Nonmedical prescription stimulant use among youth in the emergency department: prevalence, severity and correlates

Screening for problematic opioid use in the emergency department: Comparison of two screening measures

Study objective

Earlier intervention for opioid use disorder (OUD) may reduce long-term health implications. Emergency departments (EDs) in the United States treat millions with OUD annually who may not seek care elsewhere. Our objectives were (1) to compare two screening measures for OUD characterization in the ED and (2) to determine the proportion of ED patients screening positive for OUD and those who endorse other substance use to guide future screening programs.

Methods

A cross-sectional study of randomly selected adult patients presenting to three Midwestern US EDs were enrolled, with duplicate patients excluded. Surveys were administered via research assistant and documented on tablet devices. Demographics were self-reported, and OUD positivity was assessed by the DSM 5 checklist and the WHO ASSIST 3.1. The primary outcome was the concordance between two screening measures for OUD. Our secondary outcome was the proportion of ED patients meeting OUD criteria and endorsed co-occurring substance use disorder (SUD) criteria.

Results

We enrolled 1305 participants; median age of participants was 46 years (range 18-84), with 639 (49.0%) Non-Hispanic, White, and 693 (53.1%) female. Current OUD positivity was identified in 17% (222 out of 1305) of the participants via either DSM-5 (two or more criteria) or ASSIST (score of 4 or greater). We found moderate agreement between the measures (kappa = 0.56; Phi coefficient = 0.57). Of individuals screening positive for OUD, 182 (82%) endorsed criteria for co-occurring SUD.

Conclusions

OUD is remarkably prevalent in ED populations, with one in six ED patients screening positive. We found a high prevalence of persons identified with OUD and co-occurring SUD, with moderate agreement between measures. Developing and implementing clinically feasible OUD screening in the ED is essential to enable intervention.

Overcoming defensive responding in the estimation of prevalence of non-medical use of prescription stimulants

BACKGROUND

Prevalence of Non-Medical Use of Prescription Stimulants (NMUPS) is estimated to be high among young adults enrolled in college. However, precise estimation of the prevalence of NMUPS is challenging owing to biases affecting self-report of sensitive and potentially illegal behaviors.

OBJECTIVE

This study aimed to estimate the prevalence and risk factors of NMUPS using the crosswise randomized response technique (CRRT) and compare findings to the traditionally-used direct self-report (DSR) method.

METHODS

This study utilized a cross-sectional, randomized experimental design to survey adult undergraduate students at a major southeastern university in the United States. Eligible respondents were randomly assigned to a DSR group or a CRRT group. Those in the DSR group were presented a direct question about NMUPS, but those in the CRRT group were asked to indicate whether their response to the NMUPS question was the 'same' or 'different' compared to a random non-sensitive question.

RESULTS

Prevalence of NMUPS was found to be 18.6% (95% CI:18.5%-18.7%) in the DSR group and 32.5% (95% CI:32.1%-32.9%; p = 0.003) in the CRRT group. Logistic regression analysis predicting NMUPS in the DSR group showed that it was significantly associated with positive expectancies (OR:3.50; 95% CI:2.44-5.02), negative expectancies (OR:0.49; 95% CI:0.35-0.68), perceived norms (OR:1.71; 95% CI:1.27-2.29), and religious beliefs (OR:0.69; 95% CI:0.52-0.92).

CONCLUSIONS

The setting and mechanism of the survey is likely closely related to the validity of prevalence estimation of sensitive behaviors. This study found that prevalence of sensitive behaviors such as NMUPS is significantly higher when respondents are provided increased anonymity.

Intranasal Use of Prescription Stimulants Among Adults Aged 18 to 30: Results From A Crowdsourcing Platform

OBJECTIVE

Few studies of prescription stimulant non-oral, non-medical use (NMU) (defined by use not as prescribed) have been conducted in adults beyond the college population. The purpose of this study was to characterize prescription stimulant non-oral use, specifically intranasal (IN) use (snorting) in young adults.

