THE CURRENT STATE OF TEENAGE DRUG ABUSE: TREND TOWARD PRESCRIPTION DRUGS

Transcription

1 Supplement to The Journal of School Nursing June 2008 The Official Publication of the National Association of School Nurses THE CURRENT STATE OF TEENAGE DRUG ABUSE: TREND TOWARD PRESCRIPTION DRUGS Jointly Sponsored by and Free CNE Program included and available online.* *The National Association of School Nurses, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. This activity is supported by an educational grant from PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.

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3 THE CURRENT STATE OF TEENAGE DRUG ABUSE: TREND TOWARD PRESCRIPTION DRUGS Program Faculty Paula Apa-Hall, RN, MEd, NCSN Past-President, Oregon School Nurses Association Board of Directors, National Association of School Nurses 325 Green Link Way Newburg, OR (503) Rochelle D. Schwartz-Bloom, PhD Professor of Pharmacology Director, Duke Center for Science Education Duke University Medical Center Durham, North Carolina Elizabeth S. McConnell Deputy Director for Education D.A.R.E America St. Louis, Missouri ABSTRACT: The problem of prescription drug misuse by US adolescents is increasing. Several surveys have indicated that teenage use of prescription drugs is common and that they typically do not realize the extent to which these substances can cause harm when misused. Teenagers obtain drugs from various sources, including friends, dealers, the Internet, and, especially, their families medicine cabinets. Parents and grandparents are often unaware of the need to inventory and lock away their own prescription medications. School nurses are in a position to help prevent, identify, and manage the problem by educating students, parents, and other school staff on the dangers and signs of adolescent prescription drug misuse. The information in this supplement is intended to educate and help facilitate school nurses efforts in protecting our nation s adolescents. KEY WORDS: adolescent, medications, prescription drugs, misuse, school nurse, drug use, drug abuse LEARNING OBJECTIVES Upon completing this program participants should be able to: Summarize the prevalence of prescription drug abuse, dependency, and addiction potential among adolescents Describe recommended approaches to identification and treatment of prescription drug abuse Discuss preventive strategies aimed at reducing prescription drug abuse Apply practical approaches to facilitating communication with students, parents, educators, and others in the community INTRODUCTION With the increasing number of teens abusing prescription drugs, now is the time for adults working with schoolchildren to join together to prevent this frightening trend. Elizabeth S. McConnell, Deputy Director for Education, D.A.R.E. America The problem of prescription drug misuse among adolescents is a recently recognized phenomenon. As such, it has not been the subject of a great deal of scientific investigation and publication, but it is known to be a burgeoning issue. School nurses have an opportunity to be in the forefront of efforts to prevent, identify, and control this epidemic. In 2007, the National Association of School Nurses (NASN, 2007) conducted a survey of more than 1,000 school nurses across the United States. Those surveyed were asked four questions regarding misuse of prescription drugs by adolescents in their communities. The results of this survey, shown in Figure 1 (page S2), suggest that school nurses consider this a significant problem and that they would be likely to take a prominent role and be more proactive in addressing it, but they believe that they need more training and resources to help them fulfill that role (NASN, 2007). To help school nurses effectively recognize and manage the problem of adolescent drug abuse and inform students, parents, and teachers, NASN has created a program comprising this supplement and a toolkit that is available online. The toolkit consists of information sheets for use with parents, students, teachers, and the community. Worksheets and lists of commonly abused prescription medications are included. The toolkit is conveniently housed in one location S1

4 56% 49% 1A: Is prescription drug abuse by teens a problem in your community? 22% 22% Little or none Moderate Growing/significant 1B: How knowledgeable do you consider yourself regarding this problem? 12% 39% Little or not at all Fairly Very or expert 1C: How confident are you in your ability to recognize this problem in students? 39% 18% 43% Little or not at all Moderately Somewhat or highly 1D: Would you take an active role regard this problem if you had an easy-to-use resource toolkit? 66% 5% Note. From NASN, Figure 1. Survey of School Nurses 29% Unlikely Probably likely Somewhat/very likely for school nurses to access freely and use in their efforts. Throughout these materials, the terms drug and medication or medicine are used interchangeably, as they are not talking about illicit street drugs but rather about medications that can provide a range of benefits if used appropriately but can have negative effects if misused or abused. The term abuse is used in these materials; however, adolescents often do not think of themselves as abusing these substances and don t recognize themselves as drug abusers. 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 by 81%, although the U.S. population increased by only 14%. The misuse of prescription drugs is increasing at a much higher rate than is the use of illicit drugs (Manchikanti, 2007). A 2005 survey by the National Center on Addiction and Substance Abuse (CASA) at Columbia University found that in 2003, 2.3 million adolescents between 12 and 17 years of age (9.3%) had misused prescription drugs. This age group constituted 15.4% of all U.S. prescription drug misusers, second 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, Bachman, & 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 who misuse medications are likely to misuse more than one 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 abuse of illicit drugs. This is often done for the purpose of either accentuating a high or counteracting the effects of 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) acknowledged preferring prescription pain relievers to illicit drugs because they are readily available and affordable, as well as for their higher level of acceptability than that of illicit drugs (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 help them lose weight, and to relieve pain (Boyd, McCabe, Cranford, & Young, 2006; Friedman, 2006). Thus, these prescription medications are likely 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 having borrowed prescription medications, 165 had shared their S2

5 own medications with others, and 115 had done both. Of those respondents 12 to 18 years of age who reported ever borrowing or sharing medications, only 3.8% stated that they would not share prescription drugs with their peers (Daniel, Honein, & Moore, 2003). Figure 2 provides a summary of commonly misused prescription medications (Johnston, O Malley, Bachman, & Schulenberg, 2007a; National Institutes of Health, 2007). The three classes of medications that are most often misused are opioids, central nervous system (CNS) depressants, and stimulants (National Institute on Drug Abuse, 2005). Of the adolescents who reported misusing prescription drugs in the CASA study, 83.4% misused opioids; 24.6% and 5.6% misused tranquilizers and sedatives, respectively; and 25.1% misused stimulants at least once in the previous year (CASA, 2005). In 2004, the prevalence of dependence or abuse of prescription drugs in the past year among adolescents between 12 and 17 years of age was 15.9%, compared with 12.7% among those 18 to 25 years of age (Office of Applied Studies, 2006a). The rate of dependence on or abuse of pain relievers increased steadily among adolescents from 2002 to 2004 (Office of Applied Studies, 2006b). Table 2 (page S4) describes the major effects of each class of prescription medications (National Institute on Drug Abuse, 2005). In addition to the possibly dangerous impact on cardiovascular, respiratory, and neurologic functioning that these drugs can have, they all carry the potential for physical dependence and addiction. Although Americans constitute only 4% of the world s population, they use 80% of its supply of all opioids (Manchikanti, 2007). This class includes analgesics such as oxycodone Table 1. Adolescents Rationales for Sharing Prescription Drugs (n=210) Rationale Respondents, %* Got it from a family member 66.2 Have a prescription but ran out 64.8 Have the same problem as the person who gave me the medicine Want something strong for pain or headache Have an emergency 39.0 Got it from someone who knows about medicine 28.1 Need help sleeping 21.9 Want something strong for pimples or oily skin Need the medicine but can t afford to buy it Have leftover medicine that would be wasted Want to relax or feel good 12.9 Have heard a lot about this medicine from ads or commercials 4.3 *Multiple reasons were accepted; therefore, total may exceed 100%. Note. Adapted with permission from Pediatrics, Vol. 111, Pages , Copyright 2003 by the AAP. Figure 2. Nonmedical Use of Prescription Psychotherapeutics by 12th graders in 2007 Any Rx Psychotherapeutic 15.4 Other Narcotics 9.2 OxyContin 5.2 Vicodin 9.6 Any Amphetamine 7.5 Ritalin 3.8 Sedatives Tranquilizers % With Nonmedical Use in Past Year Rx = prescription. Note. From Johnson, O Malley, Bachman & Schulenburg., 2007a; National Institutes of Health, S3

