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Paula Apa-Hall, RN, MEd, NCSN Rochelle D. Schwartz-Bloom, PhD Elizabeth S. MeConnell
Past-President, Professor of Pharmacology Deputy Director for Education
Oregon School Nurses Association Director, D.A.R.E America
Board of Directors, Duke Center for Science Education St. Louis, Missouri
National Association of School Nurses Duke University Medical Center
325 Green Link Way Durham, North Carolina
Newburg, OR 97132

ABSTRACT: The problem of prescription drug mis-
use by US adolescents is increasing. Several surveys
have indicated that teenage use of prescription drugs With the increasing number ofteens
is common and that they typically do not realize the abusing prescription drugs,
extent to which these substances can cause harm now is the timefor adults working
when misused. Teenagers obtain drugs from various
sources, including friends, dealers, the Internet, and, with schoolchildren to join together
especially, their families' medicine cabinets. Parents and to prevent thisfrightening trend.
grandparents are often unaware of the need to inven-
tory and lock away their own prescription medications. Elizabeth S, MeConnell,
School nurses are in a position to help prevent, identify, Deputy Director for Education, D.A.R.E. America
and manage the problem by educating students, par-
ents, and other school staff on the dangers and signs The problem of prescription drug misuse among adolescents
of adolescent prescription drug misuse. The informa- is a recently recognized phenomenon. As such, it has not
tion in this supplement is intended to educate and been the subject of a great deal of scientific investigation
heip facilitate school nurses' efforts in protecting our and publication, but it is known to be a burgeoning issue.
nation's adolescents. School nurses have an opportunity to be in the forefront
of efforts to prevent, identify, and control this epidemic. In
KEY WORDS: adolescent, medications, prescription 2007, the National Association of School Nurses (NASN,
drugs, misuse, school nurse, drug use, drug abuse 2007) conducted a survey of more than 1,000 school nurses
across the United States. Those surveyed were asked four
LEARNING OBJECTIVES questions regarding misuse of prescription drugs by adoles-
Upon completing this program participants should be cents in their communities. The results of this survey, shown
able to: in Figure 1 (page S2), suggest that school nurses consider
this a significant problem and that they would be likely to
• Summarize the prevalence of prescription drug take a prominent role and be more proactive in address-
abuse, dependency, and addiction potential among ing it, but they believe that they need more training and
adolescents resources to help them fulfill that role (NASN, 2007).
• Describe recommended approaches to identification
and treatment of prescription drug abuse To help school nurses effectively recognize and manage the
problem of adolescent drug abuse and inform students,
• Discuss preventive strategies aimed at reducing parents, and teachers, NASN has created a program com-
prescription drug abuse prising this supplement and a toolkit that is available online.
• Apply practical approaches to facilitating The toolkit consists of information sheets for use with par-
communication with students, parents, educators, ents, students, teachers, and the community. Worksheets
and others in the community and lists of commonly abused prescription medications are
included. The toolkit is conveniently housed in one location

for school nurses to access freely and use in their efforts.
Figure 1. Throughout these materials, the terms drug and medica-
Survey of School Nurses tion or medicine are used interchangeably, as they are not
talking about illicit "street drugs" but rather about medica-
1A: l5 prescription drug abuse by teens tions that can provide a range of benefits if used appropri-
a problem in your community? ately but can have negative effects if misused or abused.
The term "abuse" is used in these materials; however, ado-
22% lescents often do not think of themselves as "abusing"
these substances and don't recognize themselves as "drug
a Little or none
• Moderate
• Growing/significant EXPLAINING THE PROBLEM
Americans take a great deal more prescription medication
than do the populations of other countries (CASA, 2005). A
growing proportion of prescription medicine consumption is
not for medical use. Between 1992 and 2003, the number of
Americans misusing controlled prescription drugs increased
1B: How knowledgeable do you consider yourself by 8 1 % , although the U.S. population increased by only
regarding this problem? 14%. The misuse of prescription drugs is increasing at a much
12% higher rate than is the use of illicit drugs (Manchikanti, 2007).
A 2005 survey by the National Center on Addiction and Sub-
stance Abuse (CASA) at Columbia University found that in
2003, 2.3 million adolescents between 12 and 17 years of
• Little or not at all
• Fairly
age (9.3%) had misused prescription drugs. This age group
• Very or expert constituted 15.4% of all U.S. prescription drug misusers, sec-
49% ond only to those between 18 and 25 years of age (CASA,
2005) Misuse of several types of prescription medications has
been increasing over the years (Johnston, O'Malley, Bach-
man, & Schulenberg, 2007a, 2007b). Currently, the rate of
abuse of prescription psychotropics is second only to that of
marijuana (Office of Applied Studies, 2006c). Most people
1C: How confident are you in your ability to recognize who misuse medications are likely to misuse more than one
this problem in students? drug. Among adolescents between 12 and 17 years of age,
79.8% of those who misuse prescription medications use
multiple substances, 74.3% abuse alcohol as well as drugs,
and 59.9% combine their misuse of prescription drugs with
43% D Little or not at all
abuse of illicit drugs. This is often done for the purpose of
• Moderately either accentuating a "high" or counteracting the effects of
• Somewhat or highly a drug (CASA, 2005).

