What Parents Can Do National Rx Drug Abuse Summit 4-11-12

1. What Parents Can Do
April 10-12, 2012
Walt Disney World Swan Resort

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

3. 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.

4. 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

5. Purpose
To meet the objectives, I will:
• Review the various ways in which the nonmedical use of
controlled medications manifests itself in the adolescent
population in the United States.
• Present definitions and case examples in order to highlight the
complexity of this form of substance abuse.
• Using Problem Behavior Theory as a framework, we will focus
on the behavioral and social problems that often accompany
some forms of nonmedical use of controlled medications.
5

6. 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

7. Differences among
nonmedical users
7

8. 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

9. CASE EXAMPLES
What do these subtypes look
like?
9

10. CASE
EXAMPLES
10

11. Case Example #1
A student is prescribed an
SSRI and an anxiolytic
(benzodiazepine) for
Generalized Anxiety
Disorder. He has been
taking these medications for
two years. During his junior
year, the young man
doubled his dose of the
benzodiazepines (without
physician knowledge) in
order to reduce his anxiety;
his symptoms were
perceived as intolerable
and he was seeking relief.
11

12. 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

13. 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

14. Case Example #2: Behavior and Attributes
ATTRIBUTES:
BEHAVIOR:
• Administered in ways other
The incorrect use of than prescribed;
a prescribed • Used in higher doses either
medication by a by increasing the dosage or
patient 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

15. Case Example #3
On a Friday afternoon, a
16 year old teen, an honor
student, is planning to
attend “Homecoming”
with her new boyfriend.
Four hours before the
event, she develops a
severe migraine and is
nauseated and dizzy. In
tears, she asks her mother
for help. Her mother gives
her two hydrocodone
tablets (left over from her
own surgery). The teen
went to the event and
“had a great time.”
15

16. Case Example #3: Behavior and Attributes
BEHAVIOR: 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

17. Case Example #4
A girl with a history of
alcohol abuse is
given an oxycodone
tablet by a friend; she
wants to experiment
to see “what it does”.
She crushes and
snorts the pill. The girl
continues to buy
“Oxy” from friends
when she wants to
party.
17

18. 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

19. 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

20. Prescription Drug Misusers & Abusers:
Subtypes
Person does not possess Person does possess legal
legal prescription prescription
Sensation-seeking: Sensation-seeking:
get high, experiment, or create get high, experiment, or create
altered 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 actual
perceived health condition (w/ or perceived health condition
someone else’s meds) (w/ own meds)
Boyd CJ, McCabe SE. Subst Abuse Treat Prev Policy. 2008,3:22.

21. IS THIS CONCEPTUALIZATION
SUPPORTED BY DATA?
Do subtypes matter
.

22. 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

23. Problem Behaviors and Nonmedical
Use
.
23

24. 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
relief
Boyd, C.J., Young, A., Grey, M., & McCabe, S.E., 2009. Adolescents’ nonmedical use of
prescription medications and other problem behaviors. J Adol. Health 45, 539-540.
Boyd (PI) NIH Grant RO1 DA024678

25. Hypothesis
Youth engaging in nonmedical use for
sensation-seeking are more likely to report
other problem behaviors vs. those who are:
– non-users (who were never prescribed an
opioid)
– medical users (who were prescribed but
used correctly)
– self-treaters (who engaged in nonmedical
use for self-treatment)
Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.

26. 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 have
you used the following types of drugs, not prescribed
to 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.

27. Sample Characteristics
Female: 52.6% Mean Age: 14.97 (1.74)
(480)
Black: 53.8% (490)
Male: 47.4%
White: 43.5% (396)
(432)
Asian American: 1.4% (13)
Total: 912 Hispanic/ Latino/a: .7% (6)
American/Alaskan Native: .7% (6)
27

28. Procedure: Secondary Student Life Survey
• Data were collected, w/web-based survey
• All students in one school district (7th-12th grades)
• 968 students returned consent forms (64% response
rate)
• IRB approval was obtained, hooded computers
used
• The Secondary Student Life Survey (SSLS) is
maintained on a hosted secure Internet site running
under the secure sockets layer (SSL) protocol to
insure data were safely transmitted.
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29. 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

30. 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.

31. 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.

32. Past-yr Problem-Behaviors:
Medical & Nonmedical Users
Secondary Student Life Survey
*P<.05 vs. all 3 other gps
†P<.05 vs. nonusers & medical users *
Non-users: reference gp set to “0”
*
*
Boyd CJ, et al. J Adolesc Health. 2009;45:543-50.

33. Summary
• The nonmedical use of controlled
medications involves a variety of
behaviors;
• Consequences may be different for self-
treaters versus sensation-seekers;
• Prevention experts must decide behaviors
they are targeting;
• Everyone plays a role in prevention
• Consider the ABC’s…
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34. Our team’s next project
ABC’s and Prevention
Boyd, C.J., Anderson, K.G., Rieckman, T. (2011) ABC’s of Controlled Medications: What Patients
Need to Know about their Prescription Pain Medicine (Commentary), Journal of Addictions
Nursing. 22:1–3.

37. QUESTIONS?
THANK YOU