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abstract

Objectives: To examine the prevalence and patterns of nonmedical use of pre-scription opioid analgesics and stimulants among student pharmacists.

Design: Descriptive, nonexperimental, cross-sectional study.Setting: Private urban college of pharmacy in the United States in fall 2006.Participants: 1,538 PharmD students. Intervention: Online survey.Main outcome measures: Lifetime and past-year nonmedical prescription opi-

oid and stimulant use.Results: Response rate for the survey was 62%. Lifetime prevalence of opioid

misuse was 8%, and 5% of students had misused in the past year. Lifetime preva-lence of stimulant misuse was 7%, and 5% had misused in the past year. Whites and fraternity or sorority members were more likely than their peers to have ever mis-used opioids. Past-year opioid misuse was more likely among whites, men, and low academic achievers compared with their peers. Lifetime stimulant misuse was more likely among students who were white, older, and fraternity or sorority members, while past-year misuse was more likely among whites and low academic achievers. Common motives for opioid misuse were to have fun, to relax, and to deal with chronic pain. Stimulants were used to improve concentration and academic performance. Friends were the most common source of prescription opioids and stimulants. Non-medical prescription use was associated with greater likelihood of alcohol and other illicit substance use.

Conclusion: The prevalence of prescription medication misuse among student pharmacists was lower than (opioids) or comparable with (stimulants) reported rates in college populations. Subgroups of students demonstrated higher rates of nonmedi-cal use, including whites, students involved with fraternities or sororities, and low academic achievers. That friends were the primary source of misused medications in-dicates that diversion of prescription-only controlled substances likely occurs among student pharmacists. Nonmedical prescription medication use should be considered in the context of other substance use.

Keywords: Nonprescription medications, student pharmacists, substance abuse.J Am Pharm Assoc. 2009;49:519–528.

doi: 10.1331/JAPhA.2009.08027

Nonmedical use of prescription opioids and stimulants among student pharmacistssarah Lord, George Downs, Paul Furtaw, anamika chaudhuri, amy silverstein, arnold Gammaitoni, and simon Budman

Received February 13, 2008, and in revised form July 29, 2008. Accepted for publication July 30, 2008.

Sarah Lord, PhD, was Director of College Health Programs, Inflexxion, Inc., Newton, MA, at the time this study was conducted; she is currently Principal Investigator, Na-tional Development and Research Institutes, Inc., New York. George Downs, PharmD, is Professor of Clinical Pharmacy and Dean Emeritus, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia. Paul Furtaw, PsyD, is Director of Student Health and Counseling, University of the Sci-ences in Philadelphia. Anamika Chaudhuri, MS, is a doctoral student in biostatistics, Boston University. Amy Silverstein, BA, is a graduate student, School of Public Health, University of Michigan, Ann Arbor. Arnold Gammaitoni, PharmD, is Global Director of Scientific Affairs, Arthritis and Analgesics, Merck & Co., Inc., Whitehouse Station, NJ. Simon Budman, PhD, is CEO and President, Inflexxion, Inc., Newton, MA.

Correspondence: Sarah Lord, PhD, One Broadway, 14th Floor, Cambridge, MA 02142. Fax: 617-758-4101. E-mail: lord@ndri.org

Disclosure: The authors declare no con-flicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

Funding: Supported by an unrestricted edu-cational grant from Endo Pharmaceuticals.

Previous presentations: Annual Meeting of the College on Problems of Drug Depen-dence, Quebec City, Canada, June 16–21, 2007, and the 108th Annual Meeting of the American Association of Colleges of Phar-macy, Orlando, FL, July 14–17, 2007.

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Nonmedical use of prescription medications by young adults 18 to 25 years of age is a growing public health problem in the United States.1–3 Nonmedical use is typi-

cally defined as use of a controlled medication without a pre-scription or use of prescribed medications in ways other than as directed by a health professional. Recent survey data indicated that prevalence of nonmedical use of any prescription medica-tion in United States was highest among young adults aged 18 to 25 years compared with all other age groups. Prescription opioid analgesics and stimulants were among the most widely misused medications among this age group.4 Of young adults 18 to 25 years of age, 26% have misused prescription opioids in their lifetime and 11% have used misused stimulants.4

College students are an important segment of the 18- to 25-year-old demographic. Some evidence indicates that 18 to 25 year olds enrolled in college are more likely than those not enrolled to misuse prescription stimulants.5 Studies have indi-cated a prevalence of about 12% for lifetime nonmedical use of prescription opioids (7% past year) and about 7% for any nonmedical use of stimulants (4% past year) among college

students.6,7 Recent studies have focused on identifying student characteristics and motivations and associated with increased risk for prescription opioid and stimulant misuse.6,8–14 Gender, race, housing (on-campus/off-campus), fraternity or sorority membership, and academic achievement have emerged as in-dividual difference factors in the portrait of prescription opioid and stimulant misuse among college students.6–11 Motives for misuse include recreation (e.g., get high) and self-treatment (e.g., relax, improve concentration).9,11–14 Nonmedical pre-scription use has also been shown to significantly increase the likelihood of alcohol and other illicit drug use among college students.6–9

Relatively little research attention has focused on non-medical prescription medication use by college-aged student pharmacists, despite current focus on the public health impli-cations of substance abuse among pharmacists.15–17 Student pharmacists represent an important segment of the 18- to 25-year-old student demographic and are future practitioners who will be at the forefront of medication delivery to the public. Dabney17 reported that 88% of pharmacists who illicitly used prescription medications first began such use in college. Kenna and Wood18 found that lifetime prescription opioid and anxiolyt-ic misuse were both notably higher among student pharmacists compared with a general college population.

