What Parents Can Do April 10-12, 2012 Walt Disney World Swan Resort
Accepted Learning Objectives:1. Compare mixed-method studies that focuson behavioral factors related to drug use andabuse, especially among youth andadolescents.2. Outline proven comprehensive strategies forcombating prescription drug abuse throughthe development of community partnerships.3. Express the impact of prescription drugabuse on families and communities throughanecdotal 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.
April 2012 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 4
PurposeTo 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. 5
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. 6
Subtypes of Nonmedical Users Non-medical use of Controlled Medications Medication Diverted Misuse Sensation- Self-Treaters Seekers (With own Rx) (No Rx) Sensation- Self-Treaters (No Rx) Seekers (With own Rx) 8
CASE EXAMPLESWhat do these subtypes look like? 9
Case Example #1A student is prescribed anSSRI and an anxiolytic(benzodiazepine) forGeneralized AnxietyDisorder. He has beentaking these medications fortwo years. During his junioryear, the young mandoubled his dose of thebenzodiazepines (withoutphysician knowledge) inorder to reduce his anxiety;his symptoms wereperceived as intolerableand he was seeking relief. 11
Case Example #1: Behavior and Attributes BEHAVIOR: ATTRIBUTES: The intentional change • Has his/her own prescription; in the dosing of a prescribed, scheduled • Aware of the correct dosing instructions; medication for the purpose of relieving the • Motive is to reduce symptoms from a symptoms for which the medical disorder. medication was originally prescribed.Self-treatment w/ own Rx 12
Case Example #2 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. 13
Case Example #2: Behavior and Attributes ATTRIBUTES:BEHAVIOR: • Administered in ways otherThe incorrect use of than prescribed;a prescribed • Used in higher doses eithermedication by a by increasing the dosage orpatient with a by decreasing the time-prescription. 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 14
Case Example #3On a Friday afternoon, a16 year old teen, an honorstudent, is planning toattend “Homecoming”with her new boyfriend.Four hours before theevent, she develops asevere migraine and isnauseated and dizzy. Intears, she asks her motherfor help. Her mother givesher two hydrocodonetablets (left over from herown surgery). The teenwent to the event and“had a great time.” 15
Case Example #3: Behavior and AttributesBEHAVIOR: ATTRIBUTES: • No prescription; The intentional use of • Perceived barriers to someone else’s medical care (a prescription medication prescription is not for the purpose of available); alleviating symptoms • Motive to relieve a that may be related to condition for which the a health problem. medication, when prescribed, is generally intended. Self-treatment w/o legal rx 16
Case Example #4A girl with a history ofalcohol abuse isgiven an oxycodonetablet by a friend; shewants to experimentto see “what it does”.She crushes andsnorts the pill. The girlcontinues to buy“Oxy” from friendswhen she wants toparty. 17
Case Example #3: Behavior and Attributes DEFINITION: ATTRIBUTES: • No prescription; The use of a • May involve using in controlled combination with other medication to drugs experiment, to get • May involve delivering the high or to create an medication in a wrongful altered state. 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 18
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. 19
Prescription Drug Misusers & Abusers: SubtypesPerson does not possess Person does possess legallegal prescription prescriptionSensation-seeking: Sensation-seeking:get high, experiment, or create get high, experiment, or createaltered state (w/ someone else’s altered state (w/ own meds)meds)Self-treating: Self-treating:self-treat symptoms of actual or self-treat symptoms of actualperceived health condition (w/ or perceived health conditionsomeone else’s meds) (w/ own meds) Boyd CJ, McCabe SE. Subst Abuse Treat Prev Policy. 2008,3:22.
IS THIS CONCEPTUALIZATION SUPPORTED BY DATA? Do subtypes matter.
Background • 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):• In the past, our team has 37-45. published on motivations, • Boyd, C.J., McCabe, S.E., Cranford, J.A., & Young, diversion and problem A.M. (2006). Adolescents’ Motivations to Abuse Prescription Medications. Pediatrics, 118:2472-2480. behaviors associated with • Boyd, C.J., McCabe, S.E., Cranford, J.A., & Young, the nonmedical use of A.M. (2007). Gender Differences in Prescription Drug Abuse and Diversion among Adolescents in a scheduled medications by Southeast Michigan School-District. Archives of Adolescent and Pediatric Medicine, 161: 276-281. adolescents. • McCabe, S.E., Boyd, C.J., Young, A.M. (2007) Medical and Nonmedical Use of Prescription Drugs among Secondary School Students. Journal of• Our procedures and Adolescent Health, 40: 76-83. measures have been • Boyd, C.J., Young, A.M., Grey, M., & McCabe, S.E. (2009). Adolescents’ nonmedical use of prescription described previously in medications and other problem behaviors. Journal of Adolescent Health. 45, 543-550. great detail. • 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. NIH GRANT R01 DA024678
Conceptual Model: Problem Behavior Theory (Adapted from Jessor) Substance Medical Misuse/ Abuse Non-medical Use Problems Personal Risk factors • Medical/Psychiatric care of Rx Drugs • Social Environment • Medications • Truancy • Perceived Environment • Peers/social network • Gambling • Demographic • Medical problems • Early sexual activity • Family Support • CRAFFT Characteristics • Genetics/biology • Emotional problems • Resilience/Vulnerability • School activities • MOTIVATIONS • Illicit drug use • DAST-10 • School-based counseling • Sensation-Seeking • Psychological • Personality • Self-treatment Domains Problem Symptom Behaviors reliefBoyd, C.J., Young, A., Grey, M., & McCabe, S.E., 2009. Adolescents’ nonmedical use ofprescription medications and other problem behaviors. J Adol. Health 45, 539-540. Boyd (PI) NIH Grant RO1 DA024678
HypothesisYouth engaging in nonmedical use forsensation-seeking are more likely to reportother 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“On how many occasions in past 12 months haveyou used the following types of drugs, not prescribedto you?” (also asked about lifetime use) – Sleeping medication – Sedative/anxiety medication – Stimulant medication – Pain medication Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.
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. 28
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. 29
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*Often for third molar extractions Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.
Past-yr Problem-Behaviors: Medical & Nonmedical UsersSecondary Student Life Survey *P<.05 vs. all 3 other gps †P<.05 vs. nonusers & medical users * Non-users: reference gp set to “0” * * 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… 33
Our team’s next project ABC’s and PreventionBoyd, 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.