The reasons adolescents misuse prescription medications

are numerous. Respondents in the 2005 Partnership for a
Drug-Free America Attitude Tracking Study (PATS) acknowl-
edged preferring prescnption pain relievers to illicit drugs
because they are readily available and affordable, as well as
1D: Would you take an active role regard this problem for their higher level of acceptability than that of illicit drugs
if you had an easy-to-use resource toolkit?
(Partnership for a Drug-Free America, 2005). Certainly, some
teenagers use prescription drugs to get high, as they use
illicit drugs. Adolescents, however, often turn to prescription
medications for help in relieving anxiety, to help them sleep,
to enhance concentration, to heip them lose weight, and to
290/ D Unlikely relieve pain (Boyd, McCabe, Cranford, & Young, 2006; Fried-
• Probably likely
man, 2006). Thus, these prescription medications are likely
• Somewhat/very likely
66% to be used for their intended purpose, but not by the person
or at the dosage for which the medication was prescribed.
Table 1 summarizes the responses in one survey of rationales
for diversion of prescription drugs. This survey polled 1,568
individuals 9 to 18 years of age, of whom 206 reported hav-
Note. From NASN, 2007.
ing borrowed prescription medications, 165 had shared their

own medications with others, and 115 had done both. Of
those respondents 12 to 18 years of age who reported ever Table 1.
borrowing or sharing medications, only 3,8% stated that Adolescents' Rationales for Sharing
they would not share prescription drugs with their peers Prescription Drugs (n=210)
(Daniel, Honein, & Moore, 2003).
Rationale Respondents, %*
Figure 2 provides a summary of commonly misused prescrip-
Got it from a family member 66.2
tion medications {Johnston, O'Malley, Bachman, & Schu-
lenberg, 2007a; National Institutes of Health, 2007). The Have a prescription but ran out 64.8
three classes of medications that are most often misused
are opioids, central nervous system (CNS) depressants, and Have the same problem as the person 60.5
stimulants (National Institute on Drug Abuse, 2005), Of the who gave me the medicine
adolescents who reported misusing prescription drugs in Want something strong for pain or 43,3
the CASA study, 83,4% misused opioids; 24,6% and 5.6% headache
misused tranquilizers and sedatives, respectively; and 25.1%
misused stimulants at least once in the previous year (CASA, Have an emergency 39,0
2005). Got it from someone who knows 28.1
about medicine
In 2004, the prevalence of dependence or abuse of prescrip-
tion drugs in the past year among adolescents between 12 Need help sleeping 21.9
and 17 years of age was 15.9%, compared with 12,7%
among those 18 to 25 years of age (Office of Applied Stud- Want something strong for pimples 19.0
or oily skin
ies, 2006a). The rate of dependence on or abuse of pain
relievers increased steadily among adolescents from 2002 Need the medicine but can't afford 18.1
to 2004 (Office of Applied Studies, 2006b). Table 2 (page to buy it
S4) describes the major effects of each class of prescription
medications (National Institute on Drug Abuse, 2005). In Have leftover medicine that would be 13.8
addition to the possibly dangerous impact on cardiovascular,
respiratory, and neurologic functioning that these drugs can Want to relax or feel good 12.9
have, they all carry the potential for physical dependence
and addiction. Have heard a lot about this medicine 4.3
from ads or commercials
Although Americans constitute only 4% of the world's pop- "Multiple reasons were accepted; therefore, total may exceed 100%,
ulation, they use 80% of its supply of all opioids (Manchi- Note, Adapted with permission from Pediatrics. Vol, 111, Pages 1167-1170,
kanti, 2007), This class includes analgesics such as oxycodone Copyright © 2003 by the AAP,

Figure 2.
Nonmedical Use of Prescription Psychotherapeutics by 12th graders in 2007

Any Rx Psychotherapeutic ^ ^ ^ ^ ^ H ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ H 15.4

Other Narcotics ^ ^ ^ ^ ^ H
^^^^^^^HH^I 9.2
OxyContin ^ ^ ^ ^ ^ H ^^^^H 5.2

Vicodin ^ ^ ^ ^ ^ H ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ 1 9.6
Any Amphetamine ^ ^ ^ ^ ^ H ^ ^ ^ ^ ^ ^ ^ ^ ^ H 7.5
Ritalin ^ ^ ^ ^ ^ 1 ^^M 3.8

Sedatives ^ ^ ^ ^ ^ | ^ ^ ^ ^ ^ ^ ^ H 6.2

Tranquilizers ^ ^ ^ ^ ^ H • ^ ^ ^ ^ ^ H 6.2
0 5 10 15 20

% With Nonmedical Use in Past Year

Rx = prescription.
Note. From Johnson, O'Malley, Sachman & Schulenburg,, 2007a; National Institutes of Health, 2007,

(e.g., OxyContin®, Percocet®), hydrocodone (e.g., Vicodin®}, Vicodin® were the only individual prescription drugs whose
fentanyl (Duragesic® patches), and codeine (National Institute use had increased among adolescents in 2005 (Johnston,
on Drug Abuse, 2005). Morphine, a potent pain reliever, was O'Malley, Bachman, & Schulenberg, 2007b). Fentanyl, how-
the first prescription opioid to be abused in the United States ever, is also being abused at increasing rates as users have
(CASA, 2005), and the abuse of opioids continues today. The learned how to extract the medication from the patches. In
Monitoring the Future study reported that OxyContin® and addition, a lozenge version is becoming popular for its ease