Relative to other college students, student pharmacists may be at higher risk for misuse of prescription medications because they spend up to 6 years studying the detailed pharma-cologic effects of medications and may use this knowledge to rationalize self-treatment or their own invulnerability to addic-tion. Student pharmacists also have access to a range of medi-cations, particularly after they begin clerkships and workplace rotations, and easy access to medications may increase vulner-ability for misuse.19 Students that enter the workforce with a predisposition for abusing substances, including prescription medications, can jeopardize both their professional career and the public if they continue to misuse substances. A better un-derstanding of the characteristics and motivations of students who misuse prescription medications can help faculty and staff at colleges of pharmacy develop targeted prevention education initiatives for their students.

ObjectivesThis study addressed an important gap in the literature by

examining the prevalence and patterns of nonmedical use of prescription opioid analgesics and stimulants among student pharmacists. The primary aims of the study were to (1) assess the prevalence of misuse of prescription opioids and stimu-lants among PharmD students at a college of pharmacy, (2) identify student demographic and school-related characteris-tics associated with differences in rates of nonmedical use of prescription opioids and stimulants, (3) evaluate motives asso-ciated with misuse of prescription opioids and stimulants, (4) examine sources of illicit prescription opioids and stimulants for student pharmacists, and (5) determine the association of nonmedical use of opioids and stimulants with other substance use.

At a GlanceSynopsis: A survey examining the prevalence and

patterns of nonmedical prescription opioid analgesic and stimulant use among student pharmacists at a pri-vate urban U.S. college of pharmacy found that rates were lower than (opioids) or comparable with (stimu-lants) those in college populations. Prevalence of life-time nonmedical prescription opioid use was 7.9%, and 5.3% of students had misused in the past year. Preva-lence of lifetime nonmedical prescription stimulant use was 6.7%, and 5.0% of students reported nonmedical use in the previous year. Nonmedical use of opioids and stimulants was more common among whites, fraternity or sorority members, and low academic achievers.

Analysis: Although these results indicate that stu-dent pharmacists do not appear to misuse prescrip-tion medications at a higher rate than other college students, a considerable number of students admitted to participating in the nonmedical use of prescription medications, which could result in a felony charge depending on the circumstances. Additional research exploring the association of fraternity/sorority life with medication misuse is needed; possible sources of influ-ence include admired role models in the membership group and shared perceptions among members about the acceptability of nonmedical prescription use. Be-cause the current results indicate that diversion of medications likely occurs among student pharmacists, more research is needed to explore how beliefs and attitudes about diversion influence nonmedical pre-scription use and how these beliefs develop throughout students’ training years and subsequent transition into practice.

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MethodsThe study was approved by the institutional review boards

at Inflexxion, Inc., and at the participating college of pharmacy. An anonymous, confidential online survey (Appendix 1 in the electronic version of this article, available online at www.ja-pha.org) was distributed in fall 2006 to the entire population of 1,538 PharmD students at a large urban college of pharmacy in the northeastern United States. In this 6-year program, stu-dents complete a preprofessional curriculum during the first 2 years and the PharmD in the next 4 years. The survey link was distributed to students via e-mail pulses and social mar-keting announcements on campus and in classrooms (e.g., newsletters, flyers). Students who accessed the link completed an online consent procedure before receiving the survey. As an incentive for participation, respondents received an online $15 gift certificate for the campus bookstore at the end of the survey. As a strategy to gauge the extent to which students may have responded to the survey more than once, bookstore staff logged student identification numbers into a separate database when students presented a gift certificate. The bookstore and survey databases were completely distinct, and no information could be linked to the databases.

The 95-item survey included close-ended questions that tapped gender, race, year in school, housing location, current academic grades, and fraternity or sorority membership. Of note, the Greek organizations at the college of pharmacy at which the study took place included academic, social, service, and professional groups. No distinction was made in the sur-vey among these different groups; students were simply asked if they were a member of a fraternity or sorority. The survey also included the following drug-related constructs: lifetime and past-year nonmedical use of prescription opioid analgesics and stimulants, reasons for nonmedical use, age first misused, sources of medications, and other substance use. To the great-est extent possible, items for the survey were derived from es-tablished surveys of college-aged populations.1,20 The survey was programmed using the software package Perseus Survey Solutions, version 6.

Prescription medication misuseNonmedical prescription opioid and stimulant use was as-

sessed using the following survey item: “Which of the following prescription pain/stimulant medications have you ever used for nonmedical reasons? Nonmedical means use of a prescription drug without a prescription or for reasons other than those in-dicated by a prescription.” For opioid analgesics, respondents indicated all prescription opioids that they had ever misused from a list of 14 categories with brand-name examples: oxy-codone (Oxycontin), oxycodone (Percocet, Percodan, Roxicet), hydrocodone (Vicodin, Lortab), propoxyphene (Darvocet, Dar-von), acetaminophen with codeine (Tylenol with Codeine), me-peridine (Demerol), hydromorphone (Dilaudid), methadone, morphine (MS-Contin, Kadian, Avinza), fentanyl (Duragesic), fentanyl lollipop (Actiq), tramadol (Ultram), and hydrocodone/chlorpheniramine (Tussionex).

For stimulants, respondents selected all medications ever

misused from a list of five categories with the following ex-amples: methylphenidate (Ritalin), dextroamphetamine (Dex-edrine), dextroamphetamine (Adderall), atomoxetine (Strat-tera), and methylphenidate extended release (Concerta).

Both the opioid and stimulant lists included an open-ended “other” option to allow respondents to enter other misused medications. Skip algorithms were built into the survey to en-sure that respondents who indicated lifetime misuse of any of the medications were asked relevant follow-up items, including age first misused, frequency of past-year misuse (1, never, to 8, every day) and reasons for misuse. Nonexistent medications were included in the lists to check for data validity.