6 (e.g., OxyContin, Percocet ), hydrocodone (e.g., Vicodin ), fentanyl (Duragesic patches), and codeine (National Institute on Drug Abuse, 2005). Morphine, a potent pain reliever, was the first prescription opioid to be abused in the United States (CASA, 2005), and the abuse of opioids continues today. The Monitoring the Future study reported that OxyContin and Vicodin were the only individual prescription drugs whose use had increased among adolescents in 2005 (Johnston, O Malley, Bachman, & Schulenberg, 2007b). Fentanyl, however, is also being abused at increasing rates as users have learned how to extract the medication from the patches. In addition, a lozenge version is becoming popular for its ease Table 2. Effects of Commonly Prescribed Drugs OPIOIDS CNS DEPRESSANTS STIMULANTS Oxycodone (OxyContin, Percodan, Percocet) Propoxyphene (Darvon) Hydrocodone (Vicodin, Lortab, Lorcet) Hydromorphone (Dilaudid) Meperidine (Demerol) Diphenoxylate (Lomotil) Morphine (Kadian, Avinza, MS Contin) Codeine Fetanyl (Duragesic) Methadone Generally prescribed for: Postsurgical pain relief Management of acute or chronic pain Relief of cough and diarrhea In the body: Opioids attach to opioid receptors in the brain and spinal cord, blocking the perception of pain. Effects of short-term use: Alleviates pain Drowsiness Constipation Depressed respiration (depending on dose) Effects of long-term use: Potential for physical dependence and addiction Possible negative effects: Severe respiratory depression or death following a large single dose Barbiturates Mephobarbital (Mebaral) Pentobarbital sodium (Nembutal) Benzodiazepines Diazepam (Valium) Chlordiazepoxide hydrochloride (Librium) Alprazolam (Xanax) Triazolam (Halcion) Estazolam (ProSom) Clonazepam (Klonopin) Lorazepam (Ativan) Generally prescribed for: Anxiety Tension Panic attacks Acute stress reactions Sleep disorders Anesthesia (at high doses) In the body: CNS depressants slow brain activity through actions on the GABA system, producing a calming effect. Effects of short-term use: A sleepy and uncoordinated feeling during the first few days; as the body becomes accustomed (tolerant) to the effects, these feelings diminish Effects of long-term use: Potential for physical dependence and addiction Possible negative effects: Seizures following a rebound in brain activity after reducing or discontinuing use Dextroamphetamine (Dexedrine and Adderall) Methylphenidate (Ritalin and Concerta) Generally prescribed for: Narcolepsy Attention-deficit hyperactivity disorder (ADHD) Depressions that does not respond to other treatment In the body: Stimulants enhance brain activity, causing an increase in alertness, attention, and energy Effects of short-term use: Elevated blood pressure Increased heart rate Increased respiration Suppressed appetite Sleep deprivation Effects of long-term use: Potential for physical dependence and addiction Possible negative effects: Dangerously high body temperature or an irregular heartbeat after taking high doses Cardiovascular failure or lethal seizures 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, S4