Table 2.
Effects of Commonly Prescribed Drugs
• Oxycodone (OxyContin, Percodan, Barbiturates Dextroamphetamine (Dexedrine
Percocet) • Mephobarbital (Mebaral) and Adderall)
• Propoxyphene (Darvon) • Pentobarbital sodium (Nembutal) Methylphenidate (Ritalin and
• Hydrocodone (Vicodin, Lortab, Concerta)
• Diazepam (Valium)
• Hydromorphone (Dilaudid)
• Chlordiazepoxide hydrochloride
• Meperidine (Demerol)
• Diphenoxylate (Lomotil)
• Alprazolam (Xanax)
• Morphine (Kadian, Avinza, MS • Triazolam (Halcion)
• Estazolam (ProSom)
• Codeine
• Clonazepam (Klonopin)
• Fetanyl (Duragesic)
• Lorazepam (Ativan)
• Methadone
Generally prescribed for: Generally prescribed for: Generally prescribed for:
• Postsurgical pain relief • Anxiety • Narcolepsy
• Management of acute or chronic • Tension • Attention-deficit hyperactivity
pain • Panic attacks disorder (ADHD)
• Relief of cough and diarrhea • Acute stress reactions • Depressions that does not respond
• Sleep disorders to other treatment
• Anesthesia (at high doses)
In the body: In the body: In the body:
• Opioids attach to opioid receptors • CNS depressants slow brain activity • Stimulants enhance brain activity,
in the brain and spinal cord, through actions on the GABA causing an increase in alertness,
blocking the perception of pain. system, producing a calming effect. attention, and energy
Effects of short-term use: Effects of short-term use: Effects of short-term use:
• Alleviates pain • A "sleepy" and uncoordinated • Elevated blood pressure
• Drowsiness feeling during the first few days; as • Increased heart rate
• Constipation the body becomes accustomed • Increased respiration
• Depressed respiration (depending (tolerant) to the effects, these
• Suppressed appetite
on dose) feelings diminish
• Sleep deprivation
Effects of long-term use: Effects of long-term use: Effects of long-term use:
• Potential for physical dependence • Potential for physical dependence • Potential for physical dependence
and addiction and addiction and addiction
Possible negative effects: Possible negative effects: Possible negative effects:
• Severe respiratory depression or • Seizures following a rebound in • Dangerously high body temperature
death following a large single dose brain activity after reducing or or an irregular heartbeat after
discontinuing use taking high doses
• Cardiovascular failure or lethal
• For some stimulants, hostility or
feelings of paranoia after taking
high doses repeatedly over a short
period of time
CNS = central nervous system; GABA = gamma-aminobutyric acid.
Note. From National Institute on Drug Abuse, 2005.

of use. Because of its potency, abuse of fentanyl can easily and 24 years of age. The major cause of this trend has been
lead to overdose and death {CASA, 2005). attributed to overdose of opioid analgesics, followed closely
by prescription psychotherapeutic drugs (Centers for Disease
From the 1940s through the 1970s, when they came under Control and Prevention, 2007). A study of adolescents in
federal control, amphetamines were used, probably in Washington, DC, found that of 633 emergency department
excess, to control weight, fatigue, and depression. Amphet- visits between 1996 and 1998, 15% were drug related, and
amines continue to be abused by college students to keep 19% were specifically related to prescription medications
them awake while studying or partying {CASA, 2005). The {Cheng, Wright, Pearson-Fields, & Brenner, 2006).
current class of stimulants comprises amphetamines, {e.g.,
Dexedrine® and Adderall®) and methylphenidate, (e.g., Rit- Regrettably, prescription medications are not the only
alin®, Methylin®) {National Institute on Drug Abuse, 2005). "legal" drugs being misused. Over-the-counter {OTC) medi-
These drugs are prescribed primarily to treat attention defi- cations, such as diet pills, sleep aids, cough medicine, and
cit-hyperactivity disorder {ADHD), with 90% of methylpheni- motion sickness aids, are being abused as well. Adoles-
date in the United States being prescribed for children and cents take large quantities of diet pills, either to get high
adolescents {Poulin, 2007). The increase in the prescription or to lose weight quickly, and sleep and motion sickness
use of methylphenidate for ADHD in the past 10 years has aids can function as tranquilizers, stimulants, or even hal-
contributed to its diversion and abuse or misuse by teenag- lucinogens. Hospitals are reporting increasing numbers of
ers to get high, to stay awake and focused for studying, or cases of overdosed OTC medications, sometimes with fatal
to lose weight (CASA, 2005). The effort to minimize diver- consequences (Teen Drug Abuse, 2008). By far the most
sion of ADHD medications has resulted in the development commonly abused OTC medications are cold and cough
of extended-release formulations of methylphenidate {e.g., medicines containing dextromethorphan. Taken in sufficient
Concerta®) and mixed amphetamine salts, as there appears quantity, these products induce a hallucinogenic high. Ado-
to be a lower tendency for misuse or diversion of these for- lescents have several names for dextromethorphan-con-
mulations than of immediate-release formulations (Wilens, taining medicines, such as "dex," "DXM," and "skittles,"
Gignac, Swezey, Monuteaux, & Biederman, 2006). and the act of getting high on products such as Robitus-
sin is often called "robotripping" (James, 2006; Johnston,
CNS depressants include barbiturates such as phénobar- O'Malley, Bachman, & Schulenberg, 2007b). OTC medica-
bital (Nembutal®) and benzodiazepines such as diazepam tions can also have adverse effects when abused, including
(Valium®), clonazepam (Klonopin®), and chlordiazepoxide blurred vision, loss of coordination, abdominal pain, muscle
HCI (Librium®) {National Institute on Drug Abuse, 2005). spasms, tachycardia, and delirium (Substance Abuse and
Diazepam, said to be the "Mother's Little Helper" made Mental Health Services Administration, 2008). In the Wash-
famous by the Rolling Stones' 1966 song of the same name, ington, DC, study, 23% of visits to emergency departments
has been widely misused in the United States, often being were related to OTC drugs {Cheng, Wright, Pearson-Fields,
prescnbed for symptoms not warranting such a potent drug. & Brenner, 2006). Further, the combination of OTC and pre-
It continues to be prescribed and misused at a high rate scription drugs, or of either or both of these with alcohol,
{CASA, 2005). Dependence on benzodiazepines can develop can have even more deleterious effects.
from both intentional and unintentional misuse. Uninten-
tional misuse occurs when individuals take higher doses
than intended or take prescribed medication for longer than [Addiction occurs] because over time, use of
intended but are not using these drugs for other reasons addictive drugs changes the brain...
than those for which they were prescribed. Although depen-
dence does not always result from misuse, it is a potential Alan I. Leshner, PhD,
outcome (O'Brien, 2005). The greatest danger with benzo- Former Director, National Institute of Drug Abuse
diazepine misuse occurs if these drugs are used in combina-
tion with other CNS depressants, such as opioid analgesics
or alcohol (National Institute on Drug Abuse, 2005). The Little is known about the potential long-term effects of medi-
additive effect of respiratory depression is potentially lethal. cation misuse on the developing adolescent brain (Friedman,
2006). Alan I. Leshner, former Director of the National Institute
The adverse effects of misused prescription medications of Drug Abuse, points out that addiction results from gradual
can have dire consequences. Between 2004 and 2005, the changes in the brain, sometimes very subtle, caused by con-
overall rate of visits to emergency departments related to tinued abuse of medications. He emphasizes that although
nonmedical use of prescription drugs increased by 2 1 % , many different drugs may be implicated in brain changes, the
with the benzodiazepine-associated rate increasing by 19% effects are often quite similar. The changes may involve mood
and the rate for opioids increasing by 24%. The rate of swings, alteration in memory processes, or impairment of
emergency department visits in 2005 that were related to motor skills (Leshner, 2005). Research demonstrating that the
prescription drug misuse by adolescents between 12 and 17 brain is still in development during adolescence supports the
years of age was 193 per 100,000 population (Drug Abuse suggestion that drug misuse during this period could result in
Warning Network, 2004). The overall rate of deaths due to permanent cognitive damage (Giedd, 2008; Gogtay, Giedd,
unintentional poisoning increased from 1999 to 2004, with Lusk, Hayashi, Greenstein, Vaituzis, Nugent, Herman, Ciasen,
the largest increase {113.3%) among those between 15 Toga, Rapoport, & Thompson, 2004).

