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R x for Preven+onRoss Aikins, Ph.D.Stacy Andes, MA, Ed.D.American College Health Associa=on Annual Mee=ng 2011June 1, 20111

Who is with us today?• Counselor/Psychologist• Nurse Prac++oner/Physician/Nurse• Health or Peer Educator• AOD Professional• I do not see myself represented here.3

What do we know? What do we think we know? What do we need to know?LITERATURE & DATA REVIEW6

Perceived health risk*DangerousBenign*sample of 53 collegiate drug users (Aikins, 2011 in press); and MTF data (2010).8

Perceived legal risk*DangerousBenign*sample of 53 collegiate drug users (Aikins, 2011 in press)9

Cultural Context“Opera+on Ivy League”Columbia University, Dec. 2010“Opera+on Sudden Fall”SDSU, May 6, 200810

Cultural Context• U.S. consumer spending on ADHD meds increased more in 2010 than any other therapy class of pharmaceu+cal.• Na+onwide shortages reported in April 2011.11

Monitoring the Future (MTF)Provigil0.2%Ritalin1.7%2009 annual non-­‐medical use prevalence:Adderall7.9% Oxycon=n7.3%Vicodin8.4%TranquilizersBarbiturates 5.4%3.1%S=mulants Opiates Seda=ves• Limita+ons:Large, longitudinal dataset (1980 -­‐ present); stra+fies collegiate, – Prescrip+on non-­‐college drugs popula+ons surveyed by brand, e.g. “Adderall” and “Provigil” data started in 2009.• Non-­‐medical seda+ve, s+mulant, and opiate use– Adjusted drug categoriza+ons subjec+ve, occasionally dated (e.g. • Use prevalence of all substances lower among college students Benzedrine, methaqualone).EXCEPT alcohol and s+mulants– Non-­‐medical use only.12

Sources of Prescrip+on DrugsOpioids(n=787)S+mulants(n=458)Seda+ves(n=249)Sleeping meds (n=166)Peers 57.8% 67.7% 58.2% 51.2%Family 12.2% 3.1% 9.6% 17.5%Other 30.0% 29.3% 32.1% 31.3%• Random survey of 9,161 undergraduate students at large Midwestern Public Research University.McCabe & Boyd (2003)13

Sources of Prescrip+on Drugs• Peers -­‐ especially dealers, Greeks• Doctors -­‐ legi+mately, quasi-­‐legi+mately• Family• The internet -­‐ mostly ED meds• Interna+onally14

Na+onal Surveys on Drug Use & Health (NSDUH)• Life+me, past-­‐year and past-­‐month non-­‐medical psychotherapeu+c (tranquilizers, seda+ves, and s+mulants and pain relievers).• Life+me use of all specific prescrip+on drug use (e.g., Valium, Codeine).15

Most Prevalent Substances Used in the Past Month by U.S. Residents, % by Age Group (2008)70.0AgeAlcoholTobacco52.5 12 to 1718 to 25> 2635.017.50Marijuana Psychotherapeu=csNSDUH (2009)16

Drug Abuse Warning Network (DAWN)• 741,000 emergency room visits involved non-­‐medical prescrip+on, OTC drug and/or supplement use.• 54% involved polydrug use.• Rates did not vary between males and females.DAWN (2006)17

Drug Abuse Warning Network (DAWN)• The es+mated number of emergency department (ED) visits involving nonmedical use of narco=c pain relievers rose from 144,644 in 2004, to 305,885 in 2008, an increase of 111%. • ED visits involving oxycodone products, hydrocodone products, and methadone—the three most frequently listed narco+c pain relievers in each year—increased 152%, 123%, and 73%, respec+vely, between 2004 and 2008. • While ED visits involving hydromorphone products showed the largest increase between 2004 and 2008 (259%), far fewer visits involved these products.DAWN (2010)18