7 of use. Because of its potency, abuse of fentanyl can easily lead to overdose and death (CASA, 2005). From the 1940s through the 1970s, when they came under federal control, amphetamines were used, probably in excess, to control weight, fatigue, and depression. Amphetamines continue to be abused by college students to keep them awake while studying or partying (CASA, 2005). The current class of stimulants comprises amphetamines, (e.g., Dexedrine and Adderall ) and methylphenidate, (e.g., Ritalin, Methylin ) (National Institute on Drug Abuse, 2005). These drugs are prescribed primarily to treat attention deficit-hyperactivity disorder (ADHD), with 90% of methylphenidate in the United States being prescribed for children and adolescents (Poulin, 2007). The increase in the prescription use of methylphenidate for ADHD in the past 10 years has contributed to its diversion and abuse or misuse by teenagers to get high, to stay awake and focused for studying, or to lose weight (CASA, 2005). The effort to minimize diversion of ADHD medications has resulted in the development of extended-release formulations of methylphenidate (e.g., Concerta ) and mixed amphetamine salts, as there appears to be a lower tendency for misuse or diversion of these formulations than of immediate-release formulations (Wilens, Gignac, Swezey, Monuteaux, & Biederman, 2006). CNS depressants include barbiturates such as phenobarbital (Nembutal ) and benzodiazepines such as diazepam (Valium ), clonazepam (Klonopin ), and chlordiazepoxide HCl (Librium ) (National Institute on Drug Abuse, 2005). Diazepam, said to be the Mother s Little Helper made famous by the Rolling Stones 1966 song of the same name, has been widely misused in the United States, often being prescribed for symptoms not warranting such a potent drug. It continues to be prescribed and misused at a high rate (CASA, 2005). Dependence on benzodiazepines can develop from both intentional and unintentional misuse. Unintentional misuse occurs when individuals take higher doses than intended or take prescribed medication for longer than intended but are not using these drugs for other reasons than those for which they were prescribed. Although dependence does not always result from misuse, it is a potential outcome (O Brien, 2005). The greatest danger with benzodiazepine misuse occurs if these drugs are used in combination with other CNS depressants, such as opioid analgesics or alcohol (National Institute on Drug Abuse, 2005). The additive effect of respiratory depression is potentially lethal. The adverse effects of misused prescription medications can have dire consequences. Between 2004 and 2005, the overall rate of visits to emergency departments related to nonmedical use of prescription drugs increased by 21%, with the benzodiazepine-associated rate increasing by 19% and the rate for opioids increasing by 24%. The rate of emergency department visits in 2005 that were related to prescription drug misuse by adolescents between 12 and 17 years of age was 193 per 100,000 population (Drug Abuse Warning Network, 2004). The overall rate of deaths due to unintentional poisoning increased from 1999 to 2004, with the largest increase (113.3%) among those between 15 and 24 years of age. The major cause of this trend has been attributed to overdose of opioid analgesics, followed closely by prescription psychotherapeutic drugs (Centers for Disease Control and Prevention, 2007). A study of adolescents in Washington, DC, found that of 633 emergency department visits between 1996 and 1998, 15% were drug related, and 19% were specifically related to prescription medications (Cheng, Wright, Pearson-Fields, & Brenner, 2006). Regrettably, prescription medications are not the only legal drugs being misused. Over-the-counter (OTC) medications, such as diet pills, sleep aids, cough medicine, and motion sickness aids, are being abused as well. Adolescents take large quantities of diet pills, either to get high or to lose weight quickly, and sleep and motion sickness aids can function as tranquilizers, stimulants, or even hallucinogens. Hospitals are reporting increasing numbers of cases of overdosed OTC medications, sometimes with fatal consequences (Teen Drug Abuse, 2008). By far the most commonly abused OTC medications are cold and cough medicines containing dextromethorphan. Taken in sufficient quantity, these products induce a hallucinogenic high. Adolescents have several names for dextromethorphan-containing medicines, such as dex, DXM, and skittles, and the act of getting high on products such as Robitussin is often called robotripping (James, 2006; Johnston, O Malley, Bachman, & Schulenberg, 2007b). OTC medications can also have adverse effects when abused, including blurred vision, loss of coordination, abdominal pain, muscle spasms, tachycardia, and delirium (Substance Abuse and Mental Health Services Administration, 2008). In the Washington, DC, study, 23% of visits to emergency departments were related to OTC drugs (Cheng, Wright, Pearson-Fields, & Brenner, 2006). Further, the combination of OTC and prescription drugs, or of either or both of these with alcohol, can have even more deleterious effects. [Addiction occurs] because over time, use of addictive drugs changes the brain Alan I. Leshner, PhD, Former Director, National Institute of Drug Abuse Little is known about the potential long-term effects of medication misuse on the developing adolescent brain (Friedman, 2006). Alan I. Leshner, former Director of the National Institute of Drug Abuse, points out that addiction results from gradual changes in the brain, sometimes very subtle, caused by continued abuse of medications. He emphasizes that although many different drugs may be implicated in brain changes, the effects are often quite similar. The changes may involve mood swings, alteration in memory processes, or impairment of motor skills (Leshner, 2005). Research demonstrating that the brain is still in development during adolescence supports the suggestion that drug misuse during this period could result in permanent cognitive damage (Giedd, 2008; Gogtay, Giedd, Lusk, Hayashi, Greenstein, Vaituzis, Nugent, Herman, Clasen, Toga, Rapoport, & Thompson, 2004). S5

8 MYTHS CONTRIBUTING TO INCREASED MISUSE Several common misconceptions among adolescents and their families contribute to the high rate of prescription medicine misuse. These include, but are not limited to, the following: MYTH: There is no such thing as abuse of prescription 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 adolescents, grades 7 through 12, surveyed saw no great risk in nonmedical use of prescription drugs. A majority of teens surveyed also believed that prescription medications, even when prescribed for someone else, are safer to use than are illegal drugs (Partnership for a Drug-Free America, 2005). The principle of good medicine, bad behavior, meaning that drugs that can be very helpful when used appropriately can be extremely harmful when misused, clearly needs further reinforcement. All substances are poisonous; there is none which is not a poison. The right dose differentiates a poison from a remedy. Paracelsus (Theophrastus Bombastus von Hohenheim), ~1538 people metabolize many drugs, including antidepressants and opioid analgesics. Those who metabolize a drug rapidly may need higher doses to achieve an effect, whereas those who metabolize the same drug slowly may experience toxicity at a similar dose of that same drug (Caraco, 2004; Merck & Co., 2003). In other words, what can help one person may have no effect on another and could be lethal to a third. MYTH: If drugs are used only occasionally, they can t hurt anybody. A common impression is that there is little risk in occasional use of medications (Friedman, 2006). Many of the adolescents responding to the PATS survey believed that prescription pain relievers are not addictive. About one third of these adolescents believed that occasional nonmedical use of others prescription medications is not harmful or addictive (Partnership for a Drug-Free America, 2005). Teenagers frequently do not understand the variation in addiction potential from user to user of a medication. They never think that it s going to be them. Parents will sometimes think their kids may get into trouble with drugs 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 more. The most obvious example refuting this myth related to nonsteroidal anti-inflammatory drugs (NSAIDs), which are available as both prescription and OTC medications. Although these drugs, taken at recommended doses, can provide effective analgesia, overdosing on NSAIDs, or even their long-term use at standard doses, can result in severe gastrointestinal damage and even kidney or heart failure (Mercola, 2004; Moore, Derry, Phillips, & McQuay, 2006). In addition, an increase in dose is accompanied by an increase in potential adverse effects. MYTH: If it worked for Mom, it will work for me. VARIATION ON MYTH: If it worked for me, it will work for my friend who has the same problem/ symptoms. PARENT S MYTH: If it worked for me, it will work for my kid. Adolescents and frequently their parents need to be educated about the fact that different people can have quite varied responses to the same dose of the same medication. As shown in Figure 3, a variety of factors affect individuals responses to drugs. In addition to age, weight, height, and concomitant use of other substances, a primary differentiating factor involves genetics (Merck & Co., 2003). Genetic variations related to the cytochrome P-450 family of enzymes determine the rate at which different Occupational exposures Infection Disease Barometric pressure Sunlight Exercise Mary Louise Embrey, NASN Director of Government Affairs Drug Abuse Prevention Consultant Figure 3. Factors Affecting Responses to Drugs Psychologic status Lactation Drugs Pregnancy Circadian and seasonal variations Sex Dietary factors Drug Response Age Cardiovascular function Tobacco or marijuana smoking Gastrointestinal function Alcohol intake Immunologic function Behavior Liver function Renal function Albumin concentration Stress Fever Starvation Note. From The Merck Manual of Medical Information Second Home Edition, p. 74, edited by Mark H. Beers. Copyright 2003 by Merck & Co., Inc., Whitehouse Station, NJ. Available at: Accessed February 1, S6