MYTHS CONTRIBUTING TO people metabolize many drugs, including antidepressants
INCREASED MISUSE and opioid analgesics. Those who metabolize a drug rapidly
may need higher doses to achieve an effect, whereas those
Several common misconceptions among adolescents and
who metabolize the same drug slowly may experience toxic-
their families contribute to the high rate of prescription
ity at a similar dose of that same drug (Caraco, 2004; Merck
medicine misuse. These include, but are not limited to, the
& Co., 2003). in other words, what can help one person may
have no effect on another and could be lethal to a third,
MYTH: There is no such thing as "abuse" of prescription
MYTH: If drugs are used only occasionally, they can't hurt
drugs-after all, they're legal; also, if it's legal, it's safe.
In the PATS survey, about half of the more than 7,000 ado-
A common impression is that there is little risk in occasional
lescents, grades 7 through 12, surveyed saw no great risk in
use of medications (Friedman, 2006). Many of the adoles-
nonmedical use of prescription drugs. A majority of teens
cents responding to the PATS survey believed that prescrip-
surveyed also believed that prescription medications, even
tion pain relievers are not addictive. About one third of
when prescribed for someone else, are safer to use than are
these adolescents believed that occasional nonmedical use
illegal drugs (Partnership for a Drug-Free Amenca, 2005).
of others' prescription medications is not harmful or addic-
The principle of "good medicine, bad behavior," meaning
tive (Partnership for a Drug-Free America, 2005). Teenag-
that drugs that can be very helpful when used appropriately
ers frequently do not understand the variation in addiction
can be extremely harmful when misused, clearly needs fur-
potential from user to user of a medication.
ther reinforcement.

All substances are poisonous; there is none They never think that it's going to be them.
which is not a poison. The right dose Parents will sometimes think their
differentiates a poison from a remedy. kids may get into trouble with drugs...
Paracelsus (Theophrastus Bombastus von Hohenheim), ~1538
but kids never think that they are going
to be the one who becomes an addict.
MYTH: If a little helps a little, a lot will help even rr^ore. Mary Louise Embrey, NASN Director of Government Affairs
Drug Abuse Prevention Consultant
The most obvious example refuting this myth is
related to nonsteroidal anti-inflammatory drugs
(NSAIDs), which are available as both prescription Figure 3.
and OTC medications. Although these drugs, taken Factors Affecting Responses to Drugs
at recommended doses, can provide effective anal-
gesia, overdosing on NSAIDs, or even their long-term Cardiovascular
factors function
use at standard doses, can result in severe gastroin- Drugs
testinal damage and even kidney or heart failure Psychologic
variations Gastrointestinal function

(Mercóla, 2004; Moore, Derry, Phillips, & McQuay, status Immunologie function

2006). In addition, an increase in dose is accompa- OccupatJonai

nied by an increase in potential adverse effects. exposures

MYTH: If it worked for Mom, it will work for me. Infection

VARIATION ON MYTH: If it worked for me, it will

work for my friend who has the same problem/
PARENT'S MYTH: If it worked for me, it will work
for my kid.

Adolescents and frequently their parents need to be

Exercise Starvation
educated about the fact that different people can
have quite varied responses to the same dose of the
Lactation Behavior
same medication. As shown in Figure 3, a variety of
factors affect individuals' responses to drugs. In addi- Pregnancy Alcohol
Tobacco or mtake
tion to age, weight, height, and concomitant use Age marijuana
of other substances, a primary differentiating fac- smoking

tor involves genetics (Merck & Co., 2003). Genetic N o t e . From The M e r c k M a n u a l o f M e d i c a i I n f o r m a t i o n - Second H o m e E d i t i o n ,
variations related to the cytochrome P-450 family p. 74, e d i t e d by M a r k H. Beers. C o p y r i g h t 2003 by M e r c k & Co., Inc., W h i t e h o u s e
Station, NJ. Available at; h t t p : / / w w w . m e r c k . c o m / m m h e . Accessed February 1, 2008.
of enzymes determine the rate at which different