Drug Abuse Warning Network (DAWN)• Of the es+mated 188,981 alcohol-­‐related emergency department (ED) visits made by pa+ents aged 12 to 20 in 2008, 70% involved alcohol only, and 30% involved alcohol in combina=on with other drugs.• Illicit drug use was indicated in more than two thirds (68.4%), and pharmaceu=cal drugs were involved in more than one half (55.1%) of ED visits involving alcohol in combina=on with other drugs among pa+ents aged 12 to 20.DAWN (2011)19

Na+onal College Health Assessment-­‐II Annual Use Data20%15%10%An+depressantsEDPainkillersSeda+vesS+mulantsMore than One5%0%Fall08 Spr09 Fall09 Spr10 Fall1020

The Research Confirms• Non-­‐medical prescrip+on drug use has increased five +mes over between 1999 and 2005.• Life+me prevalence of non-­‐medical psycho-­‐s+mulant use = 6.9%• Past-­‐year prevalence of non-­‐medical psycho-­‐s+mulant use = 4.1%(Arria et al., 2005; Johnston & O’Malley, 2003; CASA, 2007; McCabe et al., 2005)21

The Risk Profile• White• Male• Greek-­‐affiliated• Lower GPA• Higher rates noted at Northeast ins+tu+ons of higher educa+on with higher admissions standards (CASA, 2007; McCabe et al., 2005)22

The College Life StudyhQp://

Perceived Harmfulness & Non-­‐MedicalPrescrip+on Drug Use50%38%S=mulantsAnalgesics25%13%0%No Risk Slight Risk Moderate Risk Great RiskArria, Caldeira, Vincent, O’Grady & Wish, 2008)24

How difficult is it obtain prescrip+on medica+ons on campus?100%75%50%25%0%10%13%19%8%7%7%16%12%23%13%18%30%23%29%28%19%15%9%Stimulants Analgesics TranquilizersCan't SayProbably ImpossibleVery DifficultFairly DifficultFairly EasyVery EasyCollege Life Study, Arria, personal communicaZon (2008)25

Linking Non-­‐Medical Use of Prescrip+on Drugs with Illicit Other Drug UseNonmedical UseRISK FOR ILLICIT DRUG USEMedical OveruseMedically Supervised UseRISK FOR ILLICIT DRUG USERISK FOR ILLICIT DRUG USE(Arria, personal communicaZon, 2008; McCabe, 2008)26

Linking Non-­‐Medical Use of Adderall® with Past Year Other Drug Use Among Full-­‐Time College Students80%60%Used Adderall non-­‐medically?YesNo40%20%0%MarijuanaPain RelieversHallucinogensCocaineTranquilizersEcstasyNSDUH (2007 & 2008)27

Emerging Research• In one study 27% of medicated college students were approached to divert medica+on; 54% of those cases involved s=mulant solicita+on (McCabe et al., 2006). Another reported that ADHD medica+ons were the most diverted prescrip+on medica+on (61.7%) followed by prescrip+on analgesics (35.1% diversion rate; Garnier et al., 2010).• Many students see s+mulant medica+ons as an academic performance enhancing drug (PED). Yet, non-­‐medical prescrip+on drug use is associated with lower academic performance. How can we create a compelling argument for students that effec+vely communicates what the research is telling us? (Arria & DuPont, 2010; Aikins, in press).28

Emerging Research• Non-­‐medical use as social use. Non-­‐medical use is a social ac+vity that involves sharing drugs and taking combina+ons of drugs with friends (and provided by friends; Rozenbroek & Rothstein, 2011).• Students diagnosed with ADHD demonstrate greater nega+ve expectancies, experience more hyperac+vity symptoms and score higher on characteris+cs of sensa+on-­‐seeking (Jardin, Looby & Earleywine, 2011).29

Emerging Research• Non-­‐medical users of prescrip+on s+mulants and analgesics had significantly lower GPAs in high school, and in college, skipped 21% of their college classes. Non-­‐medical users of prescrip+on drugs in high school comprise a high-­‐risk group of first-­‐year college students (Arria et al., 2010).• Given the opportunity to use, high perceived harmfulness and high sensa=on-­‐seeking are dis+nguishing characteris+cs between the non-­‐medical user and the non-­‐user (Arria et al., 2010). 30

