550.

•  Young, A.M, Grey, M., McCabe, S.E., Boyd, C.J. (In Press). Adolescent Sexual Assault and the Medical and Nonmedical Use of Prescription Medication. Journal of Addiction Nursing.

Problem Behaviors and Nonmedical Use

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Boyd, C.J., Young, A., Grey, M., & McCabe, S.E., 2009. Adolescents’ nonmedical use of prescription medications and other problem behaviors. J Adol. Health 45, 539-540.

Boyd (PI) NIH Grant RO1 DA024678

• Social Environment • Perceived Environment • Demographic

Characteristics • Genetics/biology • Psychological • Personality

Domains

• Medical problems • Emotional problems • Resilience/Vulnerability

Personal Risk factors • Medical/Psychiatric care • Medications • Peers/social network • Family Support • School activities • School-based counseling

Symptom

relief

• MOTIVATIONS • Sensation-Seeking • Self-treatment

Medical Misuse/Non-medical Use

of Rx Drugs • Truancy • Gambling • Early sexual activity • Illicit drug use

Problem Behaviors

• CRAFFT • DAST-10

Substance Abuse

Problems

Conceptual Model: Problem Behavior Theory (Adapted from Jessor)

Hypothesis

Youth engaging in nonmedical use for sensation-seeking are more likely to report other problem behaviors vs. those who are: – non-users (who were never prescribed an

opioid) – medical users (who were prescribed but

used correctly) – self-treaters (who engaged in nonmedical

use for self-treatment)

Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.

Problem Behaviors and Nonmedical Use

•  Administered to grades 7-12 (912 respondents in 2007) southeastern Michigan school district –  Random sample, Web-based, self-administered –  Secondary Student Life Survey

–  Sleeping medication –  Sedative/anxiety medication –  Stimulant medication –  Pain medication

“On how many occasions in past 12 months have you used the following types of drugs, not prescribed to you?” (also asked about lifetime use)

Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.

Sample Characteristics

Female: 52.6% (480)

Male: 47.4% (432)

Total: 912

Mean Age: 14.97 (1.74)

Black: 53.8% (490)

White: 43.5% (396)

Asian American: 1.4% (13)

Hispanic/ Latino/a: .7% (6)

American/Alaskan Native: .7% (6)

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Procedure: Secondary Student Life Survey

•  Data were collected, w/web-based survey •  All students in one school district (7th-12th grades) •  968 students returned consent forms (64% response

rate) •  IRB approval was obtained, hooded computers

used •  The Secondary Student Life Survey (SSLS) is

maintained on a hosted secure Internet site running under the secure sockets layer (SSL) protocol to insure data were safely transmitted.

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Measures •  Demographic information. •  Binge drinking. Illicit drug use. •  Illicit drug use was assessed •  Gambling. •  School discipline. •  Sexual activity. •  Depression (CESD scale). Depression symptoms were

measured by the Center for Epidemiological Studies Depression Scale. 

•  Impulsivity. The Impulsivity subscale, part of the Impulsivity/Sensation-Seeking scale (Imp-SS) of the Zuckerman-Kuhlman Personality Questionnaire.

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Characteristics of Respondents Past-Year Use (Pain, Stimulant, Anti-anxiety/Sedative & Sleep)

Secondary Student Life Survey

Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.

Prevalence of Medical & Nonmedical Use

Medical use Nonmedical use

Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.

*Often for third molar extractions

Past-yr Problem-Behaviors: Medical & Nonmedical Users

Secondary Student Life Survey

*P<.05 vs. all 3 other gps †P<.05 vs. nonusers & medical users

Non-users: reference gp set to “0”

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*

Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.

Summary

•  The nonmedical use of controlled medications involves a variety of behaviors;

•  Consequences may be different for self-treaters versus sensation-seekers;

•  Prevention experts must decide behaviors they are targeting;

•  Everyone plays a role in prevention •  Consider the ABC’s…

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Our team’s next project

ABC’s and Prevention

Boyd, C.J., Anderson, K.G., Rieckman, T. (2011) ABC’s of Controlled Medications: What Patients Need to Know about their Prescription Pain Medicine (Commentary), Journal of Addictions

Nursing. 22:1–3.

QUESTIONS?

THANK YOU