MotivesMotives for nonmedical use were assessed by a single item

for each medication class: “Please provide reasons why you have used prescription pain/stimulant medications nonmedi-cally.” Respondents were asked to check all that apply from a list of 18 motives: improve concentration, increase alertness, counteract other drugs, get high, perform better at school, perform better at work, perform better at sports, lose weight, increase energy, stay up all night, relax, have fun, experiment, manage chronic pain, manage depression or anxiety, feel less self-conscious, sleep better, and make sex more fun. The list was the same for opioids and stimulants. An open-ended “oth-er” option was also included to allow for respondent-generated motivations.

sourcesRespondents who indicated any misuse of opioids or stimu-

lants were asked, “Do you have a current, valid prescription in your name for any of the following pain/stimulant medica-tions?” The follow-up list included only the medications re-spondents had selected. The response scale was “Yes,” “No, but I used to,” and “No.” Respondents were then asked, “For prescription medications for which you don’t have a prescrip-tion, how do you get them?” Respondents could select all that applied from a list of seven sources: friend, parent, other family member, acquaintance, online, street, or work site.

alcohol and other drug usePast-year frequency of alcohol and other illicit drug use

was assessed by a single query: “In the past year, about how often did you use each of the following?” The follow-up list in-cluded tobacco, alcohol, marijuana, methamphetamine, co-caine, tranquilizers/sedatives, hallucinogens, steroids, heroin, inhalants, designer drugs, and over-the-counter medications to get high. Street names of the drugs were included to promote ready identification. Respondents indicated frequency on an 8-point anchored scale (1, never, to 8, every day). Respondents were also asked to indicate the number of standard alcoholic beverages consumed each day in the previous 7 days.

Data analysisAll analyses were conducted using SAS 9.1 (SAS, Cary,

NC). Prevalence of nonmedical use of prescription opioids and stimulants was calculated as the proportion of students

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who reported misuse relative to the total respondent sample. Bivariate analyses using Pearson chi-square statistics were conducted to examine differences in prevalence associated with the following student demographic and school-related characteristics: gender, race (white versus other), age (<21 vs. ≥21 years), year in school (preprofessional versus profes-sional), academic grades (As and Bs versus Bs or lower), hous-ing location (on campus versus off campus), and fraternity/so-rority membership (member versus nonmember). Multivariate logistic regressions were performed to examine the influence of demographic and school-related factors on the probability of nonmedical prescription opioid and stimulant use, adjust-ing for significant bivariate associations. Logistic regressions were also conducted to examine the association of nonmedi-cal use of opioids and stimulants with other substance use. Adjusted odds ratios and 95% CIs were reported. Two-tailed significance was established at P < 0.05.

ResultsA total of 950 respondents complied with the data validity

checks, yielding a final response rate of 62%. Data from nine respondents were deleted because nonexistent medications were selected. The response rate compares favorably with other paper-and-pencil and Web-based survey studies with college populations.1,8,9 Survey duplication was low; review of the bookstore database revealed four student numbers in the database twice. Because no identifying information was pres-ent in the survey itself, these data remained in the final dataset. Item-level missing data among completed surveys were mini-mal (≤2%).

The final respondent sample was 64% women, 46% white (non-Hispanic and Hispanic), 46% Asian (East Asian, Middle Eastern, and Asian Indian), 3% black, and 5% other racial/eth-nic group. The mean (±SD) age of students was 20 ± 2.5 years (range 17–35). The sample was distributed across the 6 school years and demographically reflective of the overall student population. Of respondents, 65% lived off campus and 10% were involved in fraternity or sorority life on campus.

Tobacco, alcohol, and other illicit drug use Approximately one-third of students (32%) reported past-

year tobacco use; 10% used regularly (a few times a month or more). Of students, 77% reported past-year alcohol use; 18% of these students reported drinking at least once a week in the past year. More than one drink per day in the previous 7 days was consumed by an average of 14% of students. Marijuana was used by 21% of students in the past year; 5% used mari-juana once a month or more during that time frame. Of stu-dents, 5% reported past-year use of prescription tranquilizers or sedatives, 3% hallucinogens, and 2% cocaine.

Prevalence of prescription medication misuse Prevalence of lifetime nonmedical prescription opioid use

was 7.9%; 5.3% of students had misused in the past year. Prevalence of lifetime nonmedical prescription stimulant use was 6.7%, and 5.0% of students reported nonmedical use in the past year. Nearly one-half (47%) of the students who re-

ported any nonmedical use first misused before college (39% in high school and 8% in junior high school). Of students who reported opioid misuse, 95% had done so in the previous 30 days and 9% indicated misusing regularly (once a month or more) during the past year. Of those reporting stimulant mis-use, 76% had done so in the past 30 days and 27% in the previ-ous year. Of students who reported any nonmedical prescrip-tion use, 35% had misused stimulants only, 45% opioids only, and 20% both types of medications.

The most frequently misused opioids were hydrocodone (Vicodin, Lortab; 29%), oxycodone (Percocet, Percodon, Roxi-cet; 28%), acetaminophen with codeine (Tylenol with Codeine; 28%), and hydrocodone chlorpheniramine (Tussionex; 13%). The most commonly misused stimulants were dextroamphet-amine (Adderall; 46%), methylphenidate immediate release (Ritalin; 16%), and methylphenidate extended release (Con-certa; 12%). The “other” option from the opioid medication list was selected by 2% of respondents, but medications added in-cluded over-the-counter pain medications (Tylenol, Advil, ibu-profen), benzodiazepines (clonazepam, diazepam), stimulants (pseudoephedrine), or redundant opioid medications (trama-dol). Less than 1% of respondents added “other” stimulant medications (caffeine pills, ephedrine).