9 MYTH: This is someone else s problem, not ours. PARENT S VERSION: Not my kid. TEEN S VERSION: It can t happen to me. It is a typical human trait to assume that a problem pertains 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. Misuse 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 drugs, in terms of both finding them at home and being able to afford buying them from peers or the Internet, than do adolescents from lower socioeconomic classes. In the large National Survey on Drug Use and Health, the highest percentage of new adolescent nonmedical users of pain relievers were in the family income bracket ranging from $20,000 to $50,000 per year, followed closely by those in the bracket of $75,000 per year or more (Office of Applied Studies, 2006d). MYTH: OTC drugs are even safer than prescription drugs or they would not be available OTC. 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 inappropriately can be just as dangerous as other drugs and have the same risks for interactions with other drugs, foods, and conditions. They also carry a risk of side effects that can Figure 4. Nonmedical Use of Prescription Psychotherapeutic Drugs by Demographics* % Using in Past Year Ethnicity White Black Asian Native American *Note. Based on statistics. From Office of Applied Studies 2006c. Education Some High school High School Graduate Some College College Graduate Figure 5. Lifetime Prevalence of Non-prescribed Use of Pain Relievers Among Adolescents Aged Years (Unweighted N=18,678) 14% 12% 10% 8% 6% 4% 2% 0% $0 $19,999 $20,000 $39,999 $40,000 $74,999 Family Income $75,000 or more Note. From Wu, Pilowsky & Patkar, Data were drawn from the public use data file of the 2005 U.S. National Survey on Drug Use and Health. be just as great as that with prescription medications. As with misused prescription medications, taking multiple OTC medicines that contain the same ingredient carries the danger of accumulating and overdosing on that ingredient, even if each drug is used within its indicated limitations (Mercola, 2004). OTHER FACTORS CONTRIBUTING TO INCREASED MISUSE Many factors contribute to the increasing prevalence of prescription drug abuse. Among these are the increasing accessibility 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 regarding the extent, potential consequences, and means of minimizing the problem. Accessibility of Drugs and Information Figure 6 (page S8) summarizes the results of one US survey addressing adolescents access to prescription pain relievers (Office of National Drug Control Policy, 2007). More than 65% of respondents reported friends or relatives as sources of prescription medications. A recent Canadian study reported that more than one fourth of adolescents 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 obtaining drugs from friends, most times at little or no cost. The other most popular source of prescription medication is the student s own home. Sixty-two percent of respondents in the PATS survey stated that prescription pain relievers were readily available in their home medicine cabinets (Partnership for a Drug-Free America, 2005). No doubt, teenagers also can find prescription drugs at grandparents and other family members homes. The ready availability of prescription S7

10 Figure 6. Sources of Prescription Pain Relievers for Adolescents 10.2% 47.3% 10.0% Other Bought (stranger) >1 Physician Internet (0.1%), Fake Rx (0.1%), Stole* (0.5%) 6.3% 4.5% 2.6% 0.7% 18.3% 1 Physician Friend (given) Friend/Relative (stole) Friend/Relative (bought) *From physician s office, clinic, hospital, or pharmacy. Rx = prescription. Note. Adapted from Office of National Drug Control Policy, Executive Office of the President, medication in adolescents own or families homes highlights the need for increased educational efforts targeting families regarding safeguarding and monitoring prescription medications in the home. The Internet has become a pharmaceutical candy store stocked with addictive drugs, available at the click of a mouse to any kid with a credit card number. Joseph A. Califano, Jr., Chairman and President, CASA A recent survey by Teenage Research Unlimited found that 58% of respondents were aware of the availability of prescription drugs on the Internet (Teenage Research Unlimited, 2006), and more than 7 million respondents in the PATS results indicated that they believe it is easy to buy drugs over the Internet (Partnership for a Drug-Free America, 2005). Estimates vary regarding the extent to which adolescents use the Internet as a source of drugs, but opportunities no doubt exist. In 2007, CASA reported that they found 581 Web sites that advertise or sell controlled prescription drugs, up from 342 in The number of sites that sell controlled prescription drugs increased from 154 in 2004 to 187 in 2007 (7%), and only 2 of the 187 sites were certified Internet pharmacy sites. Furthermore, 84% of these 187 sites did not require prescriptions, and more than half of the other 16% did not require original prescriptions but accepted faxed copies (CASA, 2005). In addition to the Internet s being a source of drugs, it also is a source of information on their use. Several Web sites exist that provide instructions regarding how to use OTC and prescription medications to get high, even identifying doses based on height and weight (Leinwand, 2003). 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 panaceas rather than dangerous substances (CASA, 2005). The media may contribute to the attraction of prescription medications 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 medications increases. Adolescents also believe there is less stigma attached to the nonmedical use of prescription medications than to the use of illicit drugs (Partnership for a Drug-Free America, 2005). The impression that prescription medications are safer and more acceptable may be contributing to the growth of a practice sometimes called pharming parties, where teenagers bring whatever prescription medications they can obtain. There the adolescents may barter one drug for another, or they may pool all the pills in a bowl from which each may take a handful of different pills. This combination is often taken along with alcohol. Although, like teenage prescription drug abuse in general, pharming parties have not been scientifically tracked, their frequent mention in the popular media and attention from official organizations suggest that this phenomenon is real and increasing (Banta, 2005; O Brien, 2005; Parents: The Anti-Drug, 2006). Mixing drugs with one another or with alcohol can intensify the effects of either substance alone or create new, more dangerous effects, as described in Table 3 (National Institute on Alcohol Abuse and Alcoholism, 2007; National Institute on Drug Abuse, 2005; Parents: The Anti-Drug, 2006). Ignorance Regarding the Problem If I get a narcotic from a dentist [I m guilty] of not counting them when I get home, or not watching them that closely, or not disposing of them properly when I am through with them, and I m a healthcare professional. Registered Nurse Stephen J. Pasierb, President of the Partnership for a Drug- Free America, recently testified before the United States Senate Committee on the Judiciary, Subcommittee on Crime and Drugs. He stated that parents who are usually our most valuable ally in preventing teen drug use are generally S8

