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Critser’s point is that, due to a variety of congressional acts and relaxed standards by the Food and Drug Administration, the pharmaceutical industry has successfully marketed a variety of medications as common consumer goods. It is not surprising, then, that nonmedical prescription drug use is experienced across all ages of the population and not simply by college students. It is also not surprising that young adults represent the highest rates of use, and that this correlates to high rates of consumption across all consumer goods for this age group.
Critser specifically identifies “high performance youth” as one of the key targets of pharmaceutical industry, and makes the vital connection between pharmaceutical marketing and the rise in ADHD diagnosis. He also makes the point that direct-to-consumer advertising itself threatens the physician-patient relationship, as more young adults see no need to seek a medical assessment to treat an obvious problem that is well defined by the drug manufacturer.1 From this perspective, it may be difficult to argue against the use of a performance enhancing stimulant for a student at an academically challenging institution who has become convinced that his or her future success lies in their ability to maintain a high grade point average while also remaining highly active in significant extra-curricular and co-curricular activities (usually while also working at least part-time to cover the expenses of the experience). It may be equally hard to argue that a student-athlete who must regularly step beyond the normal boundaries of physical ability in order to assure a place in professional sports should not use pain-relievers, and may be more inclined to do so outside of the medical establishment for fear of a loss of faith within the coaching staff.
History has made clear that our definitions of any social problem have a direct influence on our approach to addressing that problem.19 If, in fact, the increase in non-medical prescription drug use among college students represents self-diagnosis and self-treatment, then an entirely different set of policies and programs are needed to increase medical supervision of student drug use, increase the knowledge of drug interactions and other potential adverse effects, and address the environmental, social, and cultural factors that affect student mental and physical health.
Prescription Drug Abuse: Assessing the Risks and Issues Page 7
2) Explanations for prescription drug use need more study from a variety of perspectives.
Illicit drug use, like alcohol use, suffers particularly from what Hamilton and Collins described as an “assumption of malevolence” where researchers and policymakers focus on harm and ignore the potential or reported benefits to substance consumption20. In much of the literature concerning non-medical and illicit prescription drug use among college students, this assumption is clearly evident, despite the lack of clear harms data to support the assumption.
Beyond self-diagnosis and treatment, the use of prescription drugs for purely recreational purposes may also have alternative explanations. Intoxicating substances have had a place across civilizations and appear in some form in the popular culture of every generation21. In many cases, these substances – whether deemed legal or illegal by social authorities – have been a key aspect in social practices that focus on community-building. While alcohol tends to be the most common drug of choice for this purpose in contemporary Western culture, marijuana use closely mimics alcohol use in this manner; most uptake occurs within groups during social occasions and, like alcohol, is used to increase social interaction.
Currently, there is no evidence that prescription drug use holds the same social and cultural function as alcohol and marijuana, and very disputable evidence that suggests that these substances are ingested in group settings. A variety of news media outlets have reported the prevalence of “Pharming Parties” where young adults bring prescription or over the counter medications and throw them all into a bowl so that individuals can grab handfuls of unlabeled pills, a practice known as “trailmixing22,” but the prevalence of these events has been challenged23.
A more plausible social theory explaining social prescription drug use (and pharming parties in particular) may be found in the notion of edgework. Edgework is a concept originated by sociologist Stephen Lyng that explains voluntary risk-taking as a transcendent activity, much like hallucinogenic drug use itself was described in the 1970’s. The transcendence of risk-taking, however, is found in the act of coming as close to destruction as possible without going “over the edge.” The greater the danger, Lyng has discovered, the greater the thrill, and the greater the sense of freedom from social constraint24. Yet, there is a Prescription Drug Abuse: Assessing the Risks and Issues Page 8 second advantage to edgework in that successful risk-taking also yields entry into the broader “edgework community,” a group of like-minded individuals who bond through shared risktaking experiences. Examples of these closely bonded edgework communities abound in our society, from firefighters to cliff divers, surfers to test pilots, roller coaster fan clubs to street gangs.
It is interesting to note that the studies of non-medical and illicit prescription drug use indicate that sub-population use rates among college students mimic heavy episodic drinking rates; the highest use occurs among white upper-middle class students and members of fraternities and sororities or intramural athletic teams. These groups share classic edgework community characteristics, including elaborate and dangerous membership rituals and group risk-taking activities that facilitate member bonding and socialization25.
From this perspective, non-medical prescription drug use can be viewed as a social phenomenon that, through social engineering, can be restructured to meet student social needs in safer ways. The edgework perspective also provides a unique approach to individual intervention; failure to successfully negotiate the edge of dangerous prescription drug use (seen in overdose, addiction, adverse physical effects, or emergency room visits) is often leads to rejection of the edgeworker by the edgework community. Many collegiate social groups view student members who are unable to control their intoxication and become violent, ill, or place the group in legal danger as a burden to the group and are often rejected.
Efforts to refocus the failure of the individual as an opportunity for intervention and treatment have proven successful in fraternity and sorority settings25.
Rethinking the issue of non-medical prescription drug use to more accurately reflect the beliefs and behaviors of our students may actually point us to a set of environmental, medical, and cultural solutions that address the need rather than criminalize the behavior5.
3) Alcohol and Marijuana are still the recreational drugs of choice for the majority of college students.