Prevalence of misuse by student demographic and school-related characteristicsOpioids. As shown in Table 1, nonmedical use of prescription opioids differed significantly as a function of students’ race, age, gender, fraternity or sorority affiliation, and academic achievement. White students and members of fraternities or sororities were significantly more likely than their peers to have misused prescription opioids, both in their lifetime and in the past year. Low academic achievers were also significant-ly more likely than high achievers to report both lifetime and past-year opioid misuse. Older students were more likely than younger peers to have ever misused opioids, and men were more likely than women to report past-year misuse. Stimulants. Nonmedical prescription stimulant use differed as a function of students’ race, age, year in school, housing loca-tion, fraternity membership, and academic achievement. Stu-dents who were white, older, and in professional training years were all significantly more likely than their peers to have mis-used stimulants. Low academic achievers, fraternity members, and off-campus residents also had higher rates of both lifetime and past-year stimulant misuse compared with their peers.

Profiles of prescription opioid analgesic and stimulant misuse Opioids. Results of the multivariate analyses are depicted in Table 2. Race and fraternity/sorority membership both pre-dicted greater likelihood of lifetime prescription opioid misuse, adjusting for bivariate factors. White students and fraternity or sorority members were both two times more likely than their peers to have ever misused opioids. Past-year misuse was as-sociated with being white and male and having low academic grades. White students and men were two times more likely than their nonwhite and women counterparts to report past-

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year misuse, and low academic achievers were nearly two times more likely than high achievers to have misused opioids in the previous year. Stimulants. Students who were white, older, and members of a fraternity all had a higher probability of stimulant misuse, adjusting for bivariate associations. White students were near-ly 3.5 times more likely than others to report any nonmedical use. Older students were more than 2.5 times more likely than younger peers to report misuse, and fraternity or sorority mem-bers were more than 2 times more likely than nonmembers to have ever misused. Past-year misuse was more likely among white students and low academic achievers compared with nonwhite, high-achieving peers. White students were 3 times more likely than others to have misused in the past year, and those who reported low academic grades were nearly 2.5 times more likely than high achievers to report past-year misuse.

Motives for nonmedical prescription medication use Opioids. The most common reasons for nonmedical use of opi-oids were to have fun (31%), to destress or relax (29%), and to deal with chronic pain (23%). Other common reasons were to experiment (21%), to get high (21%), and to improve sleep (20%). Although less frequently reported, improved school per-formance (11%) and management of depression (11%) were also motives for opioid misuse. Less than 1% of respondents

indicated “other” motives for opioid misuse. Primarily, the moti-vations added were to self-treat acute pain or illness (e.g., head-ache, cough).

Bivariate analyses revealed a number of student sub-group differences in motives for opioid misuse. Men were more likely than women to use prescription opioids to get high (33 vs. 13%, P < 0.05). White students were more likely than their nonwhite peers to use opioids to get high (29 vs. 8%, P < 0.05), to relax (37 vs. 12%, P < 0.05), to have fun (41 vs. 12%, P < 0.01), and to improve sleep (19 vs. 3%, P < 0.05). Older students were more likely than younger stu-dents to misuse opioids to relax (46 vs. 20%, P < 0.05), while younger students were more likely than older students to re-port improved school performance as a motive (16 vs. 0%, P < 0.05). Preprofessional students were more likely than profes-sional students to indicate pain management as a reason for misuse (39 vs. 12%, P < 0.01), and low academic achievers were more likely than high achievers to report management of depression as a motive (19 vs. 3%, P < 0.05). Finally, stu-dents who lived off campus were more likely than on-campus peers to misuse opioids to relax (37 vs. 10%, P < 0.05), while on-campus residents were more likely than off-campus peers to misuse opioids to improve school performance (24 vs. 6%, P < 0.05).

Table 1. Prevalence of nonmedical use of prescription opioids and stimulants by student demographic and school-specific characteristics

Opioid analgesics Stimulants Characteristic

Total sample n

Lifetime %

Past year %

Lifetime %

Past year %

Total 950 7.9 5.3 6.7 5.0Gender Men 340 9.7 7.1a 6.5 5.0Women 602 6.6 4.2 6.8 4.7

Race White 418 11.5b 7.6a 11.2b 7.9b

Nonwhite 512 4.9 3.7 3.1 2.3Age (years) <21 635 6.7 5.3 4.4 3.6≥21 240 12.2a 5.1 15.7b 9.6c

School year 1st/2nd 444 7.0 5.9 1.9 3.23rd/4th/5th/6th 489 8.6 4.9 8.6b 6.3c

Housing On campus 324 6.5 5.3 3.1 2.2Off campus 605 8.6 5.5 8.8c 6.3c

Fraternity/sorority Nonmember 844 6.6 4.7 5.3 3.9Member 90 19.0b 11.1a 20.0b 13.3b

Academic grades Mostly As/As and Bs 592 6.4 4.1 4.2 2.7Mostly Bs or lower 358 10.0a 7.3a 10.9b 8.4b

aP < 0.05.bP < 0.001.cP < 0.01.

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Stimulants. The most common motives for stimulant misuse were to help with concentration (80%), to improve school per-formance (59%), to increase alertness (58%), to stay up all night (50%), and to increase energy (39%). To a lesser degree, students also used stimulants for recreation (i.e., to have fun [13%], to get high [13%], and to experiment [11%]). A small subset misused stimulants to manage weight (9%). None of the respondents selected the “other” option from the motivation list.