11 Table 3. Drug Interactions Drug Type Mixed With Possible Adverse Interactions Opioid CNS Depressant Stimulant Cold and cough medicine Alcohol, antihistamines, barbiturates, benzodiazepines Alcohol, prescription pain medications, OTC cold and allergy medications Alcohol OTC decongestants* Alcohol Increased respiratory depression, impaired motor control Respiratory depression, impaired motor control, dangerously slowed heartbeat Need to drink more to feel effect of alcohol Arrhythmia, dangerously high blood pressure Increased drowsiness, dizziness, risk of overdose *This does not include decongestant sprays. CNS = central nervous system Note. From National Institute on Drug Abuse, 2005; National Institute on Alcohol Abuse and Alcoholism, 2007; Parents: The Anti-Drug, ill equipped to deal with teens abuse of prescription drug use, a behavior that was probably not on their radar when they were teenagers. They find it hard to understand the scale and purposefulness with which today s teens are abusing medications, and it s not immediately clear to them that the prime source of supply for abusable prescription drugs is likely to be their own medicine cabinet. Further, many parents themselves are misusing, or perhaps abusing, prescription drugs without having a prescription. In our study, 28% of parents said they had used a prescription drug without having a prescription for it, and 8% of parents said they had given their teenaged child an Rx drug that was not prescribed for the teen (United States Senate Committee on the Judiciary, 2008). One pill makes you larger, and one pill makes you small, and the ones that mother gives you don t do anything at all. Grace Slick, White Rabbit disposing of pills safely when they are finished using them or the period of highest potency of the pills has expired (MSNBC.com, 2007). In fact, it is reasonable to assume that parents would be unaware if their children stole prescription medicine from them. Adolescents are frequently more experienced in using the Internet than their parents are. The survey by Teenage Research Unlimited (2006) noted that the majority of teenagers interviewed had bought or knew someone who had bought alcohol on the Internet and stated that their parents could not control their Internet activities. In fact, 68% reported that their parents never tried to control their Internet activities, and 39% said that their parents knew little or nothing about their Internet activities. Only 25% reported that their parents knew a great deal about their Internet activities. These findings probably are equally applicable to the accessibility of drugs on the Internet. The discrepancy between adolescents skill at navigating the Internet and their parents awareness of this ability likely enhances the ease with which teenagers can obtain drugs on the Internet. On the other hand, adolescents often are not aware of the potent effects on cognition and motor skills some commonly available drugs can have or of their potential harm, including death, even at small doses (Friedman, 2006). This is not surprising considering that adults in one study ranked NSAIDs among the safest prescription medications and, overall, underestimated the rates of adverse reactions possible with several prescription medications (Cullen, Kelly, & Murray, 2006). If parents are not aware of the risks, their children should not be expected to be aware either. RECOGNIZING THE PROBLEM Because of our unique position within the schools, students trust and confide in school nurses. We need to be prepared to respond accordingly when we hear about the misuse of prescription drugs, including drugs being mixed with alcohol or stimulant drinks. It is important to keep abreast of current trends, as students have access to so much information on the Internet that can be potentially lethal. Paula Apa-Hall Past-President, Oregon School Nurses Association Board of Directors, National Association of School Nurses Unfortunately, the statement in the Jefferson Airplane song does not apply to the pills that adolescents may take from their parents supply of prescription medication. These may do quite a bit of damage. It has been observed that parents frequently do not keep track of or control their own medications by counting pills periodically, locking up prescription medications the way they might lock away liquor, or The school nurse, a trusted health care professional, is in a unique position to be the first to recognize that a student has a problem with misuse of prescription medications. The school nurse s relationship with students is unlike that of others in that the nurse is available to the student outside of the classroom or the student s home. Therefore, students frequently feel that they can confide in the school nurse S9

12 without risking consequences such as being judged, having their privileges revoked or curtailed, or receiving lower marks in classes. With the exception of information regarding potential harm to the student or others, the school nurse can offer confidentiality to students in discussing any problems they may have with drugs. Additionally, the school nurse is in a position to educate students, teachers, and parents, as well as others in the community, about trends in prescription drug abuse and signs indicating that a problem might exist. The insidious nature of this problem makes it difficult to recognize in many cases. The signs of prescription or OTC medication abuse are not always as apparent as those of illicit drug abuse. For example, teachers may be accustomed to identifying drug use based on the odor of marijuana smoke or the presence of injection paraphernalia, pipes, or rolling papers, none of which is involved in the misuse of prescription and OTC medications. Thus, without looking for the signs associated with this type of drug abuse, teachers and parents may miss it entirely (Manchikanti, 2006). Signs that should warn parents, teachers, and nurses that there might be a problem with student medication misuse include (New York State Office of Alcoholism and Substance Abuse Services, 2007): Uncharacteristic loss of enthusiasm or symptoms of depression Irritability or hypersensitivity to criticism Truancy and/or withdrawal from usual activities An unexplained drop in school performance and grades Loss of interest in hygiene or appearance An unexplained change in the student s group of friends School nurses who observe any of these signs in a student, particularly if they are uncharacteristic, should initiate an investigation into potential problems. A straightforward conversation with the student may be the best approach. In an atmosphere of confidentiality, the nurse can even ask the student, What have you taken today? This may yield better results than a more open question. Teachers, administrators, and other school personnel need to be educated by the school nurse to recognize medication misuse problems among students (Manchikanti, 2006). Teachers should become familiar with medication policies in their school district and state, as well as with national guidelines, regarding privacy/confidentiality, self-medication at school, and boundaries of investigation, (for example, when is it permissible to search a student s locker?). ADDRESSING THE PROBLEM As with the recognition of prescription medication misuse among students, school nurses play a pivotal role in management of the problem. They are in a position to coordinate and lead the implementation of substance abuse prevention programs, as well as to educate all involved parties regarding management options and the importance of early control of the problem. Further, school nurses can refer students for treatment when necessary or at least advise parents to take their children for treatment, at the same time serving as an advocate for the student when appropriate. Education may occur at several levels and involve several types of people. Certainly, adolescent students are the primary recipients of education by the school nurse. The information included herein needs to be conveyed to them in ways that they will find acceptable and that will be easy for them to retain. Delivering facts in short, easily digested spurts has been found to be effective. Also, reinforcing the learning with illustration and repetition, as well as by having students paraphrase back what they have heard, is advisable. Although high school health classes often address use of illicit drugs, the majority do not cover misuse of prescription medications (Manchikanti, 2006). Parents and other family members also need education about recognition of a medication misuse problem in their teenagers and safeguarding and taking periodic inventory of medications in their possession. H. Wesley Clark, Director of the Center for Substance Abuse Treatment of the U.S. Substance Abuse and Mental Health Services Administration, has stressed the importance of physicians and pharmacists advising people to keep drugs in a secure place and safely dispose of drugs that have expired or that they do not intend to use (McCarthy, 2007). This includes locking medicine cabinets just as liquor cabinets are locked and periodically counting pills to ensure that no one else is using the medication. Because a great deal of adolescent behavior is learned from models observed at home, parents need to be told of the danger of casually sharing medications with other adult family members because of the example this sets for their adolescent children (Levine, 2007). Because parents do have such strong influence on their children, it is important that they establish an ongoing dialogue regarding the dangers of drug abuse. See page S15 of this supplement for help in getting started. Parents need to be made aware of school policies regarding self-medication, as they may not know that their teenagers are being exposed to drugs at school, albeit by other students who are legally permitted to have those drugs. The American Academy of Pediatrics (AAP) issued a policy statement regarding medication administration in school. The AAP points out that where states have their own guidelines for medication use in school, confusion can be minimized for all involved (American Academy of Pediatrics, 2003). As of 2001, 37 states had developed policies or regulations regarding medication administration in schools (Figure 7). 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 local policies, assuming these policies do not contradict state or federal regulations (Enotes.com). The AAP (2003) note when state guidelines do not exist or are not sufficiently specific, individual school boards and administrators, including school nurses, should establish S10