Emerging Research• Non-­‐medical prescrip=on analgesic use and concurrent alcohol consump=on is prevalent among college student users. Consistent DAWN trends demonstrate the same concern with polydrug use (Garnier et al., 2010).• The role of the prescribing provider is becoming even more pronounced. Providers managing students with ADHD need to conduct the appropriate screenings, use informed consent, and adopt monitoring strategies to prevent diversion (Arria & DuPont, 2010).31

The Data DilemmaThere is a growing body of evidence regarding college students and non-­‐medical prescrip+on drug use. More and more campuses are beginning to assess and evaluate the problem. As a result, many studies are based on convenience samples and many focus their aven+on on prescrip+on s+mulant use.32

Doctoral Research• Applied disserta+on research on non-­‐medical prescrip+on drug use at four Northeast ins+tu+ons of higher educa+on.• N= 3,264 students• NCHA-­‐II survey data collec+on (Spring 2009)• Iden+fica+on of risk and protec+ve factors related to gender, rela+onship status, ethnicity, GPA, and other drug use.Andes (2010)33

Doctoral Research• There were a number of limita=ons associated with my research:– a largely White sample;– varying survey administra=on +me periods (ranging from February, March and April 2009); – varying campus sample sizes. Andes (2010)36

Doctoral Research• Qualita+ve, 1 on 1, semi-­‐structured interviews with 53 students at an elite West Coast University.– Mostly Rx s+mulant users– Some “func+onal” polydrug use (MJ, salvia, n = 11)• Focus on use mo+va+ons, use habits, percep+ons of health, risk/benefit, ethics.Aikins (2011, in press); Aikins (2011, in progress).37

Doctoral Research• S+mulants increase “perceived self-­efficacy” (Bandura, 1997).– Psychological dependence; “academic reliance”– Some students change curricular plans, procras+na+on/study habits• Perceived ubiquity, ease of access• Mostly “func+onal” use, seldom recrea+onallyAikins (2011, in press); Aikins (2011, in progress).38

“Superhero stories”• S+mulants increase “perceived self-­efficacy” (Bandura, 1997).• When I first took it, it was amazing. It was incredible how well I studied. And then I’d have to try a livle harder to keep the focus ayer a while. – Isabel • It turned me from like a C+ paper without it, to a A-­‐, B+ paper. – Ryan• I didn’t study at all un+l the last two days and I got an A, so it’s kind of like I didn’t have to study for those four or five weeks, and then in two days I was fine. – Zoey• When it first hits me, for the first maybe three to four hours is when it's most intense, when it's most like I'm focused, I can do anything. – Vinny Aikins (2011, in press); Aikins (2011, in progress).39

Psychological Dependence“I had a friend whose GPA was high. He was always like the valedictorian. He’s a good friend of mine … he's a very smart guy, but he started to get like, literally dependent on Adderall. … The guy has like a 3.95 GPA in some of the hardest classes, but he can't pick up a newspaper without taking Adderall. He's not prescribed it or anything like that. AnyZme he wants to study or anything, he's dependent on Adderall. I feel like it's unfortunate, because he's a really smart guy, but his brain needs something else. His doses have increased, I've seen in the past couple years. … So I don't know if it's going to backfire on him, and it's going to be years off his life, or – I'm sure, right now, it's going to be worth it, because he's going to get into one of the best schools, so yeah. I don't really know.” -­‐ KarlAikins (2011, in press); Aikins (2011, in progress).40

Psychological Dependence“I actually know some people who've become dependent on it, not so much because it's addicZve, but just because they're like, "Wow. I accomplished so much in one night," and then they get into this cycle where every midterms and every finals, they just start taking Adderall. … they lose the ability to study without it, because like your mind just – it shapes itself from your experiences.” -­‐ DavidAikins (2011, in press); Aikins (2011, in progress).41

