Acknowledgements. Orange County Prescription Drug Task Force Prescription Drug Strategic Planning Session Attendees

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3 Acknowledgements This comprehensive report presents the distilled research and critical thinking of a diverse group of local experts in the alcohol and other drug prevention field. The County of Orange Health Care Agency s Alcohol and Drug Education and Prevention Team (ADEPT) would like to thank these leaders for their dedication to the field and for their thoughtful insights throughout this process. Orange County Prescription Drug Task Force Prescription Drug Strategic Planning Session Attendees In addition, a very special thanks to the following individuals and agencies for their contributions to this report: Community Service Programs, Inc. Project Positive Action Towards Health (PATH) Erica Leary, MPH North Coastal Prevention Coalition Michelle Poisson County of Orange Health Care Agency Alcohol and Drug Education and Prevention Team (ADEPT) National Council on Alcoholism and Drug Dependence-Orange County Community Alliance Network (CAN) Romeo Howe Consultant For more information regarding the County of Orange Health Care Agency s Prescription and Over-the-Counter Drug Abuse Prevention Initiative, please contact: Stacey Zapanta, MPH, CHES County of Orange Health Care Agency Alcohol and Drug Education and Prevention Team (ADEPT) 405 W. 5 th St., Suite 211, Santa Ana, CA (714) or A copy of this Report is available online at:

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5 Table of Contents I. Introduction... 1 II. Orange County Multidisciplinary Workgroup... 2 III. Overview of Prescription and Over-the-Counter Drug Abuse... 3 IV. Scope of the Problem in Orange County V. Orange County Town Hall Meetings VI. Partnership for a Drug-Free Orange County VII. Strategic Planning Session VIII. Conclusion IX. References X. Appendix A: Orange County Prescription Drug Task Force XI. Appendix B: Description of Data Sources XII. XIII. XIV. Appendix C: School Districts and Schools in Orange County by Region Appendix D: Orange County Rx/OTC Lifetime Use Rates by Region Appendix E: Orange County Rx/OTC Lifetime Use Rates by Rx/OTC Drug XV. Appendix F: Strategic Planning Session Participants... 67

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7 Introduction The nonmedical use and abuse of prescription and over-the-counter drugs to get high is a serious and growing public health problem throughout the Nation. While the use of illegal substances like methamphetamine, heroin, and marijuana has declined over the past decade abuse of prescription and over-the-counter drugs has increased sharply. According to the most recent Partnership for a Drug-Free America s annual tracking survey, one in five teens report having abused a prescription drug to get high, and one in ten young people report having abused over-the-counter cough medicines to get high (PATS, 2009). In Orange County, California, teen drug abuse of these drugs is either on par or higher than national trends. In regard to prescription drugs, 17% of 11 th grade students report having used prescription painkillers at least once in their lifetime, whereas significantly more (19% or one in four) young people in Orange County report using or trying over-the-counter cough and cold medications at least once to get high (CHKS, 2008). What is so troubling about the abuse of these drugs, is the ease of obtaining these medications and the misperception that these drugs provide a safe high after all, these drugs are prescribed by your family physicians, are available over the counter from the pharmacy down the street, or they are simply sitting at home in your medicine cabinet. In 2007, the National Survey on Drug Use and Health (NSDUH) found that over half (54%) of individuals reporting nonmedical use of psychotherapuetics got them from a friend or relative for free (SAMHSA, 2008). While the proper use of these drugs can be lifesaving, the consequences of their abuse can be as dangerous as those from illegal drugs, leading to emergency department visits and deaths. In fact, unintentional poisoning deaths involving psychotherapeutic drugs, such as sedatives and antidepressants, grew 84% from 1999 to 2004 (CDC, 2007). In July 2008, based on this growing concern around the abuse and misuse of prescription and over-the-counter drugs, the County of Orange Health Care Agency s Alcohol and Drug Education and Prevention Team (ADEPT) received funding from the Tobacco Settlement Revenue (TSR) Committee to identify the scope of the problem in Orange County, raise awareness about the issue of prescription drug abuse, and identify prevention recommendations. The funding was a one-time amount given for a yearlong initiative. ADEPT proposed to engage the three regional county-funded providers already doing work around alcohol and other drug abuse prevention in an effort to more efficiently and effectively address this issue on a countywide level. The subsequent Prescription Drug Initiative had five objectives to be completed by June 30, 2009, which included: (1) developing a multidisciplinary workgroup or task force to lead this countywide effort; (2) utilizing the workgroup/task force to identify the scope of the prescription drug abuse problem; (3) conducting at least three town halls to increase community awareness about the issue; (4) engaging local media; and (5) conducting a Strategic Planning Session in which prevention recommendations for next steps could be developed. All five objectives have subsequently been completed and are described within this report. Prescription and Over-the-Counter Drug Abuse 1