13 Figure 7. States That Have Developed Policies or Regulations Regarding Medication Administration in Schools Map not drawn to scale Note. From Enotes.com. policies with which students must comply. They further advise that all medication brought to school should be in appropriately labeled containers and accounted for at the end of a selected period. Students who are allowed to self-medicate at school need to be taught repeatedly to act responsibly (e.g., not to leave their medications in the restroom). Figure 8 (page S12) is an example of a student self-medication agreement. The lay public is not the only segment of society that requires education. Physicians may not always recognize that adolescents have problems with prescription drug abuse. The 2005 CASA survey included physicians and pharmacists, yielding some startling information. Of the physicians surveyed, only 19% had received any instruction in medical school regarding recognition of prescription drug diversion, and more than half of these reported receiving only a few hours of instruction. Of the nearly 40% who had received instruction in identification of prescription drug addiction or abuse, half had received only a few hours of instruction. Although the percentages of any instruction rose during internship and residency, the amount of training received did not change substantially. Similarly, only about half of the pharmacists responding to the CASA survey had received instruction in dispensing controlled drugs, preventing their diversion, or identifying abuse of or addiction to these medications (CASA, 2005; National Institute on Drug Abuse, 2005). School nurses should be aware of the options for treating prescription drug misuse or dependence. Primarily, these comprise behavioral and pharmacologic approaches. Depending on the drug of abuse and the extent of a student s involvement with or dependence on the drug, the treatment may consist of counseling alone, detoxification along with counseling, or, if necessary, medications to counter the effects of the culprit drugs. In the case of opioid addiction, combining opioid agonist maintenance therapy with counseling is most likely necessary for success (National Institute on Drug Abuse, 2005). Tools that school nurses can use in their educational efforts include the following: Literature in the nurse s office charts on the walls and brochures and information sheets that can be given to students and their parents Videos and slides that can be shown to students and parents Seminars for parents, particularly at the beginning of the school year, explaining the extent of the problem and the signs to look for Lists of resources offering further help and information to parents and students S11

14 Figure 8. Sample Self-Medication Agreement (Courtesy of Paula Apa-Hall, RN, MEd, NCSN) Students who are developmentally and/or behaviorally able will be allowed to self-administer prescription and nonprescription medication without the assistance of trained school personnel, subject to the following: 1. A Medication Authorization form must be submitted for self-administration of all prescription and nonprescription medication. 2. A physician must sign giving permission for a student to self-administer prescription medications (except inhalers). 3. All prescription and nonprescription medication must be kept in its appropriately labeled original container. 4. The student may have in his or her possession only the amount of medication needed for that school day. Prescription labels must specify the name of the student, name of the medication, dosage, route, and frequency or time of administration, and any other special instructions. Nonprescription medication must have the student s name affixed to the original container. 5. Sharing and/or borrowing of medication between students is strictly prohibited. 6. Permission to self-medicate may be revoked if the student violates school district policy governing administration of noninjectable medication and/ or these regulations. Additionally, the student may be subject to discipline, up to and including expulsion, as appropriate. I have read and agree to the above criteria and give permission for my child to carry his/her medication. (Parent/guardian signature) I agree to comply with the above criteria. (Student signature) The online toolkit that is a companion to this supplement provides some of these materials in a no-cost, readily available form. This toolkit can be accessed under Educational Campaigns on the right side of the NASN home page ( CONCLUSION Whichever term is used to describe it, misuse/diversion/abuse of prescription and OTC medications is a present and growing problem among adolescents. Prompt recognition of this problem is essential to controlling it, as early intervention can substantially reduce the risks of dependence, addiction, and permanent damage or death. People s health status can change at any time; they may become ill or incur injuries. Therefore, prescription medications may be brought into households where they were not previously kept. The type of abuse discussed in this supplement involves drugs that are not considered illegal but rather medicines used to treat specific symptoms or illnesses. Therefore, education, is key to preventing the potentially dire consequences of medication misuse. School nurses are in a position to play pivotal roles in controlling and preventing adolescent drug abuse. They may be the first to recognize that there is a problem. They also may be the only people in whom students feel they can confide; they are able to refer students with suspected or acknowledged problems for treatment; and, perhaps most importantly, they may be the best source of information and education for students, parents, teachers, and other school staff. The results of the NASN survey make it clear that most school nurses understand that there is a problem and are eager to take an active part in its management. To do this, they need information for themselves and tools to help them educate others. This supplement, along with the toolkit available online, will contribute to school nurses educational resources and facilitate their efforts to control and prevent the effects of the misuse of prescription medications. Acknowledgement: This supplement was supported by an educational grant from PriCara, Division of Ortho-McNeil- Janssen Pharmaceuticals Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC. REFERENCES American Academy of Pediatrics. (2003). Guidelines for the administration of medication in school. Committee on School Health. Pediatrics, 112(3 Pt 1), Banta, C. (2005). Trading for a high [Electronic Version]. Time, 166. Retrieved January 22, 2008 from article/0,9171, ,00.html. Boyd, C. J., McCabe, S. E., Cranford, J. A., & Young, A. (2006). Adolescents motivations to abuse prescription medications. Pediatrics, 118(6), Caraco, Y. (2004). Genes and the response to drugs. New England Journal of Medicine, 351(27), CASA. (2005). Under the counter: The diversion and abuse of controlled prescription drugs. Retrieved September 19, 2007, from medpagetoday.com/psychiatry/addictions/tb1/1322?pfc=101&spc=235 Centers for Disease Control and Prevention. (2007). Unintentional poisoning deaths--united States, MMWR Morbity and Mortality Weekly Report, 56(5), Cheng, T. L., Wright, J. L., Pearson-Fields, A. S., & Brenner, R. A. (2006). The spectrum of intoxication and poisonings among adolescents: surveillance in an urban population. Injury Prevention, 12(2), Cullen, G., Kelly, E., & Murray, F. E. (2006). Patients knowledge of adverse reactions to current medications. British Journal of Clinical Pharmacology, 62(2), S12

