Prescription drug misuse has become a common issue in the past few years, especially for adolescents and young adults. Recent evidence shows an increase in misuse in both age groups. In 2017, the United States Government documented that 12% of teenagers aged 12–17 had misused prescription drugs at least once in their lifetime, which was an increase of 4% compared with 2004 [1,2]. Prescription drug misuse has also been correlated with illicit drug use , decline in academic performance [4,5], future delinquency , and several mental disorders  such as depression, anxiety, and suicidal ideation [7–9]. It can lead to quality of life impairment. The relationship between prescription drug misuse and its impacts require further elucidation. However, the pharmacological actions of these medications play an important role, as the study by Grattan and colleagues , which links prescription opioid use to depression, has pointed out.
This review examines recent studies on prescription drug misuse, especially among adolescents and young adults. The aim of this review is to inform and alert clinicians, researchers, government officials, and general population of the importance of this problem. Special attention is needed to this age group because it is a phase of transition, with identity crisis and role confusion often occurring, which may increase the likelihood of prescription drug misuse . Through this review, the impacts of prescription drug misuse will be highlighted to help the development of interventions to address this problem comprehensively and effectively.
Prescription drug misuse has many definitions, such as: any form of medication-taking action in a way other than prescribed, whether related to dosage or manner of usage; when someone is using someone else's prescription even if it is intended to alleviate a legitimate medical symptom; or when someone is taking a medication to feel euphoria or to ‘get high’ . A composite definition, usually having a negative connotation, is the use of either one of four prescription drugs categories (opioids, tranquilizers, stimulants, and sedatives) not of one's own prescription or for the experience or feeling caused by the drugs .
More serious abuse of prescribed drugs can change a person's feelings, thoughts, and behaviour, and the affected individual may not understand or take into consideration the damage caused by the physical and mental effects. The person who abuses a substance can develop tolerance (more of the substance is needed to achieve the same effect ) and dependence, and this is referred to as a substance dependence syndrome or substance addiction.
Prescription drug misuse has become a global issue. In 2017, about 18 million people worldwide misused prescription drugs, with a higher prevalence in adolescents and young adults. As noted above, US data show that 12% of teenagers have misused prescription drugs at least once in their lifetime [1,2]. This prevalence is much higher than in people in older age groups . A US report from 2010 found the prevalence among young adults of prescription drug misuse during the previous month was 6.3%, three times higher than in adults aged 26 or more . A study conducted in one of the largest universities in Iran found that almost 5% of all students misused prescription drugs at least three times a week, and almost all of those students were aged 25 or below . Among adolescents and young adults across China, the prevalence of prescription drug misuse was twice as high as that of illicit drug abuse, and contrary to prescription drug misuse, illicit drug abuse in teenagers and college students is actually decreasing over time [17▪].
Worldwide, opioids remain the most highly misused prescription drugs [11,18]. In the United States, the number of people who misused opioid analgesics in 2017 was as high as 2 million , whereas in Europe, between the year 2005 and 2010, nearly 40% of all drug use comprised tranquilizer and sedative misuse . Similar findings are found in Asian countries, mostly in South Asian countries. Prescription drugs misuse comprises 12.1% of addictions in India and 22% of entire recreational drug use in Bhutan [20,21]. Southeast Asian studies are still a rarity but shows similar results. In Singapore, strict laws regulate substance usage including illegal and prescription drugs, with one of the reasons being the previous frequent use of opioids. A study in Singapore found that methadone (45.2%), morphine (38.1%), oxycodone (23.8%), and fentanyl (9.5%) were the most prescribed pain medications for chronic noncancer pain . In a 2013 study involving 100 detainees in a drug detention centre in Malaysia, 95% had opioid dependence, predominantly of illicit opioids, prior to admission . Opioid misuse was more likely reported in men especially with current tobacco, marijuana, and alcohol use .
Dextromethorphan (referred to DXM or DMP in Indonesia) is a common drug which is readily available. In therapeutic doses, DMP can be safely used as an antitussive (cough suppressant) drug or in anticold preparations. In supra-therapeutic doses, this substance can elicit psychoactive effects such as calming, dissociating, euphoric, and recreational effects. The main reason for dextromethorphan misuse in 53.4% young adolescents is recreational use [25▪].
Trihexyphenidyl has also been reported to be misused by some patients. Trihexyphenidyl is included in anticholinergic medications that are routinely used to ameliorate extrapyramidal symptoms in patients who receive antipsychotic medications. A sensation of relaxation, mood elevation, stimulation, or pleasurable sensations can be obtained after an increase of dosage. In 2000, the prevalence of anticholinergic misuse was 34% in 50 patients with chronic psychosis and trihexyphenidyl was the most common anticholinergic associated with this problem because of its psychoactive effects .