MYTH: This is someone else's problem, not ours.
PARENT'S VERSION: Not my kid. Figure 5.
Lifetime Prevalence of Non-prescribed Use of
TEEN'S VERSION: It can't happen to me. Pain Relievers Among Adolescents Aged
It is a typical human trait to assume that a problem pertains 12-17 Years (Unweighted N=18,678)
only to someone else. In the case of "drug abuse," people
often consider themselves and their families impervious,
either because they are in a socioeconomic class "above"
that of people who might have a drug problem or because,
as is common among adolescents, they think themselves
particularly invulnerable to the adverse effects of drugs. Mis-
use of prescription medication, however, is not limited to
lower socioeconomic or undereducated groups, as illustrated
in Figures 4 and 5 (Manchikanti, 2006; Office of Applied
Studies, 2006c; Wu, Pilowsky, & Patkar, 2008). In fact, teens
from affluent families may have more access to prescription $20,000- $40,000- $75.000
drugs, in terms of both finding them at home and being $39,999 $74,999 or more
able to afford buying them from peers or the Internet, than Family Income
do adolescents from lower socioeconomic classes. In the
Note. From Wu, Pilowsky & Patkar, 2008. Data were drawn from the
large National Survey on Drug Use and Health, the highest public use data file of the 2005 U.S. National Survey on Drug Use and
percentage of new adolescent nonmedical users of pain Health.
relievers were in the family income bracket ranging from
$20,000 to $50,000 per year, followed closely by those in
be just as great as that with prescription medications. As
the bracket of $75,000 per year or more (Office of Applied
with misused prescription medications, taking multiple OTC
Studies, 2006d).
medicines that contain the same ingredient carries the dan-
ger of accumulating and overdosing on that ingredient, even
MYTH: OTC drugs are even safer than prescription drugs or
if each drug is used within its indicated limitations (Mercóla,
they would not be available OTC. 2004).
Just as many adolescents believe that prescription drugs
are less dangerous than are illicit drugs, many also believe
that OTC medications are even safer than are prescription
medicines. The truth, however, is that OTC medications used INCREASED MISUSE
inappropriately can be just as dangerous as other drugs and Many factors contribute to the increasing prevalence of pre-
have the same risks for interactions with other drugs, foods, scription drug abuse. Among these are the increasing acces-
and conditions. They also carry a risk of side effects that can sibility of drugs and information on their use, the way that
misuse of prescription medications is interwoven into the
social life of many U.S. adolescents, and general ignorance
Figure 4. regarding the extent, potential consequences, and means of
Nonmedical Use of Prescription minimizing the problem.
Psychotherapeutic Drugs by Demographics'
Accessibility of Drugs and Information
Figure 6 (page S8) summarizes the results of one US survey
addressing adolescents' access to prescription pain reliev-
ers (Office of National Drug Control Policy, 2007), More
than 65% of respondents reported friends or relatives as
sources of prescription medications. A recent Canadian
Ol study reported that more than one fourth of adolescents
c with prescriptions for stimulant medications to manage
ADHD had given or sold some of their medication to peers
(Poulin, 2007). Clearly, the majority of teenagers are obtain-
Ethnicity Education ing drugs from friends, most times at little or no cost. The
other most popular source of prescription medication is the
• White • Some High school
• Black D High School Graduate student's own home. Sixty-two percent of respondents in
• Asian • Some College the PATS survey stated that prescription pain relievers were
• Native American • College Graduate readily available in their home medicine cabinets (Partnership
for a Drug-Free America, 2005). No doubt, teenagers also
•Note. Based on 2002-2004 statistics.
can find prescription drugs at grandparents' and other fam-
From Office of Applied Studies 2005c,
ily members' homes. The ready availability of prescription

of drugs, it also is a source of information on their use. Sev-
Figure 6. eral Web sites exist that provide instructions regarding how
Sources of Prescription Pain Relievers to use OTC and prescription medications to get high, even
for Adolescents identifying doses based on height and weight (Leinwand,
Social Acceptability
The increased development and marketing of drugs that
can help control psychological problems, improve sleep, and
enhance learning have contributed to their image as pana-
ceas rather than dangerous substances (CASA, 2005). The
media may contribute to the attraction of prescription medi-
cations to adolescents by fostering an impression that these
drugs are safe to use (McCarthy, 2007). Adolescents who see
adults in their families using more and more prescription and
OTC medications may then go to school and see their peers
using the same drugs for nonmedical purposes, and their
impression of the acceptability of the use of the medica-
• other • 1 Physician
tions increases. Adolescents also believe there is less stigma
• Bought (stranger) • Friend (given) attached to the nonmedical use of prescription medications
• >1 Physician • Friend/Relative (stole) than to the use of illicit drugs (Partnership for a Drug-Free
• Internet (0.1%), D Friend/Relative (bought) America, 2005).
Fake Rx (0,1%), Stole* (0.5%)
*from physician's office, clinic, hospital, or pharmacy, The impression that prescription medications are safer
Rx = prescription. and more acceptable may be contributing to the growth
Note. Adapted from Office of National Drug Control Policy, Executive of a practice sometimes called "pharming" parties, where
Office of the President, 2007.
teenagers bring whatever prescription medications they
can obtain. There the adolescents may barter one drug for
medication in adolescents' own or families' homes highlights another, or they may pool all the pills in a bowl from which
the need for increased educational efforts targeting families each may take a handful of different pills. This combination
regarding safeguarding and monitoring prescription medica- is often taken along with alcohol. Although, like teenage
tions in the home. prescription drug abuse in general, pharming parties have
not been scientifically tracked, their frequent mention in
the popular media and attention from official organizations
The Internet has hecoTne a pharmaceutical suggest that this phenomenon is real and increasing (Banta,
candy store stocked with addictive drugs, 2005; O'Brien, 2005; Parents: The Anti-Drug, 2006). Mixing
drugs with one another or with alcohol can intensify the
available at the click of a mouse to any effects of either substance alone or create new, more dan-
kid with a credit card number. gerous effects, as described in Table 3 (National Institute on
Aicohoi Abuse and Alcoholism, 2007; National Institute on
Joseph A. CaÜfano, Jr., Chairman and President, CASA Drug Abuse, 2005; Parents: The Anti-Drug, 2006).