METHOD

Amazon's MTurk platform was used to recruit participants for an online survey. Data were collected from March to April 2020.

RESULTS

Thirty-two percent (n = 157) of survey respondents (N = 975), aged 18 to 30, reported IN prescription stimulant use (average of 32.1 episodes of lifetime IN use). Adderall was the most-reported prescription stimulant used intranasally (89.2%). Most IN users (82%; n = 68) reported spending no more than 5 minutes tampering with prescription stimulants. Intranasal users said they would take the medication orally if unable to tamper or manipulate medication for IN use.

CONCLUSION

These data help quantify a complex public health issue of ongoing IN use of prescription stimulants and suggest a potential role for manipulation-deterrent medications.

Prospective Cross-Sectional Study of the Uses of Non-prescription Analgesics among Hail Residents

<p>The aim of this paper was to describe the general status of the use of non-prescription analgesics (NPA) among the residents of Hail city to ensure the safe use of non-prescription analgesics.  One hundred participants with different diseases were studied consecutively from January to March 2020. Data were collected with an online, semi-structured questionnaire; the obtained data were converted into statistical data using Microsoft Excel 2013. Most participants were taking a single, non-prescription analgesic (87.5%), while combination analgesic products were used by only 12.5% of participants. Using over-the-counter analgesics is common among residents of Hail, and most of those studied use these products in moderation and do not exceed the recommended dose. Acetaminophen is the most widely used product, but people also use NSAIDs and amphetamine-like products. The use of over-the-counter analgesics is common among residents of Hail, and most of the participants in this study use these products in moderation and do not exceed the recommended dose; therefore, exposure of patients to an increased risk of adverse effects of these products is out of the question, and this indicates that a large group of people in this region knows the risk of analgesics overuse. New studies are needed to help improve the approaches to the use of NPA drugs</p>

Development and Acceptability of a Method to Investigate Prescription Drug Misuse in Daily Life: Ecological Momentary Assessment Study

Background

Prescription drug misuse and abuse is an established public health challenge, and young adults are particularly affected. There is a striking lack of real-time, naturalistic data collection assessing intentions to misuse and other precipitating factors at the time of actual misuse, leaving the conditions under which individuals are most likely to misuse prescription medications unknown. Ecological momentary assessment (EMA) apps and protocols designed to capture this information would accelerate and expand the knowledge base and could directly contribute to prevention and treatment efforts.

Objective

The objectives of this study are to describe the development and administration of a mobile app and the EMA protocol designed to collect real-time factors associated with college students’ prescription drug misuse intentions and behaviors in daily life; present completion rates, compliance, acceptability, and reactivity associated with the EMA protocol for participants who endorsed recent prescription drug misuse at screening (ie, risk group; n=300) and those who did not (ie, nonrisk group; n=55); and establish initial construct validity by linking the reports of misuse behaviors in daily life collected via the EMA app to prescription drug misuse reported on a standard survey.

Methods

An EMA data collection app and protocol were designed specifically to capture hypothesized contextual factors along with prescription drug misuse intentions and behaviors in daily life. Using this protocol, young adult college students (N=352) completed signal- and event-contingent reports over a 28-day period. When the intention to misuse a prescription drug was endorsed, a brief follow-up prompt was sent 15 min later to collect participants’ indications of whether or not misuse had occurred.

Results

Risk-group participants were significantly more likely than nonrisk counterparts to endorse any prescription drug misuse intentions in daily life (P<.001), to complete one or more follow-up reports (P<.001), and to endorse any prescription drug misuse behavior in daily life on the follow-ups (P<.001). Overall, participants demonstrated consistent engagement with the EMA procedures and returned an average of 74.5 (SD 23.82; range 10-122) reports. Participants in the risk and nonrisk groups did not differ in the number of reports they completed (P=.12), the number of their reporting days (P=.32), or their average completion rates (P=.14). The results indicated some evidence of reactivity to the momentary reporting procedure. Participants reported uniformly positive experiences and remained highly engaged throughout the reporting protocol and broader study.