Antidepressants are also misused, though studies of the tricyclic group such as amitriptyline are limited and outdated. Most reported cases of antidepressant misuse occur in individuals with comorbid substance use and mood disorders. The most common motivation for abuse, across all classes of antidepressants, is to achieve a psychostimulant-like effect, including a ‘high’ or euphoria. Cohen et al. surveyed 46 individuals enrolled in a methadone maintenance programme and found that 25% reported taking amitriptyline purposely to achieve euphoria.
RISK FACTORS AND PROTECTIVE FACTORS
Many factors contribute to substance use in general and prescription drug misuse in particular. These factors can be simply divided into four levels: the individual level which consists of factors that are unique to the individual; relationship level which includes the individual's social circle; the community level including schools, workplaces, and neighbourhoods; and the societal level, which includes cultural norms and policies .
Previous studies have shown a wide array of individual factors which may contribute to substance misuse in general. At the individual level, mental health status is a risk factor for misuse of prescription drugs. A diagnosis of depression increased the likelihood of prescription opioid misuse in teenagers aged 12–17 . In homeless youths, a history of admission to a psychiatric ward was related to nonfatal prescription drug overdose, and prescription drug misuse was related to experiencing suicidal ideation [30,31]. Moreover, a diagnosis of antisocial personality disorder and posttraumatic stress disorder are risk factors for past-year prescription opioid misuse in young adults who inject drugs . Prescription drug misuse is also related to illicit drug abuse. Based on data between 2013 and 2017 in Singapore, more than 40% of all drug users who were seeking treatment were also involved with prescription drugs . The use of illicit substance correlates with prescription drug misuse in homeless youths, and this also applies for nonfatal prescription drug overdoses . In teenagers, the use of other substances during the past month is related to prescription opioid misuse . Particularly, past-year alcohol and marijuana use were risk factors for prescription opioid and stimulant misuse . Regarding education, individuals who had a higher commitment to excel at school or who had a 4-year college degree were found to have a lower likelihood of misusing prescription drugs, particularly opioids and stimulants [33,34].
An individual's motivation for misusing prescription drugs is also an important matter. In general, motives for misusing prescription drugs fall into two categories: recreational or academic motives . Recreational motives include motives related to partying, experimenting, getting ‘high’, and other similar purposes, whereas academic motives include all motives related to increasing personal capacity to achieve higher academic performance. Both motives can occur in adolescents and youths and it is important to distinguish both correctly to give each case an appropriate approach. A recent study found that almost half of all misusers were using prescription drugs to get ‘high’ . Moreover, directed by recreational motives, the misuse of one type of prescription drug can lead to the use of another substance. For example, misusing prescription stimulants to counteract the depressant effect of alcohol to prolong ‘party-time’ is a practice which can be found among students . Hence, the prevalence of concurrent use of prescription stimulants and alcohol amongst stimulant misusers reached over 50% .
Misusing drugs for academic purposes is more frequently found among college students. Around 60% of them misuse drugs to enhance their concentration in studying or to support their academic performance [38,39]. This is also an issue in medical students in which the misuse of drugs was highly motivated by self-treatment reasons [40▪]. Almost all of opioid misusers in the second-largest medical school in Greece reported misusing opioids to alleviate pain and to help them sleep [40▪]. Moreover, over 70% of all tranquilizers and sedative misusers were motivated by the anxiety-reducing and sleep-promoting effects of prescription drugs [40▪]. The highlight was that amongst prescription stimulant misusers, all of them reported misusing to aid concentration and none for recreational purposes, although the number of stimulant misusers was much smaller than opioid misusers [40▪].
Individual's relationships and social circle
Related to the parental side, parents who are indulgent to their teenagers’ attitudes toward drugs increase the likelihood of prescription drug misuse of their children . Regarding household and family members, when someone in the household becomes the first source of stimulants, it increases the likelihood of prescription stimulant misuse. When a child witnesses a family member overdosed at least once in their lifetime, it increases the likelihood of prescription opioid overdose in youth aged 16–25 [30,41]. Among 41.6% women who misuse opioids, the most common source of prescription opioids was the parent .
On the relationship level, having unprotected sex was related to prescription drug misuse in homeless youth , whereas experiencing childhood sexual abuse is a risk factor for adolescents and youths to initiate tranquilizer misuse .
At the societal level, teenagers who live in an urban environment or move around three or more times in the past year are prone to prescription opioid misuse . Students who live in a community which has firm norms against drug use have a lower likelihood of developing prescription drug use and misuse . In lesbian, gay, bisexual, and transgender students, having an organization which supports the alliance of gay and straight students in school also lowers the likelihood of them misusing opioids and stimulants . Finally, at the societal level, individuals (aged 16–25) who belong to a lower social class during adolescence are more prone to nonfatal prescription drug overdose .