Race and academic achievement differentiated several mo-tives for prescription stimulant misuse. White students were significantly more likely than their nonwhite peers to misuse stimulants to increase energy (53 vs. 0%, P < 0.001) and to stay up all night (57 vs. 25%, P < 0.05). High academic achiev-ers were more likely than low achievers to use stimulants to increase alertness (76 vs. 46%, P < 0.05).

sources of prescription medications Students did not have a current valid prescription for the

majority (96%) of prescription opioids and stimulants misused but did report having had a prescription in the past for 26% of opioids and 3% of stimulants. The most common sources of prescription opioids were friends (56%), parents (20%), and acquaintances (20%). Less common sources were work sites (9%) and other family members (8%). Friends (75%) and ac-

quaintances (28%) were the most common sources of stimu-lants. Parents (9%), other family members (8%), and work site (6%) were less common. The street and online pharmacies were infrequent sources of both medications (<2%).

Student subgroup differences were observed for friends as sources of medications. White students were significantly more likely than their nonwhite peers (73 vs. 45%, P < 0.001), and older students were more likely than younger peers (72 vs. 55%, P < 0.05) to report friends as sources. Low achievers were more likely than high achievers (71 vs. 49%, P < 0.01) to access medications from friends, as were those who lived off campus compared with on campus (69 vs. 41%, P < 0.01). Professional students were more likely than preprofessional students (71 vs. 45%, P < 0.01), and fraternity or sorority members were more likely than nonmembers (85% vs. 55%, P < 0.01) to access medications from friends.

association of nonmedical prescription opioid and stimulant use with other substance use

As depicted in Table 3, the odds of other substance use were significantly greater for students who reported misuse of prescription opioids or stimulants relative to those who did not. Students who had ever misused opioids were more than 4.5 times more likely to have regularly used tobacco in the past year (a few times a month or more), more than 4 times more

Table 2. Profiles of nonmedical use of prescription opioid analgesics and stimulants by student demographic and school-related characteristics

Opioid analgesics Stimulants Characteristic

Lifetime OR (95% CI)

Past year OR (95% CI)

Lifetime OR (95% CI)

Past year OR (95% CI)

Gender Men 1.79 (1.00–3.20)a

Women —Race White 2.21 (1.32–3.71)b 2.00 (1.09–3.70)a 3.44 (1.86–6.37)c 3.19 (1.57–6.47)b

Nonwhite — — — —Age (years) <21 — —≥21 1.51 (0.86–2.63) 2.59 (1.37–4.92)b 1.67 (0.80–3.49)

School year 1st/2nd

— —

3rd/4th/5th/6th 0.98 (0.46–2.07) 0.90 (0.39–2.10)Fraternity/sorority Nonmember — — — —Member 2.25 (1.20–4.24)a 1.66 (0.75–3.66) 2.16 (1.11–4.20)a 1.86 (0.87–3.99)

Housing On campus — —Off campus 1.79 (0.79–4.05) 2.04 (0.079–5.26)

Academic grades Mostly As/As and Bs — — — —Mostly Bs or lower 1.41 (0.84–2.36) 1.82 (1.01–3.29)a 1.79 (0.98–3.19) 2.45 (1.23–4.90)b

Odds ratios (ORs) are adjusted for all other predictors in the model, including sex, race, age, housing location, fraternity membership, year in school, and academic grades. aP < 0.05.bP < 0.01.cP < 0.001.

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likely to have consumed four or more drinks in the previous week, nearly 4 times more likely to have used marijuana more than once in the past year, and 5 to almost 7 times more likely to have used hallucinogens, tranquilizers, or cocaine more than once in the past year. Past-year opioid misuse was associ-ated with even higher odds of using these substances.

Stimulant misuse was also associated with greater prob-ability of other substance use. Students who reported any misuse of stimulants were almost six times more likely to use tobacco regularly, twice as likely to have consumed four or more drinks in the past week, five times more likely to have used marijuana more than once in the past year, and four to nearly nine times more likely to have used cocaine, hallucino-gens, tranquilizers, and hallucinogens more than once in the previous year. Past-year stimulant misuse was associated with slightly lower odds for recent regular tobacco use, marijuana use, and hallucinogen use, but the probabilities of tranquilizer and cocaine use were substantially higher. Past-year stimulant misuse was not associated with greater odds of having four of more drinks in the past week.

DiscussionContrary to the hypothesis that student pharmacists would

exhibit higher rates of nonmedical use of prescription medi-cations than general college students, rates of misuse of pre-scription opioids and stimulants among student pharmacists were, for the most part, comparable with those of other col-lege students. Although the prevalence of lifetime prescription opioid misuse was slightly lower among student pharmacists compared with recent national figures for general college stu-dents, rates of past-year opioid misuse and both lifetime and past-year stimulant misuse were similar to reported rates for college students.6,7 The pharmacological knowledge gained by students in the course of their training may actually work to deter them from misusing medications. The potential conse-quences of ethic code violations and risk to future professional status may also serve to prevent students from misuse. While students may have underreported prescription medication misuse, reported rates of other substance use are consistent with previous surveys of student pharmacists.18,21,22

The results in the current work contradict those of Kenna and Wood,18 who found that rates of prescription medication misuse were higher among student pharmacists relative to a general college population. The divergent results could be at-tributed to differences in methodology and study population. In Kenna and Wood, surveys were mailed to students and the response rate was relatively low (35%). Selection bias may have occurred in that those who completed the survey may have been more motivated to reveal their substance use his-tory. Kenna and Wood also included only fourth and fifth year student pharmacists, while the current study included students from all 6 years of the program. Consistent with Kenna and Wood, older students in this study were more likely than young-er students to have misused prescription stimulants.

Although our results indicate that student pharmacists do not appear to misuse prescription medications at a higher rate than other college students, they also demonstrate that illicit prescription use by student pharmacists is by no means insig-nificant. A considerable number of students admitted to par-ticipating in the nonmedical use of prescription medications, which could result in a career-ending felony charge depend-ing on the circumstances. Nearly one-half of the students who had ever misused medications had done so before they entered college, indicating that the beliefs and attitudes that underlie prescription misuse develop early for many students and that efforts to counter positive beliefs about prescription drug mis-use should occur early on in a student’s training.