8 Orange County Multidisciplinary Workgroup In November 2008, the County of Orange Health Care Agency s Alcohol and Drug Education and Prevention Team (ADEPT) convened a multidisciplinary group of county funded providers, community stakeholders, and other agencies involved in statewide or countywide prescription drug prevention or diversion efforts to begin addressing the issue of prescription and overthe-counter drug abuse in Orange County. The multidisciplinary workgroup was charged with completing the following objectives: (1) identify the scope of the problem in Orange County; (2) convene at least three town hall meetings to increase awareness amongst parents and youth about the problem; and (3) develop next steps and prevention recommendations for the County. The workgroup met on a monthly basis for the year-long project and ultimately became the Orange County Prescription Drug Task Force. The Task Force decided from the start that they would fold over-the-counter drugs into the scope, as the issues were so interrelated with prescription drug abuse. Additionally, even though the Task Force acknowledged that prescription and over-the-counter drug abuse was not just an issue amongst young people, in order to most efficiently address the year long project, that the focus would be on identifying the problem of prescription and over-the-counter amongst youth and young adults aged years. Appendix A identifies all individual members of the workgroup, but the following agencies were represented: Abbott Pharmaceuticals, Inc. Bureau of Narcotic Enforcement/Professional Diversion Investigators Network (BNE/PDIN) California National Guard Drug Demand Reduction (DDR) Community Alliances for Drug Free Youth (CADFY) Community Service Programs, Inc. - Project Positive Action Towards Health (CSP-PATH) County of Orange Health Care Agency, Alcohol and Drug Abuse Services, Prevention Team (ADAS-Prevention) County of Orange Health Care Agency, Alcohol and Drug Education and Prevention Team (ADEPT) Fourth District Parent-Teacher-Association (PTA) National Council on Alcoholism and Drug Dependence-Orange County Community Alliance Network (NCADD-OC) 2 Prescription and Over-the-Counter Drug Abuse

9 Overview of Prescription and Over-the-Counter Drug Abuse Although many prescription drugs can be abused, the most common classifications of medications abused by youth include opiates, central nervous system depressants, and stimulants. In regards to over-the-counter drugs, the most commonly abused are cough and cold medications containing dextromethorphan (DXM). Opiates Opiates, sometimes referred to as narcotics, are a group of drugs which are used medically to relieve pain, but also have a high potential for abuse. Americans, constituting only 4% of the world s population, consume 80% of the global supply of opiods and 99% of the global supply of hydrocodone (Califano, 2007). Prescriptions for opiates (hydrocodone and oxycodone products) have escalated from around 40 million in 1991 to nearly 180 million in Opiates are made from opium, a white liquid in the poppy plant, similar to heroin, but these prescription drugs are produced in laboratories. Taken as directed, opiates are very effective analgesics or pain relievers, but they also create a quick, intense sense of euphoria. The most commonly known prescription opiates are Vicodin and Oxycontin. Other examples include: morphine (Kadian, Avinza ), codeine, oxycodone (Oxycontin, Percodan, Percocet ), hydrocodone (Lortab, Lorcet, Vicodin ), propoxyphene (Darvon ), fentanyl (Duragesic), and hydromorphone (Dilaudid ). There are numerous slang terms for the various opiates. Some include: syzurp (codeine), oxy (Oxycontin), O.C. s (oxycontin), and hillbilly heroin (oxycontin). Central Nervous System (CNS) Depressants CNS depressants slow down normal brain functioning, and are often referred to as sedatives. There are two types of CNS depressants barbiturates and benzodiazepines and these are used primarily to treat anxiety and sleep disorders. In higher doses, some CNS depressants can be used as general anesthetics. Stimulants Common CNS depressants include: barbiturates, mephobarbital (Merbaral ), pentobarbital sodium (Nembutal ), butalbital (Fioricet ), benzodiazapines, diazepam (Valium ), chlordiazepoxide HCI (Librium ), alprazolam (Xanaz ), triazolam (Halcion ), and estazolam (ProSom ). There are numerous slang terms for the various opiates tranks (benzodiazepines), downers (benzodiazepines), V s (valium ) and Z bars (xanax ). Stimulants are a class of drugs that enhance brain activity and increase alertness, attention, and energy, as well as elevate blood pressure, heart rate, and respiration. These medications Prescription and Over-the-Counter Drug Abuse 3