A recent survey by Teenage Research Unlimited found that Ignorance Regarding the Problem
58% of respondents v^ere aware of the availability of pre-
scription drugs on the Internet (Teenage Research Unlimited,
2006), and more than 7 million respondents in the PATS If Iget a narcoticfrom a dentist... [Vm guilty]
results indicated that they believe it is easy to buy drugs over of not counting them when Iget home, or not
the Internet (Partnership for a Drug-Free America, 2005). watching them that closely, or not disposing
Estimates vary regarding the extent to which adolescents use
the Internet as a source of drugs, but opportunities no doubt ofthem properly when I am, through with
exist. In 2007, CASA reported that they found 581 Web sites them, andVm a healthcare professional.
that advertise or sell controlled prescription drugs, up from
342 in 2006, The number of sites that sell controlled pre- Registered Nurse
scription drugs increased from 154 in 2004 to 187 in 2007
(7%), and only 2 of the 187 sites were certified Internet Stephen J. Pasierb, President of the Partnership for a Drug-
pharmacy sites. Furthermore, 84% of these 187 sites did not Free America, recently testified before the United States
require prescnptions, and more than half of the other 16% Senate Committee on the Judiciary, Subcommittee on Crime
did not require original prescriptions but accepted faxed cop- and Drugs. He stated that "parents - who are usually our
ies {CASA, 2005). In addition to the Internet's being a source most valuable ally in preventing teen drug use - are generally
disposing of pills safely when they are finished using them
Table 3. or the period of highest potency of the pills has expired
Drug Interactions (, 2007). In fact, it is reasonable to assume that
Drug Type Mixed With parents would be unaware if their children stole prescription
Possible Adverse
medicine from them.
OpioJd Alcohol, Increased respiratory Adolescents are frequently more experienced in using the
antihistamines, depression, impaired Internet than their parents are. The survey by Teenage
barbiturates, motor control Research Unlimited (2006) noted that the majority of teen-
benzodiazepines agers interviewed had bought or knew someone who had
bought alcohol on the Internet and stated that their par-
Alcohol, Respiratory
Depressant ents could not control their Internet activities. In fact, 68%
prescription pain depression, impaired
medications, OTC reported that their parents never tried to control their Inter-
motor control,
cold and allergy dangerously slowed net activities, and 39% said that their parents knew little or
medications heartbeat nothing about their Internet activities. Only 25% reported
that their parents knew a great deal about their Internet
Stimulant Alcohol Need to drink more to activities. These findings probably are equally applicable to
feel effect of alcohol the accessibility of drugs on the Internet. The discrepancy
OTC Arrhythmia, between adolescents' skill at navigating the Internet and
decongestants^ dangerously high their parents' awareness of this ability likely enhances the
blood pressure ease with which teenagers can obtain drugs on the Internet.
Cold and Alcohol Increased drowsiness, On the other hand, adolescents often are not aware of the
cough dizziness, risk of potent effects on cognition and motor skills some commonly
nrtedicine overdose available drugs can have or of their potential harm, including
*This cJoes not include decongestant sprays. death, even at small doses (Friedman, 2006). This is not sur-
CNS = central nervous system prising considering that adults in one study ranked NSAIDs
Note. From National Institute on Drug Abuse, 2005; National Institute on among the safest prescription medications and, overall,
Alcohol Abuse and Alcoholism, 2007; Parents: The Anti-Drug, 2005.
underestimated the rates of adverse reactions possible with
several prescription medications (Cullen, Kelly, & Murray,
ill equipped to deal with teens' abuse of prescription drug 2006). If parents are not aware of the risks, their children
use, a behavior that was probably not on their radar when should not be expected to be aware either.
they were teenagers. They find it hard to understand the
scale and purposeful ness with which today's teens are abus-
ing medications, and it's not immediately clear to them that RECOGNIZING THE PROBLEM
the pnme source of supply for abusable prescription drugs
IS likely to be their own medicine cabinet. Further, many
Because ofour unique position within the
parents themselves are misusing, or perhaps abusing, pre-
scription drugs without having a prescription. In our study..., schools, students trust and confide in school
28% of parents said they had used a prescription drug with- nurses. We need to be prepared to respond
out having a prescription for it, and 8% of parents said they
had given their teenaged child an Rx drug that was not pre-
accordingly when we hear about the misuse
scribed for the teen" (United States Senate Committee on of prescription drugs, including drugs being
the Judiciary, 2008). mixed with alcohol or stimulant drinks. It is
important to keep abreast of current trends, as
One pill makes you larger, and one pill students have access to so much information
makes you small, and the ones that mother on the Internet that can be potentially lethal.
gives you don't do anything at all. Paula Apa-Hall
Past-President. Oregon School Nurses Association
Grace Slick, "White Rabbit" Board of Directors, National Association of School Nurses

Unfortunately, the statement in the Jefferson Airplane song The school nurse, a trusted health care professional, is in a
does not apply to the pills that adolescents may take from unique position to be the first to recognize that a student
their parents' supply of prescription medication. These may has a problem with misuse of prescription medications. The
do quite a bit of damage. It has been observed that parents school nurse's relationship with students is unlike that of
frequently do not keep track of or control their own medi- others in that the nurse is available to the student outside
cations by counting pills periodically, locking up prescrip- of the classroom or the student's home. Therefore, students
tion medications the way they might lock away liquor, or frequently feel that they can confide m the school nurse