The most commonly misused opioids (hydrocodone, oxyco-done with acetaminophen, and acetaminophen with codeine) and stimulants (dextroamphetamine) by student pharma-cists are consistent with those reported by other college stu-dents11,23 and adolescent clinical populations.24 The patterns of specific medications misused mirror the prescription rates and overall availability of these medications in the general pub-lic.23,25 Larger-scale studies are needed to determine whether different profiles of misuse are associated with specific types of medications.

To the best of our knowledge, this is the first study to ex-amine demographic and student school-related factors associ-ated with individual differences in prescription medication mis-

Table 3. Substance use behaviors associated with nonmedical use of prescription opioid analgesics and stimulants

Characteristic

Regular tobacco use (few times a month or more)

OR (95% CI)Marijuana OR (95% CI)

Cocaine OR (95% CI)

Hallucinogens OR (95% CI)

Tranquilizers OR (95% CI)

Alcohol use (more than four drinks/week) OR (95% CI)

Opioid analgesics Lifetime use 4.57 (2.62–7.97)a 3.84 (2.24–6.58)a 6.85 (3.11–15.06)a 5.29 (2.18–12.82)b 5.55 (2.89–10.68)a 4.06 (2.39–6.90)c

Past-year use 4.91 (2.60–9.27)a 4.48 (2.44–8.25)a 8.71 (3.85–19.70)a 6.11 (2.44–15.28)b 7.42 (3.58–15.35)a 5.59 (2.91–10.73)c

Stimulants Lifetime use 5.63 (3.09–10.06)a 5.20 (2.94–9.20)a 4.20 (1.69–10.42)b 8.77 (3.44–22.36)a 6.78 (3.45–13.32)a 2.16 (1.19–3.92)c

Past-year use 4.53 (2.32–8.84)a 3.56 (1.34–9.43)c 8.57 (4.35–16.90)a 7.57 (2.86–20.06)a 8.54 (4.14–17.65)a 1.37 (0.68–2.77)Odds ratios (ORs) are adjusted for all other predictors in the model. aP < 0.001.bP < 0.01.cP < 0.05.

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use among student pharmacists. Results revealed subgroups of students who were at considerably higher risk for misuse, namely whites, members of fraternities or sororities, and low academic achievers. Similar profiles have been demonstrated with college students.6–9

That race/ethnicity stood out as an important individual-difference factor is not surprising. Nearly one-half of the sam-ple was East Asian or Asian Indian, which is a demographic that consistently demonstrates lower rates of alcohol and oth-er drug use relative to other groups.2 Whites, in contrast, con-sistently demonstrate higher rates of substance use compared with others.2

As with other college students, fraternity and sorority life is a powerful social context for nonmedical prescription medica-tion use among student pharmacists.26 More research is need-ed to understand the nature of the association of fraternity/sorority life with medication misuse. Possible sources of influ-ence are admired role models in the membership group and shared perceptions among members about the acceptability of nonmedical prescription use.

Student pharmacists’ motives for misusing prescription opioids and stimulants parallel reports assessing college stu-dents9–14 and younger adolescents in both treatment and com-munity samples.24,27 Patterns of student differences in motives may provide some insight into different profiles of misuse. For example, the only gender difference revealed that men were more likely than women to misuse opioids to get high, which might underlie the higher probability of past-year opioid mis-use among men. In addition, white students were more likely than other students to misuse opioids to get high, to relax, and to get better sleep, but no race differences emerged for motives associated with managing chronic pain or depression, suggest-ing that different portraits of opioid misuse may exist among whites, depending on motives for misuse. Finally, low academ-ic achievers were more likely than high achievers to misuse opioids to cope with depression—an association that might underlie the overall greater likelihood of recent opioid misuse among low-achieving students. Studies with larger sample siz-es are needed to examine the mechanisms by which motives influence nonmedical prescription use and the association of different typologies of motives and student characteristics with nonmedical use.

The majority of students did not have a current prescrip-tion for the medications they had misused, indicating that the primary means of misuse was by way of diversion or illicit ac-cess to medications rather than use of medications in ways other than prescribed. Interestingly, students reported having prior prescriptions for more than 25% of the opioids misused, which suggests that students may have misused expired pre-scriptions or had learned self-medicating strategies when they had legitimately used the medications for a medical condition. Further research is needed to examine the relationship be-tween legitimate medical and illicit use of prescription medica-tions among student pharmacists.

As with other college students, friends were the primary source of misused prescription medications for student phar-

macists.11–14 Also consistent with other studies, parents were common sources of prescription opioids.11,13,28 Students also relied on acquaintances for access to stimulants, which reflects the broader availability of stimulants among peers.23 That cer-tain subgroups of students were more likely than their peers to obtain medications from friends highlights the importance of friendship network as a dimension of a student’s risk pro-file for misusing prescription opioids or stimulants. McCabe et al.29 demonstrated that college students who were prescribed a controlled medication in the previous year were approached to divert their medications at high rates; more than one-half of those with a stimulant prescription and 26% of those with an opioid prescription were approached by peers for the medica-tions. Future research will examine the nature of diversion of prescription medications among friends in the social networks of student pharmacists.

Few respondents reported diversion of medications from the workplace. Because friends were the most common source of medications, underestimation of diversion from the work-place is possible. In some cases, these friends may have been older classmates who would have greater access to prescrip-tion medications at their place of work. Some evidence for this hypothesis exists in that professional students who had begun clerkships and experience programs were more likely than pre-professional students to report friends as a source of medica-tions. More research is needed to characterize the nature of friendship networks among student pharmacists (i.e., other student pharmacists, older students) and to identify the specif-ic sources from which friends may have obtained medications.