10 historically were used to treat asthma and respiratory problems, obesity, and a variety of other ailments, but as their potential for abuse and addiction became apparent, the medical use began to decrease. Now they are prescribed for a few health conditions, including treatment of narcolepsy and attention deficit hyperactivity disorder (ADHD). Common prescription stimulants include: adderall, dextroamphetamine (Dexedrine ), and methylphenidate. Slang terms for stimulants include: dexies (dextroamphetamine), and for adderall addy, alls, bennies, amps, a-bombs, and the A train. Over-the-Counter (OTC) Medications The most commonly abused over-the-counter medications that young people are abusing are cough and cold medications which contain the ingredient dextromethorphan or DXM. DXM is a semisynthetic narcotic, and is found in well over 100 brand-name and store-brand OTC cough medicines. When used according to label directions, DXM is a safe and effective cough suppressant. At much higher doses (typically more than 360 milligrams), DXM produces dissociative effects similar to those of PCP (phencyclidine) and ketamine and can have serious health effects which can vary from vomiting to rapid heart rate to slowed breathing and even death (Bobo et al, 2006). Additionally, of concern, are the adverse reactions from overdosing on other ingredients in the cold remedies with DXM, such as acetaminophen, pseudoephedrine and antihistamines, which can cause liver damage, irregular heart beats, high blood pressure and seizures (Bryner et al, 2006). DXM is available in syrups, capsules, gel caps, lozenges, and the powder form (pure DXM) can be bought via the internet. There are numerous slang names for DXM, such as CCC, triple C, Dex, Poor Man s PCP, skittles and robo, which often refer to particular brand name products. About two-thirds of abusers now take Coricidin HBP Cough & Cold, whose candy-red tablets are nicknamed red devils, triple C and skittles. Robotripping takes its name from Robitussin, the second most abused cold medicine (Banerji et al, 2001). Polydrug Use A common practice of young people when taking prescription or over-the-counter drugs is to combine them with each other and/ or other drugs, such as alcohol. This is called polydrug use and the setting in which this can take place is called a pharming party. At these parties or gatherings young people trade or exchange prescription medications to get high, by tossing all the prescription drugs they can acquire into a communal bowl (aka trail mix ) and then they down them by the fistful to get high. This practice can be extremely harmful and even deadly. The most frequent substance found in combination with prescription and over-the-counter drugs is alcohol, but no matter what the drug, the consequences can be extremely harmful, slowing both heart and respiration, and could even lead to death (DAWN, 2004). 4 Prescription and Over-the-Counter Drug Abuse

11 Prevalence of Use National surveys and research reports have identified youth prescription and over-the-counter drug abuse as a growing concern in the United States. The abuse of prescription drugs has outpaced the use of all illegal drugs except marijuana among teens in fact, there are more teens that abuse prescription drugs than cocaine, heroin, and methamphetamine combined (ONDCP, 2008). While the abuse of many illicit drugs has declined in recent years, abuse rates of prescription and over-the-counter drugs have increased or remained steady at peak rates (MTF Survey, 2008). Although prescription and over-the-counter drugs are generally viewed as safe, the misuse of these drugs is not without consequences. Across the nation there has been a dramatic increase in the number of poisonings and deaths attributed to the abuse of these drugs (ONDCP, 2008). These national trends indicate that prescription and over-the-counter drug abuse poses a threat to public health and safety. National Prevalence In 2008, 4.7 million teens, or about 19%, reported that they had abused prescription drugs at some point in their lives. Figure 1 shows the lifetime use rate qualifies prescription drugs as the second most commonly abused substance among teens (PATS, 2008). Source: Partnership Attitude Tracking Study, 2008 Additionally, national trends in the misuse of prescription drugs among teens do not coincide with trends seen for other commonly abused substances. While the abuse of illicit drugs, alcohol, and cigarettes among teens has significantly decreased in recent years, the abuse of prescription drugs has remained relatively steady (PATS, 2008). Prescription and OTC medications were the most commonly abused drugs by high school students after marijuana. In addition, they represent 6 of the top 10 illicit drugs reported by 12 th graders (MTF, 2008). Research reveals that painkillers are the most commonly abused prescription drugs among teens, with approximately 10% of teens reporting lifetime use (PATS, 2008). In 2008, 9.7% of 12 th graders reported having used a prescription painkiller within the past 12 months, compared Prescription and Over-the-Counter Drug Abuse 5

