How to prevent misuse of psychotropics among college students

Many college students suffer from mental illness (Table 1),¹ which can have a negative impact on academic performance. Although psychotropic medications are an important part of treat­ment for many college students, the potential for misuse always is present. Drug misuse occurs when patients use medications for reasons inconsistent with legal or medical guidelines.² For example, patients may take a medica­tion that has not been prescribed for them or in a manner that is inconsis­tent with the prescriber’s instructions, including administration with other substances.³

Misuse of psychotropic drugs is prevalent among college students. A study of 14,175 students from 26 campuses reported that 14.7% of students taking a psychotropic are doing so without a prescription, including stimu­lants (52.6%), anxiolytics (38.4%), and antidepressants (17.4%).⁴ Another study states that more than one-third of responders reported misuse of >1 class of medication.⁵

Psychotropic misuse is concerning because it increases the risk of adverse events. Nearly one-half of medication errors are associated with writing and dispensing the prescription, which means that prescribers can work to reduce these errors.⁶ However, nonadherence, prescription misuse, and failure to disclose use of over-the-counter drugs, illicit drugs, and herbal products makes preventing most adverse events difficult, if not impossible, for prescribers.^7,8

Psychotropic drug misuse among college students is highly variable and unpredictable. Students misuse medications, including stimulants, ben­zodiazepines, and antidepressants, for a variety of reasons, such as study enhancement, experimentation, intoxication, self-medication, relaxation, and stress management.⁸ One survey reported that >70% of students taking a psychotropic medication took it with alcohol or another illicit drug.⁹

However, <20% of those using a psy­chotropic medication with alcohol or other illicit drugs told their health care provider(s),⁹ making it impossible for cli­nicians to predict a patient’s risk of drug− drug interactions and subsequent adverse events. Additionally, additive effects could occur¹⁰ and changes in a patient’s presenta­tion could be caused by a reaction to a com­bination of medications, rather than a new symptom of mental illness.

This article will examine common issues associated with drug misuse among col­lege-age students and review prevention strategies (Table 2).

Stimulants
Stimulants have the highest rate of diver­sion; 61.7% of college students prescribed stimulants have shared or sold their medi­cation.¹¹ A survey of 115 students from 2 universities reported that the most common reason for stimulant misuse was to enhance academic performance.¹² The same survey showed that some students take stimulants with Cannabis (17%) and alcohol (30%).¹² As a result, in addition to lowering grade point average (GPA) and other academic difficul­ties,¹³ students misusing stimulants are at risk of drug interactions.¹⁴

It is critical to ascertain the route of drug administration, because non-oral routes, including crushing then snorting or inject­ing, are associated with additional health concerns, such as accidental death or blood-borne illnesses.^15,16 Cardiac adverse effects of stimulants include hypertension, vasospasm, tachycardia, and dysrhythmia; psychiatric and other effects include sero­tonin syndrome, hallucinations, anxiety, paranoia, seizures, tics, hyperthermia, and tremor.¹⁷ Health care providers prescrib­ing or caring for people taking a stimulant should monitor for these potential effects.

The risk of switch to mania might not be apparent to those who prescribe stimulants or to young people who take non-prescribed stimulants for academic enhancement or to achieve medication-induced euphoria. Adolescent stimulant use is associated with symptoms of early-onset bipolar disorder in patients who have attention-deficit/ hyperactivity disorder (ADHD) and undi­agnosed bipolarity.¹⁸

The cardiovascular risk associated with stimulant use is debatable. Although sev­eral studies have been conducted,^19-21 meth­odological factors limit their applicability. To minimize potential risks, several precau­tions should be taken before prescribing a stimulant to treat ADHD.

First, obtain a detailed personal and family medical history, asking about pos­sible cardiovascular disease. Second, care­fully scrutinize the patient’s cardiovascular system during the physical exam. Third, consider additional testing, such as an elec­trocardiogram, if the patient’s history or physical exam indicates possible risk.²²

As a prescriber, you should be aware of the prevalence of stimulant use among students with and without ADHD, includ­ing those who could be feigning ADHD symptoms.¹⁵ Diversion could occur through sharing medications or selling them to friends and family.¹¹ It also is possible that these medications may be used with other illicit substances, such as Cannabis, ecstasy, cocaine, and opiates.²³ Students also could misuse stimulants by taking more than the prescribed dosage.²⁴

Risk factors for misuse of stimulants include: heavy alcohol use, previous illicit drug use, white race, fraternity or sorority membership, low GPA, increased hyperac­tivity symptoms, and attendance at a com­petitive college or university.^25-27

Benzodiazepines
Misuse of benzodiazepine is a significant component of prescription drug abuse and often occurs with other medications and alcohol.²⁸ Additional methods of mis­use include increased dosage and non-oral routes of administration.²⁹

A 2001 national survey reported that 7.8% of college students have misused benzodiaz­epines.²³ Common characteristics of benzo­diazepine abusers include young age, male sex, personality characteristics of impulsiv­ity and hopelessness, and abuse of other drugs, including cocaine and methadone.^28,29