Doctoral ResearchAmanda: I heard from my friends that they took Adderall. This one kid who is a pre-­‐med science major, like a really good kid. Didn’t drink or anything. He’s like, yeah, to study I take Adderall. And I was like, okay, well I guess it’s not that bad. So then I got some from him. … I had heard of it before but I wasn’t really into taking it unDl I realized that I had a few friends that were taking it. And then my one friend who was a good kid, you know, he wasn’t afraid to take it.Interviewer: What do you mean like good kid?Amanda: I mean, he never really parDed and smoked and stuff … It’s not like he did drugs all the Dme … And he sDll took Adderall.Interviewer: And that was sort of comfor+ng?Amanda: Yeah. I was like, all right, well, I do those other things so I guess it’s okay.42

Doctoral Research• Many students are self-­‐medica+ng– Licit/illicit use is not dichotomous– Generally knowledgable, misinforma+on persists:• [If] I take [Adderall], and then I get really focused that, means I don't have ADHD, right? – Eddie• I heard that it had reverse effects on people who don’t have ADD, that it could oyen make you more prone to distrac+on. – Jessica• I just read some stuff like [Adderall] kills brain cells and stuff ... On the Internet … I don't know if it's true or not. – Minh43

Doctoral Research• S+gmas not a barrier to use s+mulants– Unique appeal problema+zes preven+on• I think it's seen in a much more posiZve light than other, especially illegal drugs, because there is a perceived fit, and it's very academic. Whereas, illegal drugs, a lot of people don't see any benefit to those. – Kendall• I think [opioids] are perceived as worse just because of the purposes behind it. Like if you’re taking Adderall to help you study, that’s one thing, but if you’re just trying to take all these crazy prescripZon drugs and drink and mix – that can get really bad, and if you’re just doing that to get really messed up, then that’s different. – Jenny44

Doctoral Research45

Doctoral Research• ADHD iden+ty confusion (new DSM soon)• Diversion is lucra+ve, rela+vely low-­‐risk– It’s cheaper at the beginning of the quarter. Midterms and finals – the quotes go up … like $5-­‐7, turns into $10. It’s a seller’s market. -­‐ Joe– Yeah, I guQed a lot of people. Because they’re calling me at 1 a.m.. “I got a midterm tomorrow. I haven’t studied all quarter. I been to class once. I need it. Come on.” I remember selling a 20 [mg] for $30.00 one Zme. And I sold 3 of them. -­‐ Mike46

“Mike” on diversionInterviewer: Was he or she relieved? Mike: Yeah. Actually it was a girl. So then I just present it to them like, “This is a substance – I’ve sold a lot of different things. Is it worth $90 to you to get a B or an A, or C-­‐, B on your way to med school or law school or your honors? Is it worth $90 to you for a class?” Interviewer: $90.00? Mike: Yeah. Interviewer: For how many pills? Mike: For three. For three twenDes [mg]. For a class that our tuiDon used to be $2,600.00. It jumped this year but – “So you’re taking three classes for $2,600.00 but it’s over $800.00 a class. So is it worth $100.00 for you to not burn that other $800.00 on a grade?” “Well, when you put it like that.” They just get gu[ed, ‘cause they need it. 47

Doctoral Research• Limita+ons:– Rela+vely small sample size– Only drug users enrolled– Sample more representa+ve of illicit users (41/53)– Single protocol used across mul+ple substances• Less applicable/relevant for MJ, salvia, etc.– Would have liked to find collegiate users of beta-­blockers, ampakines.Aikins (2011, in press); Aikins (2011, in progress).48

Doctoral Research• Key ques+ons for a cap+ve audience:1. Are alleged cogni+ve neuroenhancers an academic integrity issue? Is it “chea+ng”?2. Is access to alleged “nootropics” an issue of social equality?3. What messages are we prepared to convey to students if leading bioethicists/researchers con+nue to find empirical performance gains associated with “responsible” nootropic use? (Greely et al., 2008; Riis et al., 2008)4. Can illicit use be “responsible”?49

