Notably, rates of nonmedical prescription use among 12- to 17-year-olds were higher in girls than in boys for pain relievers, stimulants, and tranquilizers.1 In all other age-groups, prescription drug abuse is more prevalent among males.
Several risk factors correlate significantly with adolescent nonmedical prescription use, including mental health treatment, use of illicit drugs, female gender, and binge drinking. Self-reported lack of religiosity, high rates of family conflict, and presence of sensation-seeking behaviors are also considered risk factors.11,12
Diversion of Prescription Psychotherapeutics
Diversion, the most common means of obtaining medications for unintended purposes, encompasses a number of inappropriate or illegal activities, including selling, trading, or sharing legitimately prescribed medications. Patients trying to obtain greater quantities than would ordinarily be prescribed (for primary or secondary purposes) may resort to doctor-shopping, falsely claiming a lost prescription, seeking escalating dosing from the provider, or forgery.
In addition to the long-established routes of diversion (eg, theft, doctor-shopping, malingering), prescription exchange among teenagers is a growing trend. Opioids and other agents are increasingly available to young patients through family members, because rising numbers of prescriptions are being written. These startling increases may reflect a fear of litigation for undertreating patients' pain or a concern to score well in patient satisfaction surveys. Other possible factors are a paradigm shift in pain management, the ever-increasing use of EDs by patients with chronic pain, or influence from the pharmaceutical industry. Nevertheless, the result is a flood of available drugs complicating a system that is already fraught with abuse.
Despite the rise in prescriptions for opioids, only about 14% of those used by teenagers are prescribed for them. Most teens who abuse prescription medications obtain them from peers or family members with legitimate prescriptions. About one-third of those who use prescription opioids rely on Internet no-prescription Web sites (NPWs) or drug dealers.8
In a 2005 Web-based survey of 1,086 high school students, 49% had been prescribed a sleeping aid, sedative, stimulant, or pain medication at least once.10 Among these students, 24% (27.5% of girls; 17.4% of boys) reported having lent their prescriptions or given them to other students.10 Having their medications stolen or being forced to give them away were often cited as significant problems.
Internet NPWs offer teenagers nearly unlimited opportunities to buy psychotherapeutics privately. The Government Accountability Office estimates that some 400 Internet pharmacies (200 based overseas) were selling drugs illegally in 2003.13 Identification beyond a credit card is rarely required, and search engines facilitate purchasing: Using search terms like "no prescription vicodin," Gordon et al14 reported a hit rate of 80% to 90% for NPWs but no links to addiction help–related sites. Buying psychotherapeutics from drug dealers is less discreet but often more expensive (see Table 215,16).
Identifying and Managing Abuse and Overdose
Three drug classes account for the majority of prescription medication abuse among teenagers: opioids, stimulants, and sedative-hypnotics (see Table 31,17). Dose-response curves suggest their anticipated effects, but individual responses vary; anyone willing to take a prescribed medication for nonmedical purposes is at risk for adverse effects. The following is a brief review of presenting signs and symptoms, appropriate intervention, and long-term complications of prescription drug abuse and overdose.18
Opioids
Of the three psychotherapeutic classes mentioned, opioids are most commonly used for nonmedical purposes. This class comprises naturally derived opiates (eg, heroin, morphine, codeine), semisynthetic opioids (eg, hydrocodone, oxycodone), and synthetically made opioids (eg, fentanyl, methadone, meperidine).
After ingestion, the initial effect is relaxation and blunted response to pain. With increasing doses, drowsiness ensues, with a reduction in pulse rate and blood pressure. Other common findings include muscle flaccidity, pupillary miosis, bradypnea, and decreased bowel sounds. (NOTE: Among the opioids, meperidine does not cause miosis.) Significant overdose results in the classic presentation of central nervous system (CNS) and respiratory depression and miosis; the episode may culminate in coma, apnea, and even death.
Treatment of a patient who pre-sents with opioid overdose consists of airway and ventilatory support, with special consideration given to opioid antagonists (eg, naloxone) that competitively inhibit the binding of opioid agonists. The goal of naloxone therapy is to elicit appropriate spontaneous ventilation, not necessarily complete arousal. Precipitation of withdrawal symptoms should be avoided, and clinicians should be aware that the half-life of naloxone is relatively short (especially compared with methadone); resedation may follow initial improvement.
Oxycodone (OxyContin®) is of particular concern, in part due to its potency—and its subsequent prevalence. According to Monitoring the Future,19 a remarkable 5.3% prevalence of oxycodone use was reported in 12th graders in 2007.
Ordinarily, an 80-mg dose of oxycodone is slowly released over 12 hours, but numerous methods are used to circumvent the pill's time-release matrix; these uses are associated with high morbidity and mortality rates. Crushed oxycodone—hillbilly heroin—is immediately available for systemic absorption. Insufflation, too, results in relatively immediate effects. Slower absorption can be achieved by parachuting—a method of rolling or folding powdered or crushed drugs in toilet paper or other thin paper and ingesting it.18