15 Daniel, K. L., Honein, M. A., & Moore, C. A. (2003). Sharing prescription medication among teenage girls: Potential danger to unplanned/ undiagnosed pregnancies. Pediatrics, 111(5 Pt. 2), Drug Abuse Warning Network. (2004). The DAWN Report. Narcotic analgesics, 2002 update. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Enotes.com. Administering medicine. Encyclopedia of Everyday Law. Retrieved February 14, 2008, from Friedman, R. A. (2006). The changing face of teenage drug abuse the trend toward prescription drugs. New England Journal of Medicine, 354(14), Giedd J. (2008). Interview. PBS Frontline. Retrieved February 20, 2008, from giedd.html Gogtay, N., Giedd, J. N., Lusk, L., Hayashi, K. M., Greenstein, D., Vaituzis, A. C., Nugent, T. F., 3rd, Herman, D. H., Clasen, L. S., Toga, A. W., Rapoport, J. L., & Thompson, P. M. (2004). Dynamic mapping of human cortical development during childhood through early adulthood. Proceedings of the National Academy of Sciences of the United States of America, 101(21), James, S. D. (2006). Robotripping grows in 9-17 age group: Cold and cough medicine abuse now rivals meth, cocaine. Retrieved January 28, 2008, from Johnston, L. D., O Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2007a) Data from in-school surveys of 8th-, 10th- and 12th-grade students. Retrieved January 28, 2008, from monitoringthefuture.org/data/07data.html Johnston, L. D., O Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2007b). Monitoring the future. National survey results on adolescent drug abuse. Overview of key findings, (NIH Publication No ). Bethesda, MD: National Institute on Drug Abuse. Leinwand, D. (2003, December 28). Youths risk death in latest drug abuse trend. USA Today. Retrieved January 21, 2008, from com/news/health/ drug-abuse-cover_x.htm?loc=interstitiaskip Leshner, A. I. (2005). Oops: How casual drug use leads to addiction. Retrieved March 3, 2008, from Articles/Oops.html Levine, D. A. (2007). Pharming : The abuse of prescription and over-thecounter drugs in teens. Current Opinion in Pediatrics, 19(3), Manchikanti, L. (2006). Prescription drug abuse: What is being done to address this new drug epidemic? Testimony before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Physician, 9(4), Manchikanti, L. (2007). National drug control policy and prescription drug abuse: Facts and fallacies. Pain Physician, 10(3), McCarthy, M. (2007). Prescription drug abuse up sharply in the USA. Lancet, 369(9572), Merck & Co., Inc. (2003). The Merck manual of medical information second edition. Retrieved January 29, 2008, from mmhe/print/sec02/ch013/ch013a.html Mercola, J. (2004). Seven common misconceptions about Tylenol and other OTC drugs. Retrieved January 22, 2008, from chattanoogahealth.com/authors/164/joseph_mercola%2c_do.aspx Moore, R. A., Derry, S., Phillips, C. J., & McQuay, H. J. (2006). Nonsteroidal anti-inflammatory drugs (NSAIDs), cyxlooxygenase-2 selective inhibitors (coxibs) and gastrointestinal harm: review of clinical trials and clinical practice. BMC Musculoskelet Disord, 7, 79. MSNBC.com. (2007). Teen abuse of prescription pills persists: Drug czar says youths get them online, from friends, medicine cabinets. Retrieved January 28, 2008, from displaymode/1098/ National Association of School Nurses. (2007). NASN prescription drug abuse 4-question survey. National Institute on Alcohol Abuse and Alcoholism. (2007). Harmful interactions: Mixing alcohol with medicines. Retrieved January 22, 2008, from National Institute on Drug Abuse. (2005). Prescription drugs: Abuse and addiction (No. NIH Publication No ). National Institutes of Health. (2007, December 11). NIDA survey shows a decline in smoking and illicit drug use among eighth graders. Prescription drug abuse still high for 12th graders. NIH News. Retrieved April 1, 2008, from New York State Office of Alcoholism and Substance Abuse Services. (2007). Addiction medicine teens and prescription drug abuse. Retrieved February 12, 2008, from teenrsabuse.cfm O Brien, C. P. (2005). Benzodiazepine use, abuse, and dependence. Journal of Clinical Psychiatry, 66(Suppl 2), Office of Applied Studies. (2006a). Misuse of prescription drugs: Highlights. Retrieved January 22, 2008, from High.htm Office of Applied Studies. (2006b). Misuse of prescription drugs: Prescription drug dependence, abuse, and treatment. Retrieved January 22, 2008, from Office of Applied Studies. (2006c). Misuse of prescription drugs: Prevalence and recent trends in misuse of prescription drugs. Retrieved January 22, 2008, from Office of Applied Studies. (2006d). Nonmedical users of pain relievers: Characteristics of recent initiates. The National Survey on Drug Use and Health (NSDUH) Report. Retrieved February 2, 2008, from samhsa.gov/2k6/pain/pain.htm Office of National Drug Control Policy, Executive Office of the President. (2007). Teens and prescription drugs. An analysis of recent trends on the emerging drug threat. Retrieved March 1, 2008, from mediacampaign.org/teens/brochure.pdf Parents: The Anti-Drug. (2006). Prescription drug abuse. Retrieved January 28, 2008, from prescription_drugs.asp Partnership for a Drug-Free America. (2005). The Partnership Attitute Tracking Study (PATS): Teens in grades 7 through 12. Retrieved November 29, 2007, from Poulin, C. (2007). From attention-deficit/hyperactivity disorder to medical stimulant use to the diversion of prescribed stimulants to non-medical stimulant use: Connecting the dots. Addiction, 102(5), Substance Abuse and Mental Health Services Administration. (2008, January 10). New study reveals more than 3 million adolescents and young adults have used non-prescription cough and cold medicine to get high at least once in their lifetimes. Retrieved March 1, 2008, from samhsa.gov/newsroom/advisories/ aspx Teen Drug Abuse. (2008). Over-the-counter drug abuse. Retrieved January 21, 2008, from drug_abuse.html Teenage Research Unlimited. (2006). Research findings: underage alcohol access & consumption. Internet, phone, and mail. Retrieved September 18, 2007, from TRUSurvey pdf The National Center on Addiction and Substance Abuse at Columbia University. (2005). Under the counter: The diversion and abuse of controlled prescription drugs. Retrieved September 19, 2007, from &spc=235 United States Senate Committee on the Judiciary, Senate Subcommittee on Crime and Drugs and the Senate Caucus on International Narcotics Control (2008). Generation Rx: The abuse of prescription and over-the-counter drugs. Testimony of Stephen J. Pasierb. Retrieved April 1, 2008, from Wilens, T. E., Gignac, M., Swezey, A., Monuteaux, M. C., & Biederman, J. (2006). Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications. Journal of the American Academy of Child and Adolescent Psychiatry, 45(4), Wu, L. T., Pilowsky, D. J., & Patkar, A. A. (2008). Non-prescribed use of pain relievers among adolescents in the United States. Drug and Alcohol Dependence, 94(1-3), S13