12 to 6.7% of 10 th graders and 2.9% of 8 th graders. Vicodin and Oxycontin are the most frequently abused prescription painkillers. While the use of Vicodin has remained relatively constant at historically high levels since 2002, the number of teens reporting past year abuse of Oxycontin increased 30% between 2002 and 2007 (MTF, 2007). Source: Monitoring the Future, 2007 In addition to prescription drugs, teens are abusing over-the-counter (OTC) cough and cold medications to get high. In 2008, 10% of youth (or 2.4 million young people) in the United States reported having used cough and cold medicines to get high at some point in their lives, and 28% report knowing someone else who has tried it (PATS, 2008). This is identical to rates of lifetime use reported in 2006 and Data from the 2008 Monitoring the Future study estimates the past year use of cough medicine among 8 th, 10 th, and 12 th graders is at 3.6%, 5.3%, and 5.5%, respectively (MTF, 2008). Statewide Prevalence: California In California, statewide norms are provided by the biennial statewide California Student Survey (CSS), sponsored by the Office of the Attorney General. The current ( ) CSS combines for the first time alcohol, illicit drugs, diverted prescription drugs and cold/cough medications (used to get high) into a total percentage of respondents who tried at least one such drug in their lifetime. The result is that 60% of 9 th and 74% of 11 th grade students reported using one of the substances at least once. The most recent survey identified the top 3 major substance abuse trends in the state of California. Of these 3 trends, 2 were directly related to prescription and over-the-counter substance abuse. The survey found that prescription drug abuse by California youth was occurring at an alarming rate, with 37% of 9 th grade and 50% of 11 th grade respondents reported using to get high ( without a doctor s order to get high or stoned ) at least once in their lifetime either an illicit/ illegal drug or a diverted prescription drug such as painkillers, sedatives or diet pills. The prescription drugs used most frequently are prescription painkillers, such as Oxycontin or 6 Prescription and Over-the-Counter Drug Abuse

13 Vicodin. Twelve percent of 9 th and 18% of 11 th graders reported using them at least once, making this by far the second most widely used category of drugs after marijuana. Also, overthe-counter drug abuse data indicates that large numbers of California teens have tried these products to get high, with 9 th graders reporting at a slightly higher rate than 11 th graders (26% vs. 25%) (CSS, 2008) (Figure 3). Source: California Student Survey, 2008 In comparison with other states, California ranked 3 rd highest in overall misuse of prescription psychotherapeutic drugs a class including prescription pain relievers, tranquilizers, stimulants, and sedatives (Table 1). Source: National Survey on Drug Use and Health, SAMSHA, 2007 Although the combined prescription drug abuse rate is among the highest in the nation, California s rates of abuse in individual subcategories, such as prescription sedatives, tranquilizers, and painkillers, were not ranked among the nation s highest or lowest (SAMHSA, 2007). Consequences Misuse of prescription and over-the-counter drugs can lead to serious health risks. Nationwide, unintentional overdose deaths involving prescription painkillers increased 117% between 2001 and 2005 from 3,944 to 8,541. Over the same 4-year period, treatment admissions for Prescription and Over-the-Counter Drug Abuse 7