Conclusions

The novel EMA app and protocol provide an effective way to assess real-time factors associated with prescription drug misuse intentions and behaviors in daily life. The resulting investigations offer the potential to provide highly translatable information for research and prevention efforts.

Prescription Drug Misuse: Taking a Lifespan Perspective

Prescription drug misuse (PDM), or medication use without a prescription or in ways not intended by the prescriber, is a notable public health concern, especially in the United States. Accumulating research has characterized PDM prevalence and processes, but age-based or lifespan changes in PDM are understudied. Given age-based differences in the medical or developmental concerns that often underlie PDM, it is likely that PDM varies by age. This review summarizes the literature on PDM across the lifespan, examining lifespan changes in prevalence, sources, motives and correlates for opioid, stimulant, and tranquilizer/sedative (or benzodiazepine) PDM. In all, prevalence rates, sources and motives vary considerably by age group, with fewer age-based differences in correlates or risk factors. PDM prevalence rates tend to decline with aging, with greater use of physician sources and greater endorsement of self-treatment motives in older groups. Recreational motives (such as to get high) tend to peak in young adulthood, with greater use of peer sources or purchases to obtain medication for PDM in younger groups. PDM co-occurs with other substance use and psychopathology, including suicidality, across age groups. The evidence for lifespan variation in PDM is strongest for opioid PDM, with a need for more research on tranquilizer/sedative and stimulant PDM. The current literature is limited by the few studies of lifespan changes in PDM within a single sample, a lack of longitudinal research, little research addressing PDM in the context of polysubstance use, and little research on minority groups, such as sexual and gender minorities.

Illicit Stimulant Use Development in Adolescence and Early Adulthood Among Juvenile Offenders: Risk Factors Predicting Heterogeneity

The objectives of this article are to identify groups of trajectories of stimulant use across adolescence and early adulthood among juvenile offenders and to identify risk factors predicting development. Group-based trajectory modeling was used to identify developmental subgroups of stimulant users during the study period. Multinomial logistic regression was used to examine baseline covariates’ relevance for predicting assignment to identified trajectory groups. A six-group model of stimulant use was found to best fit the data. Race, history of direct victimization at baseline, gender, low school commitment at baseline, low religiosity at baseline, and other substance use at baseline were all identified as predictors of trajectory group assignment. Juvenile offenders, particularly White and female offenders, are at elevated risk of illicit stimulant use during adolescence and early adulthood. Despite this, the vast majority of juvenile offenders in the sample had desisted by age 23, differing from research on other substances using this same sample.

Pharmacological cognitive enhancement in pediatrics

PURPOSE OF REVIEW

Given the pervasiveness of psychotropic medication in the youth population and an increasingly competitive culture regarding educational performance, children, teenagers, and/or their parents may increasingly seek psychotropic substances in an effort to enhance a student's cognitive abilities and/or academic performance. Physicians must become aware of this very important and clinically relevant issue and work to ensure that medications remain in the hands of patients seeking wellness and not enhancement.

RECENT FINDINGS

The current article highlights findings on the pervasiveness of stimulant misuse and diversion in youth, the motivations and effects of stimulant use, health and legal consequences associated with use, and physician perceptions and preventive practices. Ethical concerns regarding pharmacological cognitive enhancement in pediatrics are also outlined - including coercion for nonusers, inequities in access, and threats to an individual's sense of self with regard to authenticity and autonomy.

SUMMARY

Pharmacological cognitive enhancement in pediatrics will become a larger, clinically relevant issue in the coming years. Physicians who care for children and adolescents must become more aware of this issue. Given the myriad health, legal, and ethical concerns, clinicians should discourage use of pharmaceuticals for enhancement purposes in the pediatric population.

College students' perceived benefit-to-risk tradeoffs for nonmedical use of prescription stimulants: Implications for intervention designs

OBJECTIVES

Few studies have examined the benefit-to-risk tradeoffs undergraduate students perceive when engaging in the nonmedical use of prescription stimulants (NPS). This study examined the variation in college students' perceived risks and benefits for NPS.