The results demonstrate that diversion of medications like-ly occurs among student pharmacists. Because these students will eventually be independent practitioners, prevention initia-tives are essential to deter students from entering the work-force at risk for diversion and illicit prescription medication use. More research is also needed to explore how beliefs and attitudes about diversion influence nonmedical prescription use and how these beliefs develop throughout students’ train-ing years and subsequent transition into practice.

Consistent with other studies, student pharmacists in this study were less involved in substance use compared with col-lege student populations.18,21,22 As with college students, non-medical prescription use substantially increased the likelihood that students had recently engaged in other substance use.6–9 Use of alcohol and other illicit drugs figures prominently in the portrait of nonmedical prescription medication use among stu-dents. The current results also highlight that different profiles of prescription medication misuse exist among student phar-macists; some misused only opioids, some only stimulants, and some misused both. Further research is needed to better define typologies of nonmedical prescription use and other substance use and to determine whether subtypes of students misuse prescription medications exclusively (i.e., do not drink or use other illicit drugs).

To our knowledge, this is the first study to use online survey methodology to assess substance use among student pharma-cists. The online format allowed for efficient, low-impact dis-

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semination and completion of the survey. Data from completed surveys were automatically saved in a database. The respect-able response rate and low incidence of missing data highlight the promise of this methodology for reaching student popula-tions.

The findings that subsets of student pharmacists mis-used prescription opioids or stimulants at significantly higher rates than their peers and that diversion of these medications likely occurred between students suggests that more educa-tion is needed to build students’ awareness the potential con-sequences of these behaviors. Other researchers have called for health professional schools to proactively provide students with substance abuse education to prevent development of serious substance abuse issues that can persist beyond col-lege.21 Yet, surprisingly, substance abuse prevention education for student pharmacists is lacking. Dabney17 found that 67% of pharmacists indicated that they had no addiction or substance abuse training in college, and 65% reported the absence of drug abuse resources at their place of employment. A thorough review of the published literature in the past 10 years revealed just one controlled empirical study of a substance abuse edu-cation program for student pharmacists. This study is the first step in a program of research to develop the knowledge base about the nature of prescription medication misuse among stu-dent pharmacists so that colleges of pharmacy can be armed with the best information possible to create effective education programs for their future practitioners.

LimitationsThe main limitation of this study is that the sample repre-

sented a single school, which could affect the generalizability of results to other student pharmacists. Epidemiological stud-ies have indicated geographic as well as school-specific (i.e., public versus private schools) variation in nonmedical use of opioids and stimulants among college student populations.6,7 Also, a 6-year college of pharmacy school was studied. How-ever, few differences were observed between preprofessional and professional students in the prevalence or nature of pre-scription medication misuse. Future research by the team will include larger-scale, nationally representative studies of stu-dent pharmacists to examine nonmedical prescription medica-tion use among student pharmacists from different geographic regions and school contexts.

Several methodological aspects of the study could also potentially limit the validity of the results. Nonresponse may have introduced some bias to the study. This concern is less-ened by the healthy response rate, which was comparable with or higher than other substance use surveys of college students and student pharmacists.1,8,9,18,21 Moreover, the reported rates of other substance use among student pharmacists were com-parable with rates found in other survey studies of this popula-tion.21 Retrospective recall is another potential methodological limitation. However, the recall parameters used in the study (lifetime and past year) were analogous to other self-report surveys of college-aged students.1,6–9 Adolescents and young adults are also more likely to be more comfortable and hon-

est with confidential computer-based surveys relative to other interview modalities.30 Finally, the methodology allowed for duplicate survey completion. Although the degree of duplica-tion was low, efforts to prevent survey duplication (e.g., unique codes built into survey links) should be incorporated in future work.

conclusionThe prevalence of prescription medication misuse among

student pharmacists was lower than (opioids) or comparable with (stimulants) reported rates in college populations. Sub-groups of students demonstrated higher rates of nonmedical use relative to peers, including whites, those involved with fra-ternities or sororities, and low academic achievers. The finding that friends were the primary source of misused medications indicates that diversion of prescription-only controlled sub-stances likely occurs among student pharmacists. Nonmedical prescription medication use should be considered in the con-text of other substance use.

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2. Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: national findings. Rockville, MD: National Survey on Drug Use and Health; 2007 [Series H-32, DHHS publ. no. SMA 07-4293].

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4. Colliver JD, Kroutil LA, Dai L, Gfroerer JC. Misuse of prescription drugs: data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health. Rockville, MD: Substance Abuse and Men-tal Health Services Administration; 2006 [Analytic Series A-28, DHHS publ. no. SMA 06-4192].

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8. McCabe SE, Teter CJ, Boyd CA. Illicit use of prescription pain medication among college students. Drug Alcohol Depend. 2005;77:37–47.

9. Teter CJ, McCabe SE, Cranford J, et al. Prevalence and motiva-tions for the illicit use of prescription stimulants in an undergrad-uate student sample. J Am Coll Health. 2005;53:253–62.

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10. Carroll BC, McLaughlin TJ, Blake DR. Patterns and knowledge of nonmedical use of stimulants among college students. Arch Pe-diatr Adolesc Med. 2006;160:481–5

11. Lord SE, Brevard JA, Trant MA. Portraits of prescription medica-tion misuse among college students. Presentation at annual con-ference of College on Problems with Drug Dependence, Quebec City, Canada, June 16–21, 2007.

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19. Trinkoff AM, Storr CL, Wall MP. Prescription-type drug misuse and workplace access among nurses. J Addict Dis. 1999;18(1):9–17.