Especially in adolescence and young adulthood, there is one important factor which is often overlooked, that is the community factor. Peers have a big influence on a teenager's and young adult's life, in a constructive or negative way. Through modelling of substance use, provision of drugs, and direct pressure to use drugs by peers, adolescents, and young adults are put at risk of using substances . Contrary, social-isolation (or lack of peer connections) can also become a risk factor for substance use. Theoretically, social connection is needed for an individual to feel a sense of belonging, purpose, and meaning . In adolescents, those are the key points of constructing an identity. Substances may be a means for individuals to reach that sense of having identity and belonging to something meaningful, especially if they affiliate in groups which encourage them to use substances. Moreover, substance use can be seen as a way to highly value the said social group and their socially conformed identity . This argument can be implemented especially in adolescents who are in the state of psychosocial crisis of ‘identity vs. role confusion’ according to psychosocial developmental theory by Erik Erikson .
The role of peers and social networks are inseparable from adolescents and young adults’ daily lives, and also found to be related to prescription drug misuse. Greater prescription drug misuse by peers, greater peers’ favourable attitudes toward substance abuse, greater substance abuse or use by peers are all risk factors for prescription drug misuse in adolescents [31,34,47]. Teenagers and university students who affiliate with ‘Greek’ organizations, or at the other end, have weaker social bonds, are more prone to misuse prescription drugs [29,48]. The most common source of prescription opioids in 60% of men is someone from school, especially classmates. Therefore, screening for substance abuse or illicit drugs might be an effective strategy in combating opioid misuse problems .
Apart from the risk factors, there are also protective factors which lessen the likelihood of an adolescent or youth misusing prescription drugs or which decrease the negative impact of prescription drug misuse . Greater parental disapproval toward prescription drug misuse and having a stronger parental bond are both protective factors for misuse [35,48]. Based on Egan et al. in 2019, parental disapproval had a significant impact on decreasing the likelihood of opioid misuse in women whereas peer norms were effective for both genders.
As mentioned earlier, prescription drug misuse is a serious problem. Beside its harmful effects, prescription drug misuse often co-occurs with other issues. As mentioned earlier, prescription drug misuse is correlated with illicit drug use , decline in academic performance [4,5], future delinquency , and several mental issues such as depression, anxiety, and suicidal ideation [7–9].
Prescription drug misuse is associated with several mental issues, such as depression and anxiety [7–9]. In the 2018 study conducted in Singapore, the prevalence of psychiatric comorbidity in the prescribed drug abusers reached 48.1% with mood disorders (20%) and adjustment disorders (10.5%) being the most prevalent mental issues . Grattan et al. showed that prescription opioid misuse is correlated with depression. Correspondingly, tranquilizer and sedative misuse are also related to mental health disorders. Becker et al. found that nonmedical misuse of tranquilizers and sedatives was associated with panic disorder [adjusted odds ratio (AOR): 1.3; confidence interval (CI) 95%: 1.0–1.6]. Moreover, stimulant misuse is also related to depressive symptoms and anxiety traits .
It is difficult to determine the causal relationship of prescription drug misuse and mental issues. Grattan et al. argued that prescription opioid misuse might cause depression because of its effects of increasing apathy and lethargy. On the contrary, opioids’ properties as anxiolytics and mood alternator may lead to misuse in patient with depression . Furthermore, unhealthy weight control behaviour such as self-induced vomiting, inappropriate medication (diuretic, laxative, or diet pills) usage, and poor diet results in a five times higher risk for stimulant prescription misuse, especially in teenage girls . Therefore, further evaluation and longitudinal studies are needed to establish the causal relationship between opioid misuse and mental issues.
Ashrafioun et al. found that prescription opioid misuse is related to suicidal ideation, and a higher frequency of opioid misuse was associated with suicide planning and suicide attempts based on National Survey of Drug Use and Health in 2014.
Academic issues usually become motives for college students to use nonmedical prescription drugs, especially stimulants. Prescription stimulants are believed to increase academic performance. On the contrary, several studies showed that prescription stimulant misuse might have negative effects on academic performance. First, compared to nonmedical prescription stimulant users, college students with no history of stimulant usage had higher Grade Point Average scores [4,5]. Second, nonmedical prescription stimulant users skipped class more frequent and spent less time for studying .