16 CNE Questions 1. Between 2004 and 2005, the rate of emergency department visits related to nonmedical use of prescription drugs increased by a. 4% b. 15% c. 21% d. 35% 2. In 2003, about adolescents misused prescription drugs. a. 100,000 c. 2.3 million b. 1.7 million d. 5.6 million 3. Prescription psychotropics are abused. a. less than any other class of drugs b. more than any other drug except marijuana c. more than any other drug, including marijuana d. about as often as cocaine 4. Most teenagers who misuse prescription medications also use other drugs, including alcohol. a. True b. False 5. In one survey, about % of adolescents said that they would share prescription medications with their peers. a. 25 b. 96 c. 8 d Americans use about % of the world s opioids. a. 20 b. 40 c. 60 d Pharming refers to: a. growing one s own marijuana b. sharing multiple prescription drugs at parties c. buying drugs on the Internet d. selling drugs at school 8. Robotripping refers to: a. getting high on OTC cough/cold medicines b. getting so high that one loses coordination c. getting high and playing video games d. going through the school day without paying attention 9. Between 1999 and 2004, the greatest increase in deaths due to unintentional drug poisoning occurred among those between years of age. a. 65 and 85 c. 25 and 34 b. 45 and 54 d. 15 and Of all of the certified Internet pharmacy sites, how many do not require a prescription? a. 15% b. 46% c. 84% d. all require a prescription 11. Parents are typically very aware of their children s misuse of prescription medications. 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 friends or relatives. a. 27 b. 47 c. 67 d. 87 CNE EXAM AND EVALUATION (2.0 CNE Contact Hours free to the first 2,000 members) To receive CNE credit and a certificate, please complete the post-test and evaluation online at Your CNE certificate will be automatically generated upon completion. If you are unable to complete the post-test and evaluation online, please mail the below form to: National Association of School Nurses 8484 Georgia Avenue, Suite 420 Silver Spring, MD Attn: Marianne Engle Processing will take approximately 6-8 weeks. CE REGISTRATION/POSTTEST ANSWER FORM/EVALUATION FORM Record your posttest answers by filling in the blank with the letter from the correct answer to the corresponding question: COURSE EVALUATION We hope this program has provided information that will be useful in your practice. Your evaluation will help us plan future programs. May we have your comments? Please evaluate this publication by circling your response(s). 4 = Strongly Agree N/A = Not Applicable 3 = Agree 2 = Disagree 1 = Strongly Disagree The course objectives were met N/A The course was informative and N/A well organized. The topic(s) presented were N/A pertinent to school nursing. The course contributed to my N/A professional growth. The content was NOT affected N/A by commercial interest. Comments: Name Address Member ID S14

17 In an effort to create a national movement, the Partnership for a Drug- Free america launched Time To Talk a year-round awareness campaign to encourage parents, family members and caregivers to begin talking with their children and teens about the risks of alcohol and drugs. Urgent health issue. Everyday, on average, more than 4,000 kids (ages 12-17) try an illegal drug for the first time. Nearly all cases of addiction begin with teenage or pre-teen drug and alcohol use. Why set aside time for this? Partnership research shows that kids who learn consistently from their parents about the dangers of drugs are 50% less likely to use than those who do not. Yet only about 3 in 10 kids report learning a lot about the risks of drugs from their parents. Of greater concern is that in recent years the number of frequent discussions between parents and teens about the risks of drug abuse has decreased significantly. With over 20 years of experience working with parents, tweens and teens, the Partnership has a deep and nuanced understanding of how to communicate about this health issue. Research underscores the fact that parents are the most powerful influence in a child s life, more so than popular music, peers, television, celebrities and the media. They provide the greatest leverage in preventing and stopping alcohol and drug abuse in their kids. But parents tell us they need the help and support from experts and each other. Time To Talk encourages parent participation by providing accessible, helpful tips, tools and resources not only to start but to also continue the conversation over the long haul. Parents are invited to sign up for free monthly e-newsletters at TimeToTalk.org and get exclusive access to great tools such as Get the conversation going and Help your kids turn down drugs and alcohol. Insightful, timely and relevant content and resources are updated and added frequently. And, parents seeking more in-depth drug information and guidance find links to the Partnership s award winning website, Visit TimeToTalk.org and sign up today! Strategic Partners: Our Strategic Partnerships with youth and parent serving organizations helps promote Time To Talk tips and tools to parents and a diverse group of caring adults to effectively engage with their kids across America. S15

18 Smart Moves, Smart Choices: A Prescription Drug Abuse Education Program The National Association of School Nurses recently launched Smart Moves, Smart Choices, a school-based program that provides resources to school nurses, teachers and parents to help address the growing rate of prescription drug abuse among middle and high school students nationwide. The program, a collaboration between NASN and PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. aims to educate teens about the serious risks of abusing prescription medicines, such as those used legitimately to treat pain. Prescription drug abuse among America s youth is surging. Every day, 2,500 youth age 12 to 17 abuse a prescription pain reliever for the first time 1 Nearly one-quarter of 12th graders report that they have abused prescription drugs by the time they graduate from high school 2 3 In 2006, more than 2.1 million teens abused prescription drugs The program includes four Web-based videos and lesson plans prepared for the.medic, a health and wellness feature of MacNeil/Lehrer Productions the.news, a new national news service for middle and high school students. Videos feature interviews with experts on drug abuse, scientists, health practitioners, parents and recovering teens. Each video is accompanied by science and language arts curricula to facilitate classroom activities and discussion. A fifth video was developed for parents. the.medic Video Topics Segment One: Myth Busting The truth behind teens common beliefs about prescription drugs and abuse. Segment Two: Science of Addiction Information on the physical consequences of prescription drug abuse on the developing brain. Segment Three: Changes for Life First-hand accounts from teens on how prescription drug abuse impacts relationships with family and affects social lives, participation in sports and academics. Segment Four: Media Literacy Analyzing messages in the media about abuse of prescription drugs by popular figures. Segment Five: What Parents Should Know Information for parents about prescription drug abuse, communicating with teens, recognizing signs of abuse and resources. Visit for more information about the program and to download materials. 1 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (October 18, 2007). The OAS Report: A Day in the Life of American Adolescents: Substance Use Facts. Rockville, MD. 2 Johnston, L. D., O Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2007). Monitoring the Future national results on adolescent drug use: Overview of key findings, (NIH Publication No ). Bethesda, MD: National Institute on Drug Abuse. 3 National Survey on Drug Use and Health (NSDUH), Office of Applied Studies. Substance Abuse and Mental Health Services Administration (SAMHSA). S16

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