14 painkiller addictions increased 74% (USDOJ, 2009). In 2006, data submitted from hospitals across the nation show that there were approximately 741,425 Emergency Department visits involving nonmedical use of prescription and over-the-counter drug and dietary supplements. Additionally, 92% of drug-related suicide attempts in 2006 involved misuse of pharmaceuticals (SAMHSA, 2006). The consequences of prescription and over-the-counter drug abuse extend beyond the personal health of those who abuse them. Violent and property crimes associated with prescription drug diversion and abuse increased nationally between The Drug Enforcement Agency reported that the amount of prescription drugs stolen in armed robberies doubled from 0.5 million quantities in 2002 to nearly 1.1 million in 2007 (SAMHSA, 2009). In addition to safety risks, prescription and over-the-counter drug diversion and abuse pose financial liabilities to the public as well. Nationally, the estimated cost of prescription drug abuse to public and private medical insurers is $72.5 billion per year (SAMHSA, 2009). Contributing Factors A number of factors contribute to the high rates of prescription and over-the-counter drug abuse among teens and young adults. First, many teens tend to view these legal drugs as safer than using street drugs (ONDCP, 2008). Additionally, many parents are not aware of teen prescription drug abuse only 24% of teens reported that their parents had talked to them about the dangers of abusing prescription and over-the-counter drugs. The vast majority of parents feel unprepared to prevent their children from abusing these types of drugs (PATS, 2008). Lastly, prescription and over-the-counter drugs are viewed as easy to obtain and inexpensive by teens and young adults (ONDCP, 2008). Perception of Harm Many teens abuse prescription and over-the-counter drugs because they believe they are a safe way to get high (ONDCP, 2008). The dangers of prescription and over-the-counter drugs are not well understood by many teens and young adults. Forty-one percent of teens indicated that they believe prescription drugs were much safer to use than illegal drugs (PATS, 2008). Nearly 1/3 of teens (31%) believe that there is nothing wrong with using prescription medicines with a prescription every once in a while. Additionally, 32% of teens say they abuse prescription painkillers because they believe there are fewer side effects than street drugs (PATS, 2008). The perception of harm from abuse of over-the-counter cough and cold medicines is increasing among teens in 2008, 48% agreed that abusing cough medicine is risky versus 40% in 2004 (PATS, 2008). Despite this positive trend, the majority of teens (52%) still do not believe that abusing these medicines is dangerous. Parental Awareness Research has demonstrated that parents play an important role in preventing their children from using drugs. A study by SAMHSA showed that youth ages whose parents express strong disapproval of drug use are far less likely to engage in substance abuse (SAMHSA, 2007). Yet, parents often do not address the issues of prescription and over-the-counter substance abuse with their children. Only 24% of teens reported having prescription drug abuse discussions with their parents; 18% reported having cold and cough medicine abuse discussions (PATS, 2008) (Figure 4). 8 Prescription and Over-the-Counter Drug Abuse

15 The majority of parents do not feel prepared to handle situations involving prescription drug abuse and over-the-counter substance misuse, with only 34% of parents reporting that they feel extremely prepared to safeguard their medicine cabinets to prevent their child from abusing prescription drugs (PATS, 2008). Access and Availability Young people are able to acquire prescription and over-the-counter drugs easily and rather quickly. A recent national survey asked years old, which is easiest for someone your age to buy: cigarettes, beer, marijuana, or prescription drugs such as OxyContin, Percocet, Vicodin or Ritalin, without a prescription? Nineteen percent of questioned teenagers reported that it s easier to buy prescription drugs than cigarettes, beer, and marijuana. This is a significant increase compared to 13% teens reporting the same a year ago (CASA, 2009). Another study reported even higher rates, with approximately 6 out of 10 teens agreeing that prescription drugs are easier to get than illegal drugs (PATS, 2008). More than 1/3 of teens (8.7 million) also reported that they can get prescription drugs to get high within the day; nearly 1 in 5 teens (4.7 million) can get them within the hour (CASA, 2009). When asked where they would get prescription drugs, the most common sources were home, parents, and other family members or friends. In fact, the NSDUH found that half of individuals reporting nonmedical use of psychotherapuetics got them from a friend or relative for free (Figure 5). In a follow-up question, the majority of these respondents indicated that their friend or relative had obtained the drugs from one doctor (SAMHSA, 2008). Prescription and Over-the-Counter Drug Abuse 9

16 Source: National Survey on Drug Use and Health, 2007 Other common sources include obtaining medication from a physician, purchasing the medications over-the-counter or through rogue internet sites, and theft (usually from friends or relatives). Of note in regards to internet sales, in a June 2006 CASA report, the internet was found as a growing source of drugs with increased prescription drug abuse. They also found that there were no controls on blocking the sale to children and substantial shipments were from within the United States. (CASA, 2006). Yet, due to the tragic death of a local teen Ryan Haight who died at the age of 18 from an overdose of painkillers, including Vicodin that he ordered off the internet at age 17 without a legitimate prescription and the continued advocacy of his family and the support of several law enforcement and prevention agencies, Congress passed the Ryan Haight Online Pharmacy Consumer Protection Act in 2008 to combat these illegal online pharmacies. 10 Prescription and Over-the-Counter Drug Abuse