METHODS

An online survey was administered to 259 college students (ages 18-25) at six public universities who had engaged in NPS in the past year. A best-worst scaling (BWS) instrument assessed the relative importance of 12 perceived benefits and risks of NPS. Probabilities of selection of each factor and 95% confidence intervals were estimated for the aggregate sample and latent preference subgroups were derived using latent class analysis (LCA).

RESULTS

For the aggregate sample, the strongest motivators for NPS were better grades (m=2.33, p<0.05) and meeting deadlines (m=1.62, p<0.05). The LCA generated four subgroups: 1) assuredly performance-driven (n=64; 25%), who prioritized academic performance and nonacademic responsibilities; 2) cautiously grade/career-oriented (n=117; 45%), who balanced academic improvements with expulsion and limiting future career opportunities; 3) risk-averse (n=64; 25%), who prioritized expulsion above academic improvements; and 4) recreational (n=14; 5%), who most valued having fun partying.

CONCLUSIONS

These findings identify subgroups of college NPS users that could have vastly different trajectories in terms of future drug use and college performance. Given this heterogeneity among students regarding perceived risks and benefits of NPS, interventions should be designed to assess motives and provide personalized feedback. Further research is needed with larger, more diverse samples and to assess the prospective stability of perceived risks and benefits.

Predicting young adults' risk for engaging in prescription drug misuse in daily life from individual, partner, and relationship factors

BACKGROUND

Mounting evidence based on retrospective and global assessments has established associations between prescription drug misuse and illicit drug use, alcohol abuse, mental health problems, risky sexual behaviors, and overdose deaths. However, there is a notable absence of identified risk and protective factors for an individual's likelihood of engaging in misuse in real-world environments.

METHODS

Using an experience sampling approach, the authors collected repeated moments of young adults' (n = 95 participants drawn from 49 romantic couples) prescription drug misuse instances in daily life and tested multiple factors associated with the misuse.

RESULTS

When examined in separate multilevel models, individual and relationship factors (but not partner factors) reliably predicted the likelihood of females' and males' prescription drug misuse in daily life. Specifically, females' elevated dysphoria symptoms, alcohol problems, and relationship closeness were linked with an increased likelihood of misuse, whereas cohabiting decreased the likelihood of their misuse. Males' higher levels of illicit drug use and relationship closeness were associated with increased likelihood of misuse, whereas their dysphoria symptoms were related to a lower likelihood of misuse. When examined in models that considered the predictors simultaneously, females' misuse was associated with individual, partner, and relationship factors, whereas males' misuse was not reliably associated with any of the factors.

CONCLUSIONS

An experience sampling approach was effective for the near-real-time assessment of young adults' prescription drug misuse in daily environments, and the likelihood of misuse was associated with risk and protective factors from multiple levels of influence. Education and treatment efforts designed to reduce prescription drug misuse may need to be tailored to accommodate males' and females' distinct predictors of misuse.

Lifetime nonmedical use of prescription medications and socioeconomic status among young adults in the United States

BACKGROUND

Despite decreases in the use of illicit drugs in the United States, prescription medications have become a major category of substances used by young adults.

OBJECTIVE

This study examines the relationship between the socioeconomic status (SES) of young adult respondents (ages 24-32) and their history of nonmedical use of prescription medications (NUPM).

METHOD

A secondary analysis was conducted with nationally representative data gathered from several waves (n = 15 701) of the National Longitudinal Study of Adolescent Health (Add Health). Four categories of NUPM were examined: (i) sedatives; (ii) tranquilizers; (iii) stimulants; and (iv) pain killers. SES was defined by several measures in the Add Health survey. Given the complex sampling plan of the Add Health, all analyses were weighted appropriately.

RESULTS

Results indicated higher levels of personal SES, such as having health insurance or not experiencing a financial hardship in the past year, decreased the likelihood of reporting lifetime NUPM. In contrast higher levels of parent SES (e.g. parental education) were associated with an increased likelihood of reporting lifetime use of NUPM tranquilizers and stimulants.

