Adolescents and young adults are at high risk of using prescription medications for purposes other than initially intended by the prescriber due to developmental imbalances in brain maturation. They may use opioids to “get high,” stimulants hoping to gain an edge at school or sedatives in an attempt to alleviate anxiety.
A new AAP clinical report describes risk factors for nonmedical prescription drug use (NMPDU) and short- and long-term health outcomes of such use, including sleep difficulties, addiction, poor educational outcomes, increased health care utilization and overdose risk. It also provides recommendations for pediatricians on how to prevent and reduce harms related to NMPDU.
The clinical report Nonmedical Use of Controlled Medications by Adolescents and Young Adults, from the Committee on Substance Use and Prevention, is available at https://doi.org/10.1542/peds.2024-069298 and will be published in the December issue of Pediatrics.
Recent trends
NMPDU may include use of prescription medications, such as opioids, sedatives or stimulants, that were prescribed for someone else; use of one’s own medication in a way that was not as prescribed (e.g., different amount, frequency or indication); or any intentional use of prescribed medications for the feeling they cause.
Trends in NMPDU rates vary by medication class. Notably, nonmedical use of prescription opioids has been decreasing steadily over the past decade, while nonmedical use of prescription stimulants and sedatives has remained relatively stable.
These trends have been occurring in parallel with growing awareness among health care providers of the addictive potential of opioid medications and an increase in the toxicity, contamination and lethality of the illicit drug supply.
Rates of NMPDU vary among racial and ethnic groups. A 2019 national survey, for example, showed rates of nonmedical opioid use was highest among American Indian and Alaska Native adolescents (2.9%) and lowest in Asian adolescents (0.3%). A review of 76 studies on prescription opioid misuse from 2013-’18 had mixed findings. Given that race designation is a social construct and has no biologic basis, it is important to highlight the need for more research to elucidate disparities in NMPDU rates and mechanisms underlying these disparities.
Studies also show that rates of lifetime NMPDU are significantly higher among high school students identifying as lesbian, gay, bisexual or questioning (26%) compared with adolescents identifying as heterosexual (16%). More research is needed on rates of NMPDU among transgender and gender-diverse youth.
Risk and protective factors
There are numerous risk factors for NMPDU, many of which overlap with those seen with use of other licit and illicit substances. Risk factors specific to NMPDU generally are related to the environment (e.g., access and availability of prescription medications), interpersonal relationships with family and peers, and the individual (e.g., untreated pain or mental health conditions).
Nonetheless, the presence of a supportive family environment with consistent parenting rules and monitoring, as well as involvement in fulfilling extracurricular activities can play important protective roles.
Reasons leading to NMPDU generally fall under two broad categories: recreational use (e.g., “getting high”) and self-medication (e.g., seeking relief from untreated pain, attention-deficit/hyperactivity disorder (ADHD), anxiety or insomnia).
Family members or peers with a valid prescription represent the most common initial source for medications used nonmedically, suggesting an important opportunity for physician education at the time of prescribing.
Recommendations
The clinical report outlines the following recommendations for pediatricians to help reduce NMPDU in adolescents and young adults.
- Ask patients and caregivers about all controlled medication prescriptions and provide appropriate education.
- Discuss strategies to protect children and youth from the risks of NMPDU, including:
- securing medications at home,
- supervising access and administration of controlled medications, and
- disposing of unused medications properly.
- Provide anticipatory guidance on sharing, trading or selling medications and the role of naloxone for overdose death prevention.
- When prescribing controlled medications,
- stay up to date on practice guidelines for the treatment of conditions such as ADHD, chronic pain and mental illness;
- screen for substance use;
- be familiar with their state’s legal and practice requirements regarding prescription monitoring databases;
- explain the risks of NMPDU to youth and families; and
- prescribe naloxone for overdose death prevention (specifically when prescribing opioids).
- When NMPDU has been identified,
- use validated tools to screen for and address co-occurring mental health conditions and other risk factors such as trauma, uncontrolled pain, insomnia and untreated ADHD; and
- prescribe and recommend naloxone for overdose death prevention, and teach patients and families how and when to use it.
Dr. Chadi and Dr. Walker-Harding are lead authors of the clinical report. Dr. Walker-Harding is a former member of the AAP Committee on Substance Use and Prevention.