What are we asking? How are we asking it? What should we be asking?DATA COLLECTION50

What is your primary source of data on non-­‐medical prescrip+on drug use?• Na+onal surveys (e.g., NSDUH, MTF)• College student health surveys (e.g., NCHA, Core)• Homegrown college student surveys • College student surveys (e.g., NSSE, CIRP)• Focus groups• Other (e.g., DAWN, The College Life Study)51

Are You Pu ng All of Your Eggsin One Basket?• Are you relying solely on na+onal data sources for your students’ other drug use?• Are you complemen+ng na+onal data with other sources of data on campus?• Are you asking more than “have you ever…?” ques+ons?52

Can You Answer These Ques+ons About Your Students?• How many first year students are coming to campus with prescribed medica+on(s)?• How many +mes have your students non-­‐medically used prescrip+on drugs in the past 12 months/past month?• How frequently are your students being solicited for their medica+on(s)? sharing their medica+on(s)?• How do your students perceive non-­‐medical prescrip+on drug use on your campus?• How accurate are their percep+ons?53

Can You Answer These Ques+ons About Your Students?• How difficult is it for your student(s) to obtain a prescrip+on medica+on without a prescrip+on on your campus?• How many of your students perceive non-­‐medical prescrip+on drug use as harmful? Illegal with clear consequences?• How many alcohol and other drug-­‐related incidents on and off-­‐campus involve prescrip+on drug use?54

Have You Considered…• Focus groups• Audience response system or “clicker” technology• Guerilla surveying• Research or capstone projects• Online & PDA surveying tools• First year student & senior surveys• Health records & clinical notes• Social networking site scans(Arria & Wish, 2010;Arria & DuPont, 2010)55

Just One Simple Search Can Uncover a Goldmine!56

Just One Simple Search Can Uncover a Goldmine!57

What are we doing about it? What should we be doing about it?PROMISING PRACTICES58

3-­‐in-­‐1 Framework• Research strongly supports use of comprehensive, integrated programs• Educa+on alone = behavior change• Components should target:– individual at-­‐risk and dependent students– popula+on as a whole– surrounding community59

Villanova UniversityToolkit includes:• Execu+ve Summary of the data• Data Sources & Tools• Primary, Secondary & Ter+aryStrategies• Supplemental Handouts on:-­‐Commonly used medicines, misuse & interac+ons-­‐Time, stress, & study strategies-­‐Refusal strategies for studentsprescribed medica+on(s)-­‐Ques+ons to ask a healthcare provider-­‐Smart disposal strategies60


Genera+on R xhQp://­‐rx/62

University of Washington63

University of WashingtonhQp://

University of Washington65

University of­‐informaZon/otc-­‐prescripZon-­‐drug-­‐abuse/signs-­‐prescripZon-­‐drug-­‐abuse.aspx66

University of WashingtonhQp://­‐talk-­‐friend.aspx67

Na+onal Council on Pa+ent Informa+on & Educa+on (NCPIE)

USC “Trojans Care for Trojans”69

Print Resources70

Web Resources• Alcohol and Alcohol Problems Science Database • Center for Substance Abuse Research (CESAR)• Higher Educa+on Center – Recently Published• Drug Abuse Warning Network (DAWN)• Project Cork• Substance Abuse and Mental Health Services Administra+on (SAMHSA)samhsa.gov71

Professional Associa+on Resources• ACHA, Alcohol, Tobacco and Other Drug• ACPA Commission for Alcohol and Other Drug Issues• NASPA Alcohol and Other Drug Knowledge• The

Ques+ons? Comments?Ross Aikins, Ph.D.UCLA Graduate School of Educa+on & Informa+on Studiesraikins@ucla.edu310.995.1915Stacy Andes, MA, Ed.D.stacy.andes@villanova.edu610.519.7409For on “Toolkit” on right-­‐hand side73

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