without risking consequences such as being judged, hav- management options and the importance of early control of
ing their privileges revoked or curtailed, or receiving lower the problem. Further, school nurses can refer students for
marks in classes. With the exception of information regard- treatment when necessary or at least advise parents to take
ing potential harm to the student or others, the school nurse their children for treatment, at the same time serving as an
can offer confidentiality to students in discussing any prob- advocate for the student when appropriate.
lems they may have with drugs. Additionally, the school Education may occur at several levels and involve several
nurse is in a position to educate students, teachers, and types of people. Certainly, adolescent students are the pri-
parents, as well as others in the community, about trends in mary recipients of education by the school nurse. The infor-
prescription drug abuse and signs indicating that a problem mation included herein needs to be conveyed to them in
might exist. ways that they will find acceptable and that will be easy
for them to retain. Delivering facts in short, easily digested
The insidious nature of this problem makes it difficult to
spurts has been found to be effective. Also, reinforcing the
recognize in many cases. The signs of prescription or OTC
learning with illustration and repetition, as well as by having
medication abuse are not always as apparent as those of
students paraphrase back what they have heard, is advis-
illicit drug abuse. For example, teachers may be accustomed
able. Although high school health classes often address use
to identifying drug use based on the odor of marijuana
of illicit drugs, the majority do not cover misuse of prescrip-
smoke or the presence of injection paraphernalia, pipes, or
tion medications (Manchikanti, 2006).
rolling papers, none of which is involved in the misuse of
prescription and OTC medications. Thus, without looking for Parents and other family members also need education
the signs associated with this type of drug abuse, teachers about recognition of a medication misuse problem in their
and parents may miss it entirely (Manchikanti, 2006). Signs teenagers and safeguarding and taking periodic inventory
that should warn parents, teachers, and nurses that there of medications in their possession. H. Wesley Clark, Direc-
might be a problem with student medication misuse Include tor of the Center for Substance Abuse Treatment of the U.S.
(New York State Office of Alcoholism and Substance Abuse Substance Abuse and Mental Health Services Administra-
Services, 2007): tion, has stressed the importance of physicians and phar-
• Uncharacteristic loss of enthusiasm or symptoms of macists advising people to keep drugs in a secure place
depression and safely dispose of drugs that have expired or that they
do not intend to use (McCarthy, 2007). This includes lock-
• Irritability or hypersensitivity to criticism
ing medicine cabinets just as liquor cabinets are locked and
• Truancy and/or withdrawal from usual activities periodically counting pills to ensure that no one else is using
• An unexplained drop in school performance and the medication. Because a great deal of adolescent behavior
grades is learned from models observed at home, parents need to
• Loss of interest in hygiene or appearance be told of the danger of casually sharing medications with
other adult family members because of the example this sets
• An unexplained change in the student's group of
for their adolescent children (Levine, 2007). Because parents
do have such strong influence on their children, it is impor-
School nurses who observe any of these signs In a student, tant that they establish an ongoing dialogue regarding the
particularly if they are uncharacteristic, shouid initiate an dangers of drug abuse. See page SI 5 of this supplement for
investigation into potential problems. A straightforward con- help in getting started.
versation with the student may be the best approach. In an
atmosphere of confidentiality, the nurse can even ask the Parents need to be made aware of school policies regarding
student, "What have you taken today?" This may yield bet- self-medication, as they may not know that their teenag-
ter results than a more open question. ers are being exposed to drugs at school, albeit by other
students who are legally permitted to have those drugs. The
Teachers, administrators, and other school personnel need American Academy of Pediatrics (AAP) issued a policy state-
to be educated by the school nurse to recognize medica- ment regarding medication administration in school. The
tion misuse problems among students (Manchikanti, 2006). AAP points out that where states have their own guidelines
Teachers should become familiar vwith medication policies for medication use in school, confusion can be minimized
in their school district and state, as well as with national for all involved (American Academy of Pediatrics, 2003).
guidelines, regarding privacy/confidentiality, self-medication As of 2001, 37 states had developed policies or regulations
at school, and boundaries of investigation, (for example, regarding medication administration in schools (Figure 7).
when is it permissible to search a student's locker?). These policies vary from state to state, but most include a
requirement for signed waivers of liability. In addition, most
authorize school systems and school boards to implement
ADDRESSING THE PROBLEM local policies, assuming these policies do not contradict state
As with the recognition of prescnption medication misuse or federal regulations (
among students, school nurses play a pivotal role in man-
agement of the problem. They are in a position to coordinate The AAP (2003) note when state guidelines do not exist or
and lead the implementation of substance abuse prevention are not sufficiently specific, individual school boards and
programs, as well as to educate all involved parties regarding administrators, including school nurses, should establish

Figure 7.
States That Have Developed Policies or Regulations
Regarding Medication Administration in Schools

Map not drawn to scale

Note. From

policies with which students must comply. They further advise School nurses should be aware of the options for treat-
that all medication brought to school should be in appropri- ing prescription drug misuse or dependence. Primarily,
ately labeled containers and accounted for at the end of a these comprise behavioral and pharmacologie approaches.
selected period. Students who are allowed to self-medicate Depending on the drug of abuse and the extent of a stu-
at school need to be taught repeatedly to act responsibly dent's involvement with or dependence on the drug, the
(e.g., not to leave their medications in the restroom). Fig- treatment may consist of counseling alone, detoxification
ure 8 (page SI2) is an example of a student self-medication along with counseling, or, if necessary, medications to coun-
agreement. ter the effects of the culprit drugs. In the case of opioid
addiction, combining opioid agonist maintenance therapy
The lay public is not the only segment of society that requires
with counseling is most likely necessary for success {National
education. Physicians may not always recognize that adoles-
Institute on Drug Abuse, 2005).
cents have problems with prescription drug abuse. The 2005
CASA survey included physicians and pharmacists, yielding Tools that school nurses can use in their educational efforts
some startling information. Of the physicians surveyed, only include the following;
19% had received any instruction in medical school regarding
recognition of prescription drug diversion, and more than half • Literature in the nurse's offic^charts on the walls and
of these reported receiving only a few hours of instruction. Of brochures and information sheets that can be given to
the nearly 40% who had received instruction in identification students and their parents
of prescription drug addiction or abuse, half had received • Videos and slides that can be shown to students and
only a few hours of instruction. Although the percentages parents
of any instruction rose during internship and residency, the
amount of training received did not change substantially. • Seminars for parents, particularly at the beginning of
Similarly, only about half of the pharmacists responding to the school year, explaining the extent of the problem
the CASA survey had received instruction in dispensing con- and the signs to look for
trolled drugs, preventing their diversion, or identifying abuse
• Lists of resources offering further help and information
of or addiction to these medications {CASA, 2005; National
to parents and students
Institute on Drug Abuse, 2005).