Without question, the prevalence data collected across a variety of studies on college substance use indicates that alcohol and marijuana continue to be the recreational drugs of choice for the vast majority of college students. According to the 2008 NSDUH data,
Figure 1: NSDUH 2008 Data Epidemiologically, however, the comparison between drug and alcohol use is rather awkward and less helpful; alcohol and its effects are measured by quantity consumed, and a clear correlation has been established between the amount of alcohol consumed and the prevalence of harms that accompany overuse. In fact, harm reduction – a philosophy that is central to the alcohol prevention efforts on college campuses -- assumes that for students of legal age, limited use is both acceptable and non-problematic. Drug use is studied and addressed without attention to quantity consumed. All the studies cited here ask for whether or not a student has consumed a drug in the past year, month, or lifetime, and never inquires about the amount consumed in any given event. In fact, there is no research literature that describes the amount consumption for prescription or illicit drugs, though one could argue that, like alcohol, a small amount of Adderall® that is ingested will have profoundly different effects than a large amount of Adderall®, particularly over time. Moreover, the primary impact of alcohol consumption is consistent; alcohol causes intoxication, and a wide variety of medical, legal, and social harms can be tied to that state of being. The rate at which alcohol causes intoxication, measured by blood alcohol concentration, is often the centerpiece of alcohol education programming. Many students lack similar knowledge about
substances and effects when experimenting with prescription drugs for the purpose of intoxication or sensation-seeking.
4) We may be talking about the same students.
Several of the studies do establish a correlation between the non-medical use of prescription drugs and the use of other substances and high-risk behaviors, suggesting that there may be a limited set of students who misuse and abuse a wide array of substances for a variety of purposes. The University of Michigan study found that non-medical prescription stimulant users were more likely to report use of alcohol, cigarettes, marijuana, ecstasy, cocaine and other risky behaviors.6 The NSDUH also found that among youths aged 12 to 17 who were binge drinkers, 68.5 percent also were current illicit drug users, which was higher than the rate among nondrinkers (4.3 percent).3 Data from the University of Maryland study also supports this conclusion. A clear group of students could be identified as “high sensation-seekers” who were most resistant to beliefs about prescription substance harm, and who showed tendencies across substances.18 Other studies have drawn similar conclusions. Ultimately, the data indicates that for high sensation-seekers, choice of drug may be more an issue of opportunity than preference, and that the ultimate goal of intoxication, for whatever reason, may be the dominant factor in substance use.
Luckily, high sensation-seekers are rarely hidden in the college culture. Often, these students tend to be identified by their peers as the center of most legendary drinking or drug stories or as the bane of the group’s existence. They are rarely strangers to judicial officers, though they may be unknown by student health practitioners.
5) Perceptions of use are significantly greater than actual use.
Perhaps one of the most intriguing findings from recent studies is the dramatic misperception by college students of the non-medical use of prescription drugs by their peers.
The University of Michigan found that undergraduates overestimated the prevalence of nonmedical use of prescription stimulants (70.2%) and prescription opioids (69.9%) among peers on their campus.26 The discrepancy between perceived and actual use rates is significantly Prescription Drug Abuse: Assessing the Risks and Issues Page 11 higher than student misperceptions of excessive alcohol use among their peers, which suggests that the misperception is more a reflection of cultural myth than of observed reality.
Although normative research of non-medical prescription drug use is limited to this single study, the data confirms the impact of popular culture on the belief among college students that non-medical prescription drug use is an expected and accepted “normal” behavior in college. Focus groups at the Ohio State University confirmed that students have come to accept the use of stimulants during final exams as commonplace, despite actual use figures that suggest that approximately 10% of students actually use stimulants during that time.27 Implications for Policy and Programming Given some clarified perspective on the issue, it seems appropriate to feel some concern over the non-medical use of prescription drugs by college students, particularly as an indication of increased self-medicating and pharmaceutical consumerism. Clearly, additional research is needed to better quantify the specific harms to students, the campus, and society caused by this trend, but there is regardless a need for colleges and universities to address prescription drug use along with alcohol and marijuana consumption. Yet, there are specific approaches that can and should be taken that can reduce the likelihood of prescription drug misuse.28 As with all prevention approaches, the more comprehensive and collaborative the programs have been shown in evaluation to be more successful. Therefore, it is critical that campus approaches incorporate educational, individual, and environmental strategies.
1) Limit access to prescription medications on campus Several policy approaches have been attempted to reduce access for students to prescription drugs, though no evaluation data has been collected to measure their success.
Access to prescription medications is a difficult issue to manage on college campuses, as many students come to college with legitimate diagnoses and prescriptions. Like alcohol, there is a mix of medical drug users who share space and relationships with non-medical drug users. Unlike alcohol, however, fewer campuses have established a clear policy (or have adapted their present substance policy) to include the provision or sales of prescription medications for non-medical users. While such a policy may be difficult to enforce, it is Prescription Drug Abuse: Assessing the Risks and Issues Page 12 critical that it be included in discussions of student conduct policy for new students and parents, and that a campus judicial system has created an infrastructure for addressing such cases. It is important to remember when doing so that a college campus does not have the same burden of evidence as the courts and can use reasonable assumptions to enact an appropriate and educational sanction for students who provide or sell. It is critical that such sanctions are communicated broadly across campus to increase student likelihood of consequences, which has been shown to be a deterrent.