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Appendix 1. Survey of nonmedical prescription opioid and stimulant use among student pharmacists

(Note: The items in this survey are the subset of items from a 95-item survey that were used for the analyses in the present study. Please do not use this survey without written permission by the authors.)

1. What is your gender?

Male Female

2. What kinds of grades have you been getting this year?

Mostly A’s A’s and B’s Mostly B’s B’s and C’s Mostly C’s C’s and D’s Mostly D’s

3. Which of the following prescription PAIN MEDICATIONS have you EVER used for non-medical reasons? (Non-medical means use of a prescription drug without a prescription or for reasons other than those indicated by a physician).

Oxycodone (OxyContin) [Oxy, OC, Oxycotton] Oxycodone (Percocet, Percodan, Roxicet) [Percs] Hydrocodone, (Vicodin, Lortab) [Hydro, Vikes] Darvocet, Darvon Acetaminophen with Codeine (Tylenol w/ Codeine) [T-3s, T-4s, T-5s] Meperidine (Demerol) [Demmies] Hydromorphone (Dilaudid) [Dillies] Norphindin [Norphie, Norph] Methadone [Dollies, ‘Done] Morphine (MS-Contin, Kadian, Avinza, MSIR) [M, Morph, Miss Emma] Fentanyl (Duragesic (Fentanyl patch) [Pain patch, Morphine patch] Fentanyl lollipop (Actiq) [Perc-a-pop] Tramadol (Ultram) Other prescription pain meds not listed (please specify) None of the above_________________________

3a. In the PAST YEAR, about how often have you used the following prescription PAIN MEDICATIONS for non-medical reasons? [list includes medications selected above]

Never Once A few times

2

Once a month A few times a month Once a week A few times a week Every day

3b. Please provide reasons why you’ve used prescription PAIN MEDICATIONS non-medically. (check all that apply)

To help me concentrate or focus To help increase my alertness To counteract the effects of other drugs To get high To help me perform better at school To help me perform better at work To help me perform better at sports To lose weight/not gain weight To give me energy To stay up all night To de-stress/ to relax To have fun To experiment because I’m curious To help with chronic pain To help with depression or anxiety To help me feel less self-conscious/to help me socialize better To sleep better/to fall sleep To be sexier/to make sex more fun Other (please specify) ___________________________________

4. Which of the following prescription STIMULANTS have you EVER used for non-medical reasons? (Non-medical means use of a prescription drug without a prescription or for reasons other than those indicated by a physician). (Check all that apply).

Ritalin Cadrine Dexedrine Adderall Strattera Concerta Other prescription stimulant medication not listed (please specify) None of the above_______________

4a. In the PAST YEAR, about how often have you used the following prescription STIMULANTS non-medically? [list includes medications selected above]

Never

3

Once A few times Once a month A few times a month Once a week A few times a week Every day

4b. Please provide reasons why you’ve used prescription STIMULANTS non-medically. (Check all that apply)

To help me concentrate or focus To help increase my alertness To counteract the effects of other drugs To get high To help me perform better at school To help me perform better at work To help me perform better at sports To lose weight/not gain weight To give me energy To stay up all night To de-stress/to relax To have fun To experiment because I’m curious To help with chronic pain To help with depression or anxiety To help me feel less self-conscious/ to help me socialize better To sleep better/to fall asleep To be sexier/ to make sex more fun Other (please specify) ___________________________________

5. Do you have a current, valid prescription in your name for any of the following PAIN MEDICATIONS? [list includes medications selected in Q3]

Yes No, but I used to No

6. Do you have a current, valid prescription in your name for any of the following STIMULANT MEDICATIONS? [list includes medications selected in Q4]

Yes No, but I used to No

4

7. For prescription medications that you use that you DON’T have a prescription for, how do you get them? (Check all that apply)

Friend Parent Other family member Online Another person you know Worksite N/A; I have a prescription for each medication I use

8. When was the first time you used any prescription drug non-medically? (Non-medically means use of a prescription drug without a prescription or for reasons other than those indicated by a physician).

Junior high/middle school or before High school 1st year of college 2nd year of college 3rd year of college 4th year of college 5th year of college 6th year of college

9. In the PAST YEAR, about how often did you use the following?

Tobacco Alcohol Marijuana (Pot, Weed) Methamphetamine (Meth, Crystal, Ice) Cocaine (crack, rock) Anxiolytics, tranquilizers or sedatives (Valium, Xanax) Hallucinogens (LSD, PCP, mushrooms) Steroids or other performance-enhancing substances (Andro) Heroin (Smack, Horse) Inhalants (Glue, Solvents, Ggas) Designer/Club Drugs (Ecstasy, MDMA, GHB, Liquid G, Special K, Roofies, etc) Over-The-Counter (OTC) drugs above the recommended dose (NoDoz®, Sominex®, Coricidin®, Robitussin®)

Never Once A few times Once a month A few times a

month Once a week A few times a week Every day

5

10. In the LAST 7 DAYS, about how many alcoholic beverages did you drink each day? (Note: A 12 oz beer =a 5 oz. glass of wine =1 mixed drink with one shot of hard alcohol)

Monday: _______ Tuesday: _______ Wednesday: _______ Thursday: _______ Friday: _______ Saturday: _______ Sunday: _______

11. What is your current age? * _________

12. What year of school are you currently in?

1st year 2nd year 3rd year 4th year 5th year 6th year

13. How would you describe yourself?

White (Non-Hispanic) White (Hispanic) Black/African American (Non-Hispanic) Black/African American (Hispanic) East Asian Middle Eastern Asian Indian Pacific Islander/ Native Hawaiian American Indian/ Alaskan Native Other (please specify) ___________________________________

14. Where do you currently live?

On-Campus Off-Campus

15. Are you a member of a fraternity or sorority?

Yes No