July 20, 2009 — Adolescents who buy prescription drugs for illicit use are more likely to have ongoing substance abuse problems, but most teen-drug misuse involves drugs obtained for free from family or friends. This is important because prescription-drug misuse by teens is rising even though the use of other illicit drugs, alcohol, and tobacco has decreased.
Prescription drugs are surpassed only by alcohol, tobacco, and marijuana in misuse by adolescents. A study by Ty Schepis, PhD, and Suchitra Krishnan-Sarin, PhD, published in the August 2009 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, shows that much of this drug use likely begins at home.
The researchers also report that how an adolescent obtains prescription drugs predicts whether other substances, such as alcohol, are being abused at the same time and signals a risk for more severe substance and prescription-drug misuse problems.
Drs. Schepis and Krishnan-Sarin, both from the Department of Psychiatry at Yale University School of Medicine in New Haven, Connecticut, used data from the 2005 and 2006 National Survey on Drug Use and Health (NSDUH) to show that, across all classes of medications (opioids, stimulants, tranquilizers, and sedatives), nearly 50% were obtained from friends or family members free of charge.
With the exception of opioids, the most common source was purchasing the drug from friends or relatives (13.1% - 29.7%) or from a drug dealer (4.6% - 12.0%). For opioids, the second most common source was from a physician.
"The group with greatest odds of concurrent other substance use may be those who purchased their medication for misuse from friends, family, or drug dealers. In comparison with adolescents who misused medication obtained from a physician, adolescents who buy medication are more likely to have endorsed binge alcohol use (opioids and tranquilizers), daily cigarette use (opioids and stimulants), past month marijuana use (all 3 classes examined), and past year cocaine use (opioids and stimulants)," the authors conclude.
"Disturbingly Easy" to Obtain Drugs
Richard A. Friedman, MD, who also studies teenage drug abuse, told Medscape Psychiatry that "these data underscore how (disturbingly) easy it is for young people to obtain potentially abusable prescription drugs. It is clear from these data that the main source is not street dealers, but friends, family members, and physicians." Dr. Friedman is professor of clinical psychiatry and director of the Psychopharmacology Clinic at Cornell University's Weill Medical College in New York City.
Drs Schepis and Krishnan-Sarin say that their data indicate that physicians should be routinely screening all adolescent patients for prescription misuse.
"Screening for prescription misuse depends on your clinical impressions of your patient and of his/her current substance use. With patients who have a presenting complaint of depressive symptoms or anxiety, simply asking about substance use across the spectrum of alcohol, tobacco, marijuana, prescriptions, etc, in a nonjudgmental and matter-of-fact way is likely best," Dr. Schepis told Medscape Psychiatry.
"The main questions are about whether the patient has ever used a substance, timeframe of last use, and frequency of use over a specified time period. That information can then help a practitioner decide how to proceed with a potential intervention, if one is needed."
Urine testing may be indicated when a patient is in treatment for substance use or there is clear evidence that the patient has intentionally misled care providers about substance use. The risk inherent in urine testing, however, is that it can be very counterproductive for establishing and keeping trust, especially if it is a surprise to the patient," Dr. Schepis said.
False Impression?
Dr. Friedman suspects that because prescription drugs are approved by the US Food and Drug Administration and are widely advertised directly to consumers in the print and electronic media, young people might have the mistaken impression that these drugs are safe.
"After all, if their parents use them and their doctors prescribe them, how bad can they be? Another factor is peer acceptance. If you look at other data from this survey, acceptance of prescription drugs has been steadily rising, while attitudes among youth about cocaine and stimulants has become more negative," he said.
Dr. Schepis warned that availability is also a factor. "Many people have medications that they previously needed that remain in their medicine cabinet, perhaps an opioid analgesic for a surgery. These medications are easy targets for adolescents wishing to experiment, continue to use, or sell medications to peers. Thus, proper medication disposal is really important, and all patients should be counselled on that."
Major Implications
Dr. Friedman said that the implications of these findings for clinicians are "huge and pressing."
"Physicians have to be very careful about prescribing drugs of potential abuse to young people. Although it's true that the rates of undetected psychiatric illness are quite high in this population, the mainstays of [pharmacologic] treatment, are, with the exception of stimulants for attention-deficit/hyperactivity disorder, drugs like antidepressants, antipsychotics, and mood stabilizers — none of which are addictive. In contrast, there is rarely a medically legitimate rationale to use tranquilizers, hypnotics, narcotics, and the like in this usually medically healthy population," he said.
The study was supported in part by the National Institutes of Health. The authors have disclosed no relevant financial relationships.
J Am Acad Child Adolesc Psychiatry. 2009;48:828-836.