Figure 8. Whichever term is used to describe it, misuse/diversion/abuse
Sample Se If-¡Vied i cation Agreement of prescription and OTC medications is a present and grow-
(Courtesy of Paula Apa-Hall, RN, MEd, NCSN) ing problem among adolescents. Prompt recognition of this
problem is essential to controlling it, as early intervention
Studeiits who are developmentally and/or can substantially reduce the risks of dependence, addiction,
behaviorally able will be allowed to self-administer and permanent damage or death. People's health status can
prescription and nonprescription medication without change at any time; they may become ill or incur injuries.
the assistance of trained school personnel, subject to Therefore, prescription medications may be brought into
the following: households where they were not previously kept. The type
1. A Medication Authorization form must be of abuse discussed in this supplement involves drugs that
submitted for self-administration of all are not considered illegal but rather medicines used to treat
prescription and nonprescription medication. specific symptoms or illnesses. Therefore, education, is key
to preventing the potentially dire consequences of medica-
2. A physician must sign giving permission for a tion misuse.
student to self-administer prescription
medications (except inhalers). School nurses are in a position to play pivotal roles in con-
trolling and preventing adolescent drug abuse. They may
3. All prescription and nonprescription medication
be the first to recognize that there is a problem. They also
must be kept in its appropriately labeled original
may be the only people in whom students feel they can
confide; they are able to refer students with suspected or
4. The student may have in his or her possession acknowledged problems for treatment; and, perhaps most
only the amount of medication needed for that importantly, they may be the best source of information and
school day. education for students, parents, teachers, and other school
staff. The results of the NASN survey make it clear that most
• Prescription labels must specify the name of
school nurses understand that there is a problem and are
the student, name of the medication, dosage,
eager to take an active part in its management. To do this,
route, and frequency or time of
they need information for themselves and tools to help them
administration, and any other special
educate others. This supplement, along with the toolkit
available online, will contribute to school nurses' educational
• Nonprescription medication must have the resources and facilitate their efforts to control and prevent
student's name affixed to the original the effects of the misuse of prescription medications.
Acknowledgemer)t: This supplement was supported by an
5. Sharing and/or borrowing of medication between educational grant from PriCara, Division of Ortho-McNeil-
students is strictly prohibited. Janssen Pharmaceuticals Inc., administered by Ortho-McNeil
6. Permission to self-medicate may be revoked if the Janssen Scientific Affairs, LLC.
student violates school district policy governing
administration of noninjectable medication and/
or these regulations. Additionally, the student REFERENCES
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(2.0 CNE Contact Hours free to the first 2,000 members)
1. Between 2004 and 2005, the rate of emergency
department visits related to nonmedical use of To receive CNE credit and a certificate, please complete the
prescription drugs increased by post-test and evaluation online at
a. 4% b. 15% c. 21% d. 35% Your CNE certificate will be automatically generated upon
2. In 2003, about adolescents misused
prescription drugs. If you are unable to complete the post-test and evaluation
a. 100,000 c. 2.3 million online, please mail the below form to:
b. 1.7 million d. 5.6 million
National Association of School Nurses
3. Prescription psychotropics are abused 8484 Georgia Avenue, Suite 420
Silver Spring, MD 20910
a. less than any other class of drugs Attn: Marianne Engle
b. more than any other drug except marijuana
Processing will take approximately 6-8 weeks.
c. more than any other drug, including marijuana
d. about as often as cocaine
4. Most teenagers who misuse prescription medications CE REGISTRATION/POSTTEST
also use other drugs, including alcohol. ANSWER FORM/EVALUATION FORM
a. True b. False
Record your posttest answers by filling in the blank with
5. In one survey, about % of adolescents said that the letter from the correct answer to the corresponding
they would share prescription medications with their
a. 25 b. 96 c. 8 d. 4 1. 2. 3. 4. 5. 6. 7.
6. Americans use about % of the world's opioids.
a. 20 b. 40 c. 60 d. 80 8. 9. 10. 11. 12. 13.
.. ..
7. "Pharming" refers to:
a. growing one's own marijuana COURSE EVALUATION
b. sharing multiple prescription drugs at parties
c. buying drugs on the Internet We hope this program has provided information that will
d. selling drugs at school be useful in your practice. Your evaluation will help us pian
future programs. May we have your comments? Please
8. "Robotripping" refers to: evaluate this publication by circling your response(s).
a. getting high on OTC cough/cold medicines
b. getting so high that one loses coordination 4 = Strongly Agree N/A = Not Applicable
c. getting high and playing video games 3 = Agree
d. going through the school day without paying 2 = Disagree
attention 1 = Strongly Disagree

9. Between 1999 and 2004, the greatest increase in deaths The course objectives were met. 4 3 2 1 N/A
due to unintentional drug poisoning occurred among
those between years of age. The course was informative and
well organized. 4 3 2 1 N/A
a. 65 and 85 c. 25 and 34
b. 45 and 54 d. 15 and 24 The topic(s) presented were
pertinent to school nursing. 4 3 2 1 N/A
10. Of all of the certified Internet pharmacy sites, how many
do not require a prescription?
The course contributed to my
a. 15% professional growth. 4 3 2 IN/A
b. 46%
c. 84% The content was NOT affected
by commercial interest. 4 3 2 1 N/A
d. all require a prescription
11. Parents are typically very aware of their children's misuse
of prescription medications. Comments:
a. True b. False
12. African American teenagers abuse prescription
medications substantially more than do white teenagers.
a. True b. False
13. About % of adolescents who misuse
prescription medications report getting them from Address
friends or relatives.
a. 27 b. 47 c. 67 d. 87 Member ID