Prescription drug misuse is associated with delinquency. One study by Ford et al. focusing on prescription drug misuse and delinquency among adolescents showed that they were significantly correlated. Moreover, prescription drug misuse is also related to arrest history . Prescription drug misuse might be correlated with delinquency among adolescents because of similar mechanisms as are seen with abuse of other psychoactive (including illicit) substances. First, they might have a reciprocal relationship. Substance use might provoke delinquency by lowering inhibitions against criminal acts, whereas adolescents might commit crime to obtain money for buying substances. Second, they might co-occur because of the shared risk factor, for instances disrupted family environment, parental substance use, and novelty-seeking personality. Third, the influence of peer group might result in their co-occurrence. Finally, delinquency and substance abuse might be parts of delayed developmental signs . Therefore, prescription drug misuse may predict future delinquency, especially among adolescence.
Association with illicit drug use
The prevalence of co-occurring prescription drug misuse and illicit substance use is very high . A multivariate analysis revealed that prescription drug misuse is correlated with alcohol use (AOR: 5.29; CI 95%: 2.65–10.56) and illicit substance use (odds ratio [OR]: 3.22; CI 95%: 1.3–7.95) . Moreover, marijuana, cocaine, and heroin use are linked to prescription drug misuse . In the last few years, the popularity of alcohol mixed energy drink consumption has increased. Based on a study from Khan et al. in 2015, the use of tobacco and marijuana were significantly correlated with prescription stimulant misuse. Therefore, evaluation of other substance use is imperative to give a comprehensive treatment.
Prevention and treatment for prescription drug misuse are extremely challenging. First, these drugs are very important for some treatments (opioids for cancer pain, sedatives for anxiety) therefore their usage cannot be prohibited but restricted only. This condition causes a burden for the monitoring of prescription drug usage compared to other illicit drugs. Second, treatment for prescription drug misuse varies between study participants and drugs. For instance, opioid misuse may respond to methadone treatment whereas stimulant misuse may respond to behavioural therapy . Therefore, collaboration between the government, clinicians, pharmacists, patients, and patients’ family is mandatory to combat prescription drug misuse .
Prevention is the most important step to overcome prescription drug misuse. A prevention programme should consist of monitoring and initial assessment . The United States has already implemented an electronic database to monitor the usage of prescription drugs. This database is called the Prescription Drug Monitoring Program (PDMP). Based on a review including 11 relevant articles published between 2000 and 2016, the purpose of PDMPs was to increase the reporting and monitoring of prescription drug usage, subsequently reducing prescriptions by clinicians and decreasing opportunity to misuse drugs, and finally suppressing the frequency of negative consequences . However, studies about PDMPs and its benefit are still varied . In spite of their variation, several studies show that PDMPs benefits in helping clinicians communicate with patients. Through patients’ prescription histories, providers are helped in verifying patients’ current prescriptions hence avoiding ‘doctor shopping’ or drug misuse .
Several published guidelines and clinical practice recommend clinicians to evaluate and assess the risk of misuse at the time of presentation . It is quite difficult to predict who will misuse prescription drugs . There are several screening tools which can be used to evaluate prescription drug misuse [60–63]. The Alcohol, Smoking and Substance Involvement Screening Consisting Test is an example of a screening tool that can be used in clinical practice . Of eight main questions, the Alcohol, Smoking and Substance Involvement Screening Consisting Test questionnaire evaluates the use of several drugs, including prescription drug misuse. This screening tool has also been validated and translated into several languages with good reliability and validity [62,63].
As mentioned earlier, treatment for prescription drug misuse will vary according to the patient's condition and type of drug use. However, treatment for prescription drug misuse may be divided into two main categories: pharmacological and nonpharmacological/behavioural treatment . Pharmacological treatment is especially effective for opioid misuse. Treatment with buprenorphine, naltrexone, and methadone may be beneficial for opioid misuse to avoid relapse. However, evidence of the effectiveness of medication for other drugs is still not available. Therefore, behavioural treatment remains essential for prescription drug misuse treatment. Behavioural treatment assists patients by altering their way of thinking and their behaviour through education about ways to overcome cravings and to avoid situations which may lead to relapse .
This review provides the global picture of prescription drug misuse in adolescents and young adults. Owing to their easily available nature and how commonly they are used, prescription drugs have the potential to be consumed in a way other than they should be, whether related to dosage or manner of usage. Illicit drug use, academic performance, delinquency, and several mental disorders are conditions which occur together with prescription drug misuse, therefore awareness of this issue should be brought into prominence. Drug misuse factors can be divided into individual level, relationship level, community level, and societal level such as peer norms and policies. Parental disapproval and norms are protective factors. By considering the risk factors, protective factors and co-occurring issues, we can help develop comprehensive prevention and treatment methods for this issue.
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Conflicts of interest
There are no conflicts of interest.
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