17 Scope of the Problem in Orange County Data from the Orange County California Healthy Kids Survey (CHKS) confirms that prescription and over-the-counter substance abuse is a prevalent issue in Orange County as well. In recognition of this growing problem, WestEd expanded the CHKS instrument from measuring only prescription painkiller abuse trends to measuring trends in other prescription and over-thecounter products, including barbiturates, sedatives, stimulants, and cold medicine, in Lifetime Use Rates in Orange County The California Healthy Kids Survey analyzed the prevalence of specific prescription and over-the-counter drug abuse rates at a local level. Figure 6 shows lifetime use rates among 9 th and 11 th grade students, as well as students at nontraditional school, which include continuing education, community day schools, and other alternative school types. Source: California Healthy Kids Survey, As seen above, the most commonly abused prescription and over-the-counter products in Orange County are cough and cold medicines and prescription painkillers. With the exception of the barbiturates, lifetime use of each drug increases between 9 th and 11 th grade. In addition to the lifetime use differences between grade levels in Orange County schools, differences in lifetime use rates are also evident between traditional and nontraditional schools, with students reporting significantly higher rates of use. Lifetime Use Rates: Local vs. State Lifetime use rates of prescription drugs in Orange County, including painkillers, barbiturates, sedatives, and stimulants, are relatively similar to those of the state of California among 9 th and 11 th grade students (Figure 7-8). Among 9 th and 11 th graders in Orange County, the abuse of prescription painkillers is slightly below that of the state. In particular, 9 th grade students in Orange County have a slightly higher lifetime usage rate of barbiturates, but this difference Prescription and Over-the-Counter Drug Abuse 11

18 disappears by the 11 th grade. State and local lifetime use rates of sedatives and stimulants are remarkably similar among 9 th grade students. However, there is a more distinct difference in these rates among 11 th grade students, with Orange County 11 th graders demonstrating higher rates of lifetime use (California Healthy Kids Survey, 2008). Sources: County - California Healthy Kids Survey, ; State California Student Survey, 2008 Sources: County - California Healthy Kids Survey, ; State California Student Survey, 2008 Despite the similarities in prescription drug abuse rates, abuse rates of over-the-counter cold medicines in Orange County are considerably different from those of the state (Figure 9). Data from the California Healthy Kids Survey indicate that abuse rates of cough and cold medicine in Orange County are significantly lower than those of the state in both 9 th and 11 th grade students. 12 Prescription and Over-the-Counter Drug Abuse

19 Sources: County - California Healthy Kids Survey, ; State California Student Survey, 2008 Among prescription and over-the-counter substances, another distinction occurs between state and local trends. With the exception of barbiturates, Orange County demonstrates larger increases in lifetime use rates between 9 th and 11 th grade students than those of the state (Table 2). This may indicate that a greater proportion of Orange County students experience their first lifetime use between 9 th and 11 th grade. Sources: County - California Healthy Kids Survey, ; State California Student Survey, 2008 Prescription and Over-the-Counter Drug Abuse 13

20 Regional Prevalence ADEPT divides Orange County into three service provider areas, identified as: North, Central, and South. Within each region, data is reported by school district. Appendix C provides a detailed list of the school districts within each region, as well as the schools within each school district. Appendix D contains reported lifetime use rates of painkillers, barbiturates, sedatives, cough medicines, diet pills, and stimulants for each school district in Orange County, grouped by regions. Appendix E lists the percentage of students across Orange County reporting lifetime use for each prescription drug and over-the-counter category, including painkillers, barbiturates, tranquilizers/sedatives, stimulants, inhalants, diet pills, and cold/cough medicines. Overall, among 9 th grade students in Orange County, the two substances with highest lifetime use rates were cold medicines and prescription painkillers. This trend is true of all school districts in Orange County with the exception of Santa Ana Unified School District (SAUSD) in the Central Region of Orange County, where lifetime use rates of diet pills exceeds those of painkillers (California Healthy Kids Survey, ). Of all 9 th grade students in Orange County, those in the Brea-Olinda Unified School District (BOUSD) reported the highest rates of lifetime painkiller use at 17%, while students in the Tustin Unified School District (TUSD) reported the lowest rates of lifetime painkiller use at 6% (Figure 10). Source: California Healthy Kids Survey, Prescription and Over-the-Counter Drug Abuse

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