CONCLUSIONS

The results of this study suggest parental SES may have a stronger influence over NUPM than personal levels of SES, particularly for the categories of tranquilizers and stimulants. Furthermore, these findings indicate more research is needed on this subject to better understand the NUPM epidemic in order to effectively develop comprehensive clinical, public health, and policy-related intervention and prevention approaches.

Predictors of Sustained Prescription Opioid Use After Admission for Trauma in Adolescents

PURPOSE

The study objectives are to describe the longitudinal trajectory of prescription opioid use among adolescents requiring a trauma admission and then identify predictors of sustained opioid use.

METHODS

Randomly sampled adolescents (12-18 years) admitted to a Level I trauma center were surveyed. Follow-up assessments were obtained at 2, 5, and 12 months. Self-reported prescription opioid use, defined as "taking an opioid prescribed by a physician," was obtained at baseline and every follow-up time point. At the baseline interview, validated mental health measures and pain scales were obtained as well as preinjury substance use. A fixed-effects mixed Poisson regression analysis was performed to predict prescription opioid use over time.

RESULTS

A total of 120 adolescents (mean age 15.5 years [1.9 standard deviation], 75% male) completed the baseline interview with 98% follow-up at 12 months. At baseline, 7% of adolescents reported prescription opioid use before their trauma, with rates of prescription opioid use of 52% at 2 months, 13.3% at 5 months, and 12.5% at 12 months after discharge. After adjusting for demographic characteristics and injury severity score, those with sustained prescription opioid use were more likely to report preinjury marijuana use and higher baseline pain scores.

CONCLUSIONS

Approximately one in eight adolescents (12.5%) was using prescription opioids 12 months after injury hospitalization. Readily identifiable risk factors predicted sustained prescription opioid use, including preinjury marijuana use and baseline pain score. Screening for substance use including marijuana at the time of injury could help identify patients at risk for both substance use problems and sustained prescription opioid use.

Diversion of prescription stimulant drugs among 10-18-year-olds

PURPOSE OF REVIEW

Public health concern regarding the nonmedical use of prescription stimulants among youth has generated the need for increased understanding of diversion, which is the illegal sharing and selling of prescription drugs. Although our understanding of nonmedical use of stimulants has increased, the same cannot be said of diversion behavior among youth.

RECENT FINDINGS

The aim of this article is to use data from the National Monitoring of Adolescent Prescription Stimulants Study, which assessed prescription stimulant use among 10-18 years old across 10 US cities to report on prescription stimulant diversion among those who misused those medications. Findings indicate that more than one half (52%) of youth had engaged in one of the three forms of diversion (incoming only, outgoing only and both incoming and outgoing diversion). Engaging in incoming diversion only and both incoming and outgoing diversion increased with age and nonmedical use of prescription stimulants. All forms of diversion increased with marijuana use and among 16-18 years old with a friend's use of prescription stimulant.

SUMMARY

Findings provide an understanding of the subtypes of diversion and risk correlates of youth prescription stimulant diverter's that has value in preventing prescription stimulant diversion.

Prescription drug abuse: from epidemiology to public policy

Prescription drug abuse has reached an epidemic level in the United States. The prevalence of prescription drug abuse escalated rapidly beginning in the late 1990s, requiring a significant increase in research to better understand the nature and treatment of this problem. Since this time, a research literature has begun to develop and has provided important information about how prescription drug abuse is similar to, and different from the abuse of other substances. This introduction to a special issue of the Journal of Substance Abuse Treatment on prescription drug abuse provides an overview of the current status of the research literature in this area. The papers in this special issue include a sampling of the latest research on the epidemiology, clinical correlates, treatment, and public policy considerations of prescription drug abuse. Although much has been learned about prescription drug abuse in recent years, this research remains in early stages, particularly with respect to understanding effective treatments for this population. Future research priorities include studies on the interaction of prescription drugs with other licit and illicit substances, the impact of prescription drug abuse across the lifespan, the optimal treatment for prescription drug abuse and co-occurring conditions, and effective public policy initiatives for reducing prescription drug abuse.