Nonmedical use of prescription drugs in adolescents and young adults: not just a <scp>W</scp>estern phenomenon
Authors: Silvia S. Martins, Lilian A. Ghandour
Journal: World Psychiatry (2017)

Nonmedical prescription drug use, generally defined as use without a prescription or use for reasons other than what the medication is intended for, is a global concern, primarily driven by the high and rising phenomenon of nonmedical use of prescription opioids in young populations. Prescription drugs are legal and hence tend to be more easily available than most illegal drugs. Nonmedical use merits particular attention given the high degree of abuse potential1 and numerous ill-health consequences, that vary depending on the drug. Nonmedical use of prescription stimulants can lead to irregular heart rate, hypertension, cardiovascular system failure, stroke and seizures, while nonmedical use of prescription opioids can cause respiratory suppression and overdose2. Most of drug-related deaths worldwide are due to either prescription opioid or heroin overdoses. A recent review has illustrated worldwide increased rates of deaths from prescription opioids3, with the exception of Australia. In Europe, prescription opioids account for three-quarter of overdose deaths, which represent 3.5% of total deaths among 15-39 year olds. Nonmedical use of stimulants and prescription opioids among adolescents and young adults has also been linked to increased harmful use of other substances4, reporting of psychiatric symptoms, psychiatric disorders and suicidal ideation5. Despite the undisputed worldwide concern, it is important to note the variability in the prevalence/patterns of nonmedical use of prescription drugs among young people. In the US, according to the 2014 National Survey on Drug Use and Health, past-year nonmedical use of prescription drugs (opioids, stimulants, tranquilizers and sedatives) was reported by 6.2% of 12-17 year-olds and 11.8% of 18-25 year-olds, mainly driven by nonmedical use of prescription opioids, which has remained stable in the past decade despite rising trends since the late 1990s. Data from the 2012 Canadian Alcohol and Drug Use Monitoring Survey showed that 4.9% of 15-24 year olds were past-year nonmedical users of the above cited prescription drug classes. Data from the 2013 Australian National Household Survey showed an increase in nonmedical use of prescription drugs since 1998, particularly among 14-19 year olds; the 2013 past-year estimates were 4% among 14-19 year olds, and 5.8% among 20-29 year olds. While comparability is hindered by the varying methodologies, definitions, and age categorizations, data clearly supports the global concern for the nonmedical use of prescription drugs among young vulnerable populations. General household population data among young populations in other countries are not as readily available, but there is data from school-based and college-based surveys in Europe, Latin America, Asia and the Middle East. In Europe, data from 36 countries collected as part of the 2011 European School Survey Project on Alcohol and other Drugs showed that, on average, 6% of European school students (mean age of 15.8 years) reported lifetime nonmedical use of tranquilizers (data on other drug classes are unavailable). Data on high school or university students from the Middle East or Arab world indicate that nonmedical use of prescription drugs warrants closer attention. In Beirut, Lebanon, past-year nonmedical use of any prescription drugs was 21.6% among private university students, and 10% among high school students. In both populations, prescription opioids were the drugs most commonly used nonmedically. In Saudi Arabia, a recent school-based survey showed a lifetime prevalence of 7.2% for the nonmedical use of any prescription drug. In Brazil, the most recent national school-based survey, conducted in 2010, showed that the past-year prevalence of nonmedical use of prescription stimulants among middle/high school students in public and private schools was 1.6% and 2.2%, respectively. Only lifetime data on nonmedical prescription opioid use was collected (0.3% of all middle/high school students). One study from Southern China conducted in 2007-2009 revealed that 6% of the middle/high school students had tried any prescription medication nonmedically, mostly opioids, followed by cough medicine with codeine. A 2012 high school survey from Chongqing, China reported a lifetime prevalence of 11.3% for the nonmedical use of prescription opioids only. For comparison purposes, data from the 2015 US Monitoring the Future school and college-based surveys showed that 12.8% of 12th graders used any prescription drugs nonmedically. It is important to shed light on important socio-demographic differences. College-based studies exclude significant proportions of minority or low socio-economic status young adults, who are at higher risk of developing a prescription drug use disorder once they start using the drugs. Evidence on gender differences among adolescents and young adults has been mixed: some studies have found no difference; others have found a higher prevalence in males or in females6, 7. Early age of initiation of nonmedical use has been associated with higher likelihood of ill-health outcomes, including a higher probability of developing substance use disorders8. Individuals with previous nonmedical use of prescription opioids may be at greater risk of heroin use and heroin dependence9. Motives for nonmedical use also vary (i.e., to get high; to self-medicate), leading to the presence of several heterogeneous subgroups of nonmedical users that are at varying risks of other substance use10. Worldwide comparisons are hampered by the variations in the study methodologies, including definitions of nonmedical use or prescription drugs included. The impact is also different given the varied availability and cultural acceptance of the drugs worldwide. Prescription drug monitoring programs, recently implemented in the US, Canada and Australia, are not widely available globally and, where available, there is unevenness in how they operate. Today, the biggest challenge is balancing a country's need to make available prescription drugs to those in need (i.e., those with chronic pain) while simultaneously curbing diversion and nonmedical use. Pharmacists in some countries struggle between providing medical advice and service to those who cannot afford a doctor's prescription while meeting the requirements of their governmental regulations. Another challenge is controlling the top most reported sources of supply, including parents, doctors and friends, highlighting the need to target multiple sources simultaneously. The greater "social acceptance" for using these medications (versus illegal substances) and the misconception that they are "safe" may be contributing factors to their misuse. Hence, a major target for intervention is the general public, including parents and youth, who must be better informed about the negative consequences of sharing with others medications prescribed for their own ailments. Equally important is the improved training of medical practitioners and their staff to better recognize patients at potential risk of developing nonmedical use, and to consider potential alternative treatments as well as closely monitor the medications they dispense to these patients. The United Nations Office of Drugs and Crime is already assisting several governments in collecting epidemiologic data more efficiently as well as developing monitoring and training programs that ensure these drugs are available to those who need them while strictly avoiding diversion for nonmedical purposes. Silvia S. Martins1, Lilian A. Ghandour2 1Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA; 2Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon