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Nonmedical Use of Over-the-Counter Medications Is Significantly Associated with Nonmedical Use of Prescription Drugs among University Students

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Title: Nonmedical Use of Over-the-Counter Medications Is Significantly Associated with Nonmedical Use of Prescription Drugs among University Students
Language: English
Authors: Le, Vi T. (ORCID 0000-0001-8622-8724), Norris Turner, Abigail, McDaniel, Anne, Hale, Kenneth M., Athas, Christina, Kwiek, Nicole C.
Source: Journal of American College Health. 2018 66(1):1-8.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 8
Publication Date: 2018
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Descriptors: College Students, Drug Abuse, Correlation, Student Surveys, Online Surveys, Student Characteristics, Gender Differences, Age Differences, Racial Differences, Ethnicity, Sororities, Fraternities, Questionnaires, Statistical Analysis
DOI: 10.1080/07448481.2017.1356312
ISSN: 0744-8481
Abstract: Objective: To examine the association between nonmedical use of over-the-counter medications (NMUOTC) and nonmedical use of prescription drugs (NMUPD). Participants: University students surveyed on NMUOTC and NMUPD between August and December 2011 (N = 939). Methods: Cross-sectional data analysis of online survey. Results: The majority of respondents were women, undergraduate, Caucasian, and not affiliated with Greek life. NMUPD and NMUOTC were reported by 21.4% and 11.2% of students, respectively. NMUOTC was significantly associated with NMUPD in unadjusted analyses and after adjustment for gender, age, race/ethnicity, and Greek membership (odds ratio: 3.37, 95% confidence interval: 2.17, 5.23). Secondary analyses showed a relationship between over-the-counter (OTC) cough medication misuse and NMUPD, OTC stimulant misuse and prescription stimulant misuse, and OTC sleep aid misuse with prescription depressant misuse. Conclusions: Results suggest the importance of both measuring the prevalence of OTC misuse and incorporating its misuse into assessments of polydrug use in the university population.
Abstractor: As Provided
Number of References: 29
Entry Date: 2017
Accession Number: EJ1164893
Database: ERIC
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  Value: <anid>AN0126917684;acl01jan.18;2019Jan31.13:40;v2.2.500</anid> <title id="AN0126917684-1">Nonmedical use of over-the-counter medications is significantly associated with nonmedical use of prescription drugs among university students. </title> <p>Objective: To examine the association between nonmedical use of over-the-counter medications (NMUOTC) and nonmedical use of prescription drugs (NMUPD). Participants: University students surveyed on NMUOTC and NMUPD between August and December 2011 (N = 939). Methods: Cross-sectional data analysis of online survey. Results: The majority of respondents were women, undergraduate, Caucasian, and not affiliated with Greek life. NMUPD and NMUOTC were reported by 21.4% and 11.2% of students, respectively. NMUOTC was significantly associated with NMUPD in unadjusted analyses and after adjustment for gender, age, race/ethnicity, and Greek membership (odds ratio: 3.37, 95% confidence interval: 2.17, 5.23). Secondary analyses showed a relationship between over-the-counter (OTC) cough medication misuse and NMUPD, OTC stimulant misuse and prescription stimulant misuse, and OTC sleep aid misuse with prescription depressant misuse. Conclusions: Results suggest the importance of both measuring the prevalence of OTC misuse and incorporating its misuse into assessments of polydrug use in the university population.</p> <p>Keywords: Community health; over-the-counter misuse; prescription medication misuse; substance abuse</p> <p>Since the mid-1990s, prevalence of nonmedical use of prescription drugs (NMUPD) has dramatically risen among university students.[<reflink idref="bib1" id="ref1">1</reflink>] NMUPD is defined as the use of a prescribed substance without a doctor's prescription or in a manner other than as directed or prescribed.[<reflink idref="bib2" id="ref2">2</reflink>] Some examples of misuse include: taking the medication in a higher dose or a different way (eg, snorting or injecting crushed tablets) than directed, using the medication for a purpose other than the intended use (eg, to get high), or taking medication not legitimately prescribed. In the university population, men, Caucasians, and affiliation with Greek life have been associated with NMUPD.[<reflink idref="bib3" id="ref3">3</reflink>]<sups>,</sups>[<reflink idref="bib4" id="ref4">4</reflink>] Prescription medications often are considered safer than illicit street drugs and are perceived as "easy" to obtain on university campuses.[<reflink idref="bib5" id="ref5">5</reflink>]<sups>,</sups>[<reflink idref="bib6" id="ref6">6</reflink>] Moreover, the <emph>perceived</emph> prevalence of NMUPD is consistently higher than the <emph>observed</emph> prevalence among university students, as measured through anonymous surveys.[<reflink idref="bib4" id="ref7">4</reflink>]<sups>,</sups>[<reflink idref="bib7" id="ref8">7</reflink>] The high accessibility and misperceptions of safety and legality of NMUPD, combined with misperceptions about the pervasiveness of NMUPD, may contribute to the high prevalence of NMUPD among university students.[<reflink idref="bib4" id="ref9">4</reflink>]<sups>,</sups>[<reflink idref="bib7" id="ref10">7</reflink>]<sups>,</sups>[<reflink idref="bib8" id="ref11">8</reflink>]</p> <p>Due to the greater accessibility of over-the-counter (OTC) medications compared to prescription medications, the potential for misuse of OTC medications is also present. Nonmedical use of OTC medications (NMUOTC) is defined as: taking a drug for a purpose not intended by the manufacturer, taking a drug at a higher dose than recommended, or taking a drug by a nonrecommended route of administration.[<reflink idref="bib9" id="ref12">9</reflink>] NMUOTC may be correlated with NMUPD. Increased tolerance and cravings following NMUOTC could increase the desire for a more potent or longer-lasting high or other desired effect.[<reflink idref="bib10" id="ref13">10</reflink>] For example, in 2014, over 2 million people aged 18–25 were estimated to have misused nonprescription cough or cold medicine to get high in their lifetime.[<reflink idref="bib11" id="ref14">11</reflink>] Dextromethorphan (DXM), a cough suppressant that is found in over 140 OTC cold products,[<reflink idref="bib12" id="ref15">12</reflink>] can produce dissociative, euphoric, and stimulant effects when misused, and its misuse can result in tolerance, dependence, psychosis, and upon cessation of use, physical withdrawal.[<reflink idref="bib13" id="ref16">13</reflink>] Increased tolerance of the effects stemming from cough medications containing DXM could translate to the misuse of various prescription drugs—including pain, sedatives, or stimulant medications—for those seeking a similar, and intensified, "high."[<reflink idref="bib2" id="ref17">2</reflink>]<sups>,</sups>[<reflink idref="bib14" id="ref18">14</reflink>] For OTC stimulants or sleep aids, misuse of their prescription counterparts could be an extension of therapeutic use. Further, the university environment may facilitate a transition from NMUOTC to NMUPD, given that it is a high-risk environment for substance use and that prescription medications are often easily obtained—often for free—from peers.[<reflink idref="bib4" id="ref19">4</reflink>]<sups>,</sups>[<reflink idref="bib14" id="ref20">14</reflink>]<sups>,</sups>[<reflink idref="bib15" id="ref21">15</reflink>] The low perceived risk and high perceived benefits of prescription medications could further promote the progression of NMUOTC to NMUPD. Identifying potential pathways into prescription drug misuse is important given the high prevalence and risks associated with prescription drug misuse.</p> <p>While considerable research has focused on NMUPD among university students, few studies have focused on NMUOTC. Given the accessibility of OTC medications, studies exploring this relationship and assessing the extent of poly-prescription drug misuse could aid in the identification of at-risk populations and could be advantageous in mitigating prescription drug misuse. The aim of the current analysis was to assess the relationship between NMUOTC and NMUPD in a diverse cohort of university students. We further characterized the associations between drug types by examining the relationship between OTC cough medication misuse and any NMUPD, OTC stimulant misuse and prescription stimulant misuse, and OTC sleep aid misuse and prescription depressant misuse. Lastly, we assessed the relationship between any NMUOTC and poly-prescription drug misuse in our sample.</p> <hd id="AN0126917684-2">Methods</hd> <p></p> <hd id="AN0126917684-3">Participants and procedure</hd> <p>Data were collected between August and December 2011 from a simple random sample of students attending a large public Midwest university. A total of 5000 randomly selected undergraduate, professional, and graduate students, at least 18 years of age, were recruited via email to participate in a 10- to 15-minute anonymous online survey on nonmedical use of prescription and OTC medications. The initial email invitation described the purpose and goals of the study and provided a link to the self-administered questionnaire. Before starting the survey, students were asked to consent to the research. Those who did not provide consent were directed to the end of the survey. Three reminder emails were delivered to all students, and since identifiers were not collected, reminder emails were delivered regardless of students' response. All email correspondence informed students of the sensitivity of questions, the confidentiality of their responses, and their ability to skip questions without penalty. All participants were eligible to participate for a drawing of cash prizes, regardless of whether they completed the survey or not. The instrument was developed through a collaborative approach involving representatives from several student services offices and the College of Pharmacy. Questions were developed subsequent to review of existing instruments that had assessed university students' behaviors related to OTC and prescription medication misuse[<reflink idref="bib16" id="ref22">16</reflink>] and in consideration of national surveys implemented by federal organizations (eg, the National Institute on Drug Abuse, Substance Abuse and Mental Health Services Administration, and the Office of National Drug Control Policy). A total of 975 students consented to the research and responded (response rate of 19.5%), and 939 (96% of respondents) had nonmissing data on NMUPD and are included in this analysis. The university's institutional review board approved the study.</p> <hd id="AN0126917684-4">Measurements and variable descriptions</hd> <p></p> <hd id="AN0126917684-5">Demographics</hd> <p>The survey measured demographic information including gender, age, race/ethnicity, and Greek membership. Campus demographics were obtained from the IPEDS Data Center from the National Center for Education Statistics in order to compare survey respondents to the underlying campus demographics. Data on Greek membership were obtained from the university's Office of Student Life.[<reflink idref="bib17" id="ref23">17</reflink>]</p> <hd id="AN0126917684-6">Nonmedical use of OTC medications</hd> <p>NMUOTC was assessed via questions that separately asked the frequency of nonmedical use of OTC cough medicines, OTC sleep aids, and OTC stimulants (Table 1). Possible responses to each question were: never; at least once per year; at least once per quarter; at least once per month; at least once per week; at least once per day; I'd rather not say. Due to the small number of people reporting NMUOTC for some time frames, NMUOTC was dichotomized as "never" vs. "ever" any NMUOTC, regardless of drug class. In secondary analyses, NMUOTC was analyzed separately by drug class and coded as dichotomous variables: "never" vs. "ever" nonmedical use of OTC cough medications, "never" vs. "ever" nonmedical use of OTC sleep aids, and "never" vs. "ever" nonmedical use of OTC stimulants.</p> <p>Table 1. Ascertainment of nonmedical use of over-the-counter (OTC) medications and prescription drugs from survey.</p> <p> <ephtml> <table><thead><tr><td align="center" /><td align="center">Nonmedical use: never vs. ever</td><td align="center">Survey questions</td></tr></thead><tbody><tr><td align="left">Primary analysis: Comparing any OTC medication misuse vs. any NMUPD</td><td align="left">Nonmedical use of OTC medications</td><td align="left">How often do you generally use over-the-counter, nonprescription COUGH MEDICINES (eg, Robitussin, Coricidin) for nonmedication purposes (eg, to get high or for the feeling they cause)?" How often do you generally use over-the-counter, nonprescription STIMULANTS (eg, NoDoz, Vivarin) for nonmedication purposes (eg, to get high or for the feeling they cause)? How often do you generally use over-the-counter, nonprescription SLEEP AIDS (eg, Unisom, Sominex) for nonmedication purposes (eg, to get high or for the feeling they cause)?</td></tr><tr><td align="left">Nonmedical use of prescription drugs</td><td align="left">How often do you generally use prescription PAIN MEDICATIONS that were not prescribed for you (eg, OxyContin, Vicodin, Percodan, Dilaudid, Codeine)? How often do you use prescription SEDATIVES, SLEEPING MEDICATIONS OR TRANQUILIZERS that were not prescribed for you (eg, Valium, Xanax, Librium, Ativan, Mebaral, Ambien)? How often do you generally use prescription STIMULANTS that were not prescribed for you (eg, Ritalin, Adderall, Dexedrine, Concerta)?</td></tr><tr><td align="left">Secondary analysis: Comparing OTC cough medication misuse vs. any NMUPD</td><td align="left">Nonmedical use of OTC cough medications</td><td align="left">How often do you generally use over-the-counter, nonprescription COUGH MEDICINES (eg, Robitussin, Coricidin) for nonmedication purposes (eg, to get high or for the feeling they cause)?"</td></tr><tr><td align="left">Nonmedical use of prescription drugs</td><td align="left">How often do you generally use prescription PAIN MEDICATIONS that were not prescribed for you (eg, OxyContin, Vicodin, Percodan, Dilaudid, Codeine)? How often do you use prescription SEDATIVES, SLEEPING MEDICATIONS OR TRANQUILIZERS that were not prescribed for you (eg, Valium, Xanax, Librium, Ativan, Mebaral, Ambien)? How often do you generally use prescription STIMULANTS that were not prescribed for you (eg, Ritalin, Adderall, Dexedrine, Concerta)?</td></tr><tr><td align="left">Secondary analysis: Comparing OTC stimulant misuse vs. prescription stimulant misuse</td><td align="left">Nonmedical use of OTC stimulants</td><td align="left">How often do you generally use over-the-counter, nonprescription STIMULANTS (eg, NoDoz, Vivarin) for nonmedication purposes (eg, to get high or for the feeling they cause)?</td></tr><tr><td align="left">Nonmedical use of prescription stimulants</td><td align="left">How often do you generally use prescription STIMULANTS that were not prescribed for you (eg, Ritalin, Adderall, Dexedrine, Concerta)?</td></tr><tr><td align="left">Secondary analysis: Comparing OTC sleeping aid misuse vs. prescription depressants</td><td align="left">Nonmedical use of OTC depressants</td><td align="left">How often do you generally use over-the-counter, nonprescription SLEEP AIDS (eg, Unisom, Sominex) for nonmedication purposes (eg, to get high or for the feeling they cause)?</td></tr><tr><td align="left">Nonmedical use of prescription depressants</td><td align="left">How often do you use prescription SEDATIVES, SLEEPING MEDICATIONS OR TRANQUILIZERS that were not prescribed for you (eg, Valium, Xanax, Librium, Ativan, Mebaral, Ambien)?</td></tr></tbody></table> </ephtml> </p> <hd id="AN0126917684-7">Nonmedical use of prescription drugs</hd> <p>NMUPD was assessed via questions that separately asked the frequency of nonmedical use of prescription pain medications, prescription depressants (eg, sedatives, sleeping medications, or tranquilizers), and prescription stimulants (Table 1). Possible responses were: never; at least once per year; at least once per quarter; at least once per month; at least once per week; at least once per day; I'd rather not say. Similar to OTC drug misuse, for the purpose of this analysis, NMUPD was classified as a dichotomous variable: "never" vs. "ever" any NMUPD. In secondary analyses, nonmedical use of OTC stimulants and OTC sleep aids were separately coded as a series of dichotomous variables: "never" vs. "ever" nonmedical use of each drug class. We also assessed the relationship between "ever" NMUOTC and poly-prescription drug misuse. Respondents who reported nonmedical use of more than one class of prescription medications (poly-prescription misusers) were compared to those who reported "never" engaging in NMUPD.</p> <hd id="AN0126917684-8">Statistical analyses</hd> <p>All statistical analyses were conducted using Stata 13 (StataCorp LP, College Station, TX). For our primary analysis, we used logistic regression to examine the association between any NMUOTC and any NMUPD. For secondary analyses, we first conducted a logistic regression model with NMUPD as a dichotomous outcome and nonmedical use of OTC cough medications as the exposure of interest. We then separately examined associations between OTC stimulant misuse and prescription stimulant misuse and between OTC sleeping aid misuse and prescription depressant misuse. Lastly, we assessed the relationship between any NMUOTC and poly-prescription drug misuse through logistic regression modeling with any poly-prescription drug misuse in the previous year as the outcome and any NMUOTC in the previous year as the exposure. The referent outcome group in this analysis included those who reported never engaging in NMUPD. All adjusted estimates controlled for age, gender, race/ethnicity, and Greek membership. Given that we do not know whether NMUOTC preceded or followed NMUPD, we chose to report odds ratios (ORs) from logistic regression models since our goal was to establish association, not causation. Respondent age was categorized into three groups, 18 and 19, 20 and 21, and ≥22 years, based on the sample size for each year of age. Race/ethnicity was dichotomized as "Non-minority" (white) and "Minority" due to the small percentage of African American/black, American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, Hispanic/Latino(a), multiracial, and "Other" racial and ethnic heritages. Based on prior research on this topic among university students, we hypothesized that these covariates could confound the association between NMUOTC and NMUPD.</p> <hd id="AN0126917684-9">Results</hd> <p></p> <hd id="AN0126917684-10">Participant characteristics</hd> <p>Majority of the respondents were women (59.8%) and Caucasian (75.2%) (Table 2). The remainder were Asian (12.5%), African American/black (4.2%), Hispanic/Latino(a) (1.8%), American Indian/Alaska Native (0.8%), Native Hawaiian/Pacific Islander (0.2%), multiracial (2.8%), and "other" racial and ethnic heritage (1.3%). Undergraduates comprised a majority of the sample (69.3%). Eight percent of the respondents were members of Greek life. The sample was relatively representative of the underlying university student population in terms of age (Table 2), although survey respondents were more likely to be female and to be enrolled in a graduate program when compared to the source population. NMUPD was reported by 21.4% of students, while 11.2% of respondents reported NMUOTC (Table 3).</p> <p>Table 2. Characteristics and comparison of the study population (N = 939) to campus demographics.</p> <p> <ephtml> <table><thead><tr><td align="left" /><td align="center">Study participants N = 939</td><td align="center">University students<xref ref-type="fn" rid="t2fn0001" /> N = 56,867</td></tr><tr><td align="left">Characteristics</td><td align="center">n</td><td align="center">%</td><td align="center">%</td></tr></thead><tbody><tr><td align="left">Gender</td><td align="center" /></tr><tr><td align="left"> Female</td><td align="center">561</td><td align="char" char=".">59.8</td><td align="char" char=".">48.5</td></tr><tr><td align="left"> Male</td><td align="center">361</td><td align="char" char=".">38.4</td><td align="char" char=".">51.5</td></tr><tr><td align="left"> Missing</td><td align="center">17</td><td align="char" char=".">1.8</td><td align="center" /></tr><tr><td align="left">Age</td><td align="center" /></tr><tr><td align="left"> <18</td><td align="center" /><td align="center" /><td align="char" char=".">0.8</td></tr><tr><td align="left"> 18–19</td><td align="center">223</td><td align="char" char=".">23.7</td><td align="char" char=".">23.6</td></tr><tr><td align="left"> 20–21</td><td align="center">275</td><td align="char" char=".">29.3</td><td align="char" char=".">31.0</td></tr><tr><td align="left"> ≥22</td><td align="center">433</td><td align="char" char=".">46.1</td><td align="char" char=".">44.6</td></tr><tr><td align="left"> Missing</td><td align="center">8</td><td align="char" char=".">0.9</td><td align="center" /></tr><tr><td align="left">Race/Ethnicity</td><td align="center" /></tr><tr><td align="left"> African American/black</td><td align="center">40</td><td align="char" char=".">4.2</td><td align="char" char=".">5.8</td></tr><tr><td align="left"> American Indian/Alaska Native</td><td align="center">8</td><td align="char" char=".">0.8</td><td align="char" char=".">0.2</td></tr><tr><td align="left"> Asian</td><td align="center">117</td><td align="char" char=".">12.5</td><td align="char" char=".">5.3</td></tr><tr><td align="left"> Native Hawaiian/Pacific Islander</td><td align="center">2</td><td align="char" char=".">0.2</td><td align="center" /></tr><tr><td align="left"> Hispanic/Latino(a)</td><td align="center">17</td><td align="char" char=".">1.8</td><td align="char" char=".">3.1</td></tr><tr><td align="left"> Caucasian</td><td align="center">706</td><td align="char" char=".">75.2</td><td align="char" char=".">72.1</td></tr><tr><td align="left"> Multiracial</td><td align="center">26</td><td align="char" char=".">2.8</td><td align="char" char=".">1.3</td></tr><tr><td align="left"> Other</td><td align="center">12</td><td align="char" char=".">1.3</td><td align="center" /></tr><tr><td align="left"> Missing</td><td align="center">11</td><td align="char" char=".">1.2</td><td align="char" char=".">12.2</td></tr><tr><td align="left">Greek membership<xref ref-type="fn" rid="t2fn0002" /></td><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">75</td><td align="char" char=".">8.0</td><td align="char" char=".">9.5</td></tr><tr><td align="left"> No</td><td align="center">855</td><td align="char" char=".">91.1</td><td align="char" char=".">90.5</td></tr><tr><td align="left"> Missing</td><td align="center">9</td><td align="char" char=".">0.9</td><td align="center" /></tr><tr><td align="left">Rank</td><td align="center" /><td align="center" /><td align="center" /></tr><tr><td align="left"> Undergraduate</td><td align="center">641</td><td align="char" char=".">68.3</td><td align="char" char=".">75.5</td></tr><tr><td align="left"> Graduate</td><td align="center">286</td><td align="char" char=".">30.5</td><td align="char" char=".">24.5</td></tr><tr><td align="left"> Missing</td><td align="center">12</td><td align="char" char=".">1.2</td><td align="center" /></tr></tbody></table> </ephtml> </p> <ulist> <item>3 <emph>Note</emph>.</item> <item>20001 Demographics of enrolled students on the main campus, not restricted by age, obtained from the IPEDS Data Center from the National Center for Education Statistics.</item> <item>20002 Membership reported from the Office of Student Life.[<reflink idref="bib17" id="ref24">17</reflink>]</item> </ulist> <p>Table 3. General prevalence of nonmedical use of over-the-counter (OTC) and prescription medications.</p> <p> <ephtml> <table><thead><tr><td align="left">Drug class</td><td align="center">n</td><td align="center">%</td></tr></thead><tbody><tr><td align="left">Any prescription medications</td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">201</td><td align="char" char=".">21.4</td></tr><tr><td align="left"> No</td><td align="center">738</td><td align="char" char=".">78.6</td></tr><tr><td align="left"> Missing</td><td align="center">0</td><td align="char" char=".">0</td></tr><tr><td align="left">Prescription stimulants</td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">107</td><td align="char" char=".">11.4</td></tr><tr><td align="left"> No</td><td align="center">829</td><td align="char" char=".">88.3</td></tr><tr><td align="left"> Missing</td><td align="center">3</td><td align="char" char=".">0.3</td></tr><tr><td align="left">Prescription depressants<xref ref-type="fn" rid="t3fn0001" /></td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">65</td><td align="char" char=".">6.9</td></tr><tr><td align="left"> No</td><td align="center">872</td><td align="char" char=".">92.9</td></tr><tr><td align="left"> Missing</td><td align="center">2</td><td align="char" char=".">0.2</td></tr><tr><td align="left">Prescription pain medications</td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">100</td><td align="char" char=".">10.6</td></tr><tr><td align="left"> No</td><td align="center">838</td><td align="char" char=".">89.2</td></tr><tr><td align="left"> Missing</td><td align="center">1</td><td align="char" char=".">0.2</td></tr><tr><td align="left">Poly-prescription (> one prescription misuse)</td><td align="center">57</td><td align="char" char=".">6.1</td></tr><tr><td align="left"> Any OTC medications</td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">105</td><td align="char" char=".">11.2</td></tr><tr><td align="left"> No</td><td align="center">796</td><td align="char" char=".">84.8</td></tr><tr><td align="left"> Missing</td><td align="center">38</td><td align="char" char=".">4.0</td></tr><tr><td align="left">OTC stimulants</td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">28</td><td align="char" char=".">3.0</td></tr><tr><td align="left"> No</td><td align="center">883</td><td align="char" char=".">94.0</td></tr><tr><td align="left"> Missing</td><td align="center">28</td><td align="char" char=".">3.0</td></tr><tr><td align="left">OTC sleeping aids</td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">37</td><td align="char" char=".">3.9</td></tr><tr><td align="left"> No</td><td align="center">876</td><td align="char" char=".">93.3</td></tr><tr><td align="left"> Missing</td><td align="center">26</td><td align="char" char=".">2.8</td></tr><tr><td align="left">OTC cough medications</td><td align="center" /><td align="center" /></tr><tr><td align="left"> Yes</td><td align="center">77</td><td align="char" char=".">8.2</td></tr><tr><td align="left"> No</td><td align="center">828</td><td align="char" char=".">88.2</td></tr><tr><td align="left"> Missing</td><td align="center">34</td><td align="char" char=".">3.6</td></tr></tbody></table> </ephtml> </p> <p>30001 <emph>Note.</emph> *Prescription depressants comprise prescription sedatives, sleeping pills, and tranquilizers.</p> <hd id="AN0126917684-11">Primary analyses</hd> <p>In unadjusted analyses, respondents who reported NMUOTC had greater odds of NMUPD, compared to respondents who reported no NMUOTC (unadjusted OR: 3.47, 95% confidence interval [CI]: 2.27, 5.31) (Table 4). After adjustment for gender, age, race/ethnicity, and Greek membership, the effect measure remained significantly elevated (adjusted OR [AOR]: 3.37; 95% CI: 2.17, 5.23).</p> <p>Table 4. Associations between over-the-counter (OTC) medication misuse (never vs. ever) and nonmedical use of prescription drugs (NMUPD) (never vs. ever).</p> <p> <ephtml> <table><thead><tr><td align="center" /><td align="center">OR</td><td align="center">95% CI</td><td align="center">P-value</td><td align="center">AOR<xref ref-type="fn" rid="t4fn0001" /></td><td align="center">95% CI</td><td align="center">P-value</td></tr></thead><tbody><tr><td align="left">Primary analysis: Comparing any OTC medication misuse vs. any NMUPD</td><td align="center">3.47</td><td align="center">2.27, 5.31</td><td align="center"><0.001</td><td align="center">3.37</td><td align="center">2.17, 5.23</td><td align="center"><0.001</td></tr><tr><td align="left">Secondary analysis: Comparing OTC cough medication misuse vs. any NMUPD</td><td align="center">2.95</td><td align="center">1.81, 4.78</td><td align="center"><0.001</td><td align="center">3.06</td><td align="center">1.85, 5.07</td><td align="center"><0.001</td></tr><tr><td align="left">Secondary analysis: Comparing OTC stimulant misuse vs. prescription stimulant misuse</td><td align="center">8.58</td><td align="center">3.86, 19.1</td><td align="center"><0.001</td><td align="center">7.23</td><td align="center">3.08, 17.0</td><td align="center"><0.001</td></tr><tr><td align="left">Secondary analysis: Comparing OTC sleeping aid misuse vs. prescription depressants misuse<sup>b</sup></td><td align="center">7.91</td><td align="center">3.75, 16.7</td><td align="center"><0.001</td><td align="center">7.15</td><td align="center">3.31, 15.5</td><td align="center"><0.001</td></tr><tr><td align="left">Secondary analysis: Comparing OTC medication misuse vs. poly-prescription misuse</td><td align="center">4.53</td><td align="center">2.46, 8.34</td><td align="center"><0.001</td><td align="center">3.82</td><td align="center">2.01, 7.26</td><td align="center"><0.001</td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 <emph>Note.</emph> OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval.</item> <item>40001 Adjusted for gender, age, race/ethnicity, and Greek membership.</item> <item>40002 Prescription depressants comprise prescription sedatives, sleeping pills, and tranquilizers.</item> </ulist> <hd id="AN0126917684-12">Secondary analyses</hd> <p>Respondents who reported nonmedical use of OTC cough medications (n = 77) had significantly greater odds of NMUPD (unadjusted OR: 2.95, 95% CI: 1.81, 4.78) (Table 4). After adjustment, the relationship was essentially unchanged (adjusted OR: 3.06, 95% CI: 1.85, 5.07). Participants reporting nonmedical use of OTC stimulants (n = 28) had significantly greater odds of nonmedical use of prescription stimulants in both unadjusted (OR: 8.58, 95% CI: 3.86, 19.1) and adjusted analyses (AOR: 7.23, 95% CI: 3.08, 17.0). Respondents who reported nonmedical use of OTC sleeping aids (n = 37) also had significantly greater odds of nonmedical use of prescription depressants in both unadjusted (OR: 7.91, 95% CI: 3.75, 16.7) and adjusted analyses (AOR: 7.15, 95% CI: 3.31, 15.5). Our final analysis examined nonmedical poly-prescription drug misuse. In unadjusted analyses, respondents who reported any NMUOTC (n = 105) had greater odds of poly-prescription drug misuse, compared to respondents who reported no NMUOTC (unadjusted OR: 4.53, 95% CI: 2.46, 8.34) (Table 4). NMUOTC in the previous year remained significantly associated with poly-prescription drug misuse after adjustment (AOR: 3.82, 95% CI: 2.01, 7.26).</p> <hd id="AN0126917684-13">Comment</hd> <p>In order to mitigate the adverse health consequences associated with NMUPD, a concrete understanding of NMUPD and the multiple aspects associated with its usage is necessary. With an increase in advertising and warnings about NMUPD, as well as efforts by physicians, educators, and others to reduce NMUPD, it is possible that more students could be introduced to prescription drug misuse through NMUOTC. This study is one of the first examinations of the association between NMUOTC and NMUPD among university students. We found a significant positive association between NMUOTC and NMUPD, in unadjusted analyses and after adjusting for sex, race/ethnicity, age, and Greek membership. When stratified by drug type, even though the reduced sample sizes led to a loss of precision, the magnitude of the associations was strengthened considerably.</p> <p>Moreover, we found a significant positive association between nonmedical use of OTC cough medication (which are the most-commonly misused OTC products) and NMUPD among university students. Our findings are consistent with those of a previous study that reported a similar relationship among adolescents, after controlling for demographical and other illicit drug use,[<reflink idref="bib18" id="ref25">18</reflink>] and another analysis that also reported a correlation between NMUOTC and NMUPD using two convenience samples of undergraduate students.[<reflink idref="bib2" id="ref26">2</reflink>] Given that OTC medications are generally more accessible than prescription medications, it is notable that NMUPD was reported by more students than NMUOTC. Our findings suggest that accessibility might not be the most important factor determining which substances students misuse in the university environment and supplement the minimal information about NMUOTC among university students, despite adverse outcomes associated with its misuse.[<reflink idref="bib13" id="ref27">13</reflink>]</p> <p>Although we could not distinguish between simultaneous or serial misuse of OTC and prescription medications, the identified association between NMUOTC and NMUPD, as well as poly-prescription drug misuse, raises the concern for unintended adverse consequences resulting from polydrug use. Among university students, NMUPD is consistently associated with polydrug use, including both alcohol and illicit drugs.[<reflink idref="bib4" id="ref28">4</reflink>]<sups>,</sups>[<reflink idref="bib19" id="ref29">19</reflink>] A higher risk for fatal overdoses has been reported among those who simultaneously misuse opioids and alcohol compared to those without simultaneous alcohol use.[<reflink idref="bib20" id="ref30">20</reflink>] Risk of hospitalization or death is higher among those who simultaneously misuse prescription benzodiazepines with opioids and alcohol compared to those who solely misuse benzodiazepines.[<reflink idref="bib21" id="ref31">21</reflink>] The existing research, albeit sparse, also suggests a correlation between NMUOTC and illicit drugs, NMUPD, and alcohol.[<reflink idref="bib2" id="ref32">2</reflink>] It is plausible that adverse drug events due to polydrug use could be exacerbated due to the positive association between NMUOTC and NMUPD. Misusers of OTC medications have reported similar motives, such as sensation seeking and self-medication, which can also drive NMUPD and illicit drug use.[<reflink idref="bib2" id="ref33">2</reflink>]<sups>,</sups>[<reflink idref="bib14" id="ref34">14</reflink>]<sups>,</sups>[<reflink idref="bib22" id="ref35">22</reflink>]<sups>,</sups>[<reflink idref="bib23" id="ref36">23</reflink>] Unfortunately, NMUOTC is seldom reported in assessments of polydrug use among university students. Assessments of polydrug use among NMUPD users have mainly focused on alcohol, tobacco, and illicit street drugs. Due to the exclusion of NMUOTC, the prevalence of polydrug use among university students may be underestimated.</p> <hd id="AN0126917684-14">Limitations</hd> <p>This study has several important limitations. Defining NMUOTC and NMUPD as a binary variable (never vs. ever) does not accurately portray the full spectrum of misuse, given that prior NMUPD usage is correlated with future usage.[<reflink idref="bib24" id="ref37">24</reflink>] While our classification of "ever" misuse does not account for frequency of misuse, our definition does represent problematic misuse due to the illegality of NMUPD. Additionally, questions generally asked whether students used prescription medications that were not prescribed for them and thus captured only one of the definitions for NMUPD. Our findings do not account for students who took prescription medications in a different way than what was prescribed (eg, snorting or injecting crushed tablets or taking a higher dose). Due to the survey's response rate (19.5%) and the difference in characteristics between our analytic sample and the underlying university population, it is possible that our effect measures are biased toward the null. Participants in our sample were more likely to be women, not affiliated with Greek life, and enrolled in a graduate program—factors that may be protective against NMUPD. However, our response rate was comparable to those reported in other university surveys employing a Web-based methodology,[[<reflink idref="bib25" id="ref38">25</reflink>]] and no significant differences existed between those retained in the analytic sample and those who had missing data on NMUPD, including by sex, age, Greek affiliation, race, and NMUOTC (p-values obtained from chi-square tests for categorical data > 0.05). Sensitivity of the survey topic and the language used may also have led to the underreporting of NMUOTC and NMUPD. The survey instrument attempted to minimize these potential biases by conducting a self-administered questionnaire, ensuring confidentially, emphasizing the importance of participation, and providing an incentive. Regardless, our prevalence of NMUPD is higher when compared to another Midwest university in 2011[<reflink idref="bib3" id="ref39">3</reflink>] but falls in the middle of the spectrum for individual universities (0–32%), obtained from the College Alcohol Survey, a nationally representative survey of 119 US universities conducted in 2001.[<reflink idref="bib28" id="ref40">28</reflink>] NMUOTC in our sample is lower than what was reported from student samples in Colorado (18.6%) and Virginia (13.0).[<reflink idref="bib2" id="ref41">2</reflink>] While our data were collected in 2011, our analysis remains applicable with the current public health crisis surrounding NMUPD and provides a quantification of NMUOTC in the university population. Moreover, the geographical location of our study population provides a unique assessment of NMUPD among university students living in a region heavily impacted by NMUPD, specifically opioids.[<reflink idref="bib29" id="ref42">29</reflink>] Finally, confounding by variables that were not measured on the survey, such as use of illicit street drugs and alcohol, is also possible.</p> <hd id="AN0126917684-15">Conclusion</hd> <p>We found a statistically significant association between NMUOTC and NMUPD in the previous year among university students. Our analysis is one of very few to evaluate this association, and our findings underscore the need for assessments of OTC misuse alongside the more widely researched effects of NMUPD among university students. Our findings confirm the importance of both measuring NMUOTC and incorporating NMUOTC in assessments of polydrug use in the university population. Due to the cross-sectional design of our study, it was not possible to determine whether NMUOTC preceded or followed NMUPD. Therefore, we are not able to elucidate a causal link between NMUOTC and NMUPD. Longitudinal studies are required to assess possible causal links between these behaviors and to examine whether progression from OTC misuse to prescription misuse is a typical or prevalent pattern leading to NMUPD. If this pattern of drug misuse is occurring, understanding its facilitators is essential in characterizing NMUPD and developing targeted preventative strategies to mitigate NMUPD. Specifically, future studies could assess how motivations for NMUOTC by drug class changed over time and the influence of curiosity and sensation seeking in the possible transition from NMUOTC to NMUPD. Results could be used to implement screening programs targeted at misusers of OTC medications, prior to the progression of illegally misusing prescription medications. Overall, more studies that quantify and assess characteristics associated with the misuse of prescription and OTC medications among university students are necessary in order to curb initiation and reduce the risks of drug dependence and other long-term consequences.</p> <hd id="AN0126917684-16">Conflict of interest disclosure</hd> <p>The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of The Ohio State University.</p> <hd id="AN0126917684-17">Funding</hd> <p>No funding was used to support this research and/or the preparation of the manuscript.</p> <ref id="AN0126917684-18"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE, Miech RA. Institute for Social Research. 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  Data: Nonmedical Use of Over-the-Counter Medications Is Significantly Associated with Nonmedical Use of Prescription Drugs among University Students
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  Data: English
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  Data: <searchLink fieldCode="AR" term="%22Le%2C+Vi+T%2E%22">Le, Vi T.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-8622-8724">0000-0001-8622-8724</externalLink>)<br /><searchLink fieldCode="AR" term="%22Norris+Turner%2C+Abigail%22">Norris Turner, Abigail</searchLink><br /><searchLink fieldCode="AR" term="%22McDaniel%2C+Anne%22">McDaniel, Anne</searchLink><br /><searchLink fieldCode="AR" term="%22Hale%2C+Kenneth+M%2E%22">Hale, Kenneth M.</searchLink><br /><searchLink fieldCode="AR" term="%22Athas%2C+Christina%22">Athas, Christina</searchLink><br /><searchLink fieldCode="AR" term="%22Kwiek%2C+Nicole+C%2E%22">Kwiek, Nicole C.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+American+College+Health%22"><i>Journal of American College Health</i></searchLink>. 2018 66(1):1-8.
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  Label: Availability
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  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Label: Peer Reviewed
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 8
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2018
– Name: TypeDocument
  Label: Document Type
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  Data: Journal Articles<br />Reports - Research
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  Label: Education Level
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  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink>
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  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Abuse%22">Drug Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Surveys%22">Student Surveys</searchLink><br /><searchLink fieldCode="DE" term="%22Online+Surveys%22">Online Surveys</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Characteristics%22">Student Characteristics</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Age+Differences%22">Age Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Racial+Differences%22">Racial Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Ethnicity%22">Ethnicity</searchLink><br /><searchLink fieldCode="DE" term="%22Sororities%22">Sororities</searchLink><br /><searchLink fieldCode="DE" term="%22Fraternities%22">Fraternities</searchLink><br /><searchLink fieldCode="DE" term="%22Questionnaires%22">Questionnaires</searchLink><br /><searchLink fieldCode="DE" term="%22Statistical+Analysis%22">Statistical Analysis</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07448481.2017.1356312
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0744-8481
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: To examine the association between nonmedical use of over-the-counter medications (NMUOTC) and nonmedical use of prescription drugs (NMUPD). Participants: University students surveyed on NMUOTC and NMUPD between August and December 2011 (N = 939). Methods: Cross-sectional data analysis of online survey. Results: The majority of respondents were women, undergraduate, Caucasian, and not affiliated with Greek life. NMUPD and NMUOTC were reported by 21.4% and 11.2% of students, respectively. NMUOTC was significantly associated with NMUPD in unadjusted analyses and after adjustment for gender, age, race/ethnicity, and Greek membership (odds ratio: 3.37, 95% confidence interval: 2.17, 5.23). Secondary analyses showed a relationship between over-the-counter (OTC) cough medication misuse and NMUPD, OTC stimulant misuse and prescription stimulant misuse, and OTC sleep aid misuse with prescription depressant misuse. Conclusions: Results suggest the importance of both measuring the prevalence of OTC misuse and incorporating its misuse into assessments of polydrug use in the university population.
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  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
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  Data: 29
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2017
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1164893
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      – SubjectFull: Drug Abuse
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      – SubjectFull: Correlation
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      – TitleFull: Nonmedical Use of Over-the-Counter Medications Is Significantly Associated with Nonmedical Use of Prescription Drugs among University Students
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