THE CURRENT STATE OF TEENAGE DRUG ABUSE

TREND TOWARD PRESCRIPTION DRUGS

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 97132
(503)673-7014
nursepaula@verizon.net
PROGRAM FACULTY
Rochelle D. Schwartz-Bloom, PhD Elizabeth S. MeConnell
Professor of Pharmacology Deputy Director for Education
Director, D.A.R.E America
Duke Center for Science Education St. Louis, Missouri
Duke University Medical Center
Durham, North Carolina

ABSTRACT: The problem of prescription drug mis-
use 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 inven-
tory and lock away their own prescription medications.
School nurses are in a position to help prevent, identify,
and manage the problem by educating students, par-
ents, and other school staff on the dangers and signs
of adolescent prescription drug misuse. The informa-
tion in this supplement is intended to educate and
heip 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 ofteens
abusing prescription drugs,
now is the timefor adults working
with schoolchildren to join together
to prevent thisfrightening trend.
Elizabeth S, MeConnell,
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 adoles-
cents 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 address-
ing 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 com-
prising this supplement and a toolkit that is available online.
The toolkit consists of information sheets for use with par-
ents, students, teachers, and the community. Worksheets
and lists of commonly abused prescription medications are
included. The toolkit is conveniently housed in one location

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

The reasons adolescents misuse prescription medications

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

S2
own medications with others, and 115 had done both. Of
those respondents 12 to 18 years of age who reported ever Table 1.
borrowing or sharing medications, only 3,8% stated that Adolescents' Rationales for Sharing
they would not share prescription drugs with their peers Prescription Drugs (n=210)
(Daniel, Honein, & Moore, 2003).
Rationale Respondents, %*
Figure 2 provides a summary of commonly misused prescrip-
Got it from a family member 66.2
tion medications {Johnston, O'Malley, Bachman, & Schu-
lenberg, 2007a; National Institutes of Health, 2007). The Have a prescription but ran out 64.8
three classes of medications that are most often misused
are opioids, central nervous system (CNS) depressants, and Have the same problem as the person 60.5
stimulants (National Institute on Drug Abuse, 2005), Of the who gave me the medicine
adolescents who reported misusing prescription drugs in Want something strong for pain or 43,3
the CASA study, 83,4% misused opioids; 24,6% and 5.6% headache
misused tranquilizers and sedatives, respectively; and 25.1%
misused stimulants at least once in the previous year (CASA, Have an emergency 39,0
2005). Got it from someone who knows 28.1
about medicine
In 2004, the prevalence of dependence or abuse of prescrip-
tion drugs in the past year among adolescents between 12 Need help sleeping 21.9
and 17 years of age was 15.9%, compared with 12,7%
among those 18 to 25 years of age (Office of Applied Stud- Want something strong for pimples 19.0
or oily skin
ies, 2006a). The rate of dependence on or abuse of pain
relievers increased steadily among adolescents from 2002 Need the medicine but can't afford 18.1
to 2004 (Office of Applied Studies, 2006b). Table 2 (page to buy it
S4) describes the major effects of each class of prescription
medications (National Institute on Drug Abuse, 2005). In Have leftover medicine that would be 13.8
wasted
addition to the possibly dangerous impact on cardiovascular,
respiratory, and neurologic functioning that these drugs can Want to relax or feel good 12.9
have, they all carry the potential for physical dependence
and addiction. Have heard a lot about this medicine 4.3
from ads or commercials
Although Americans constitute only 4% of the world's pop- "Multiple reasons were accepted; therefore, total may exceed 100%,
ulation, they use 80% of its supply of all opioids (Manchi- Note, Adapted with permission from Pediatrics. Vol, 111, Pages 1167-1170,
kanti, 2007), This class includes analgesics such as oxycodone Copyright © 2003 by the AAP,

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

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

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

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

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

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

% With Nonmedical Use in Past Year

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

S3
(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, how-
ever, 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

Effects of Commonly Prescribed Drugs
OPIOIDS
• 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
CNS = central nervous system; GABA = gamma-aminobutyric acid.
Note. From National Institute on Drug Abuse, 2005.
Table 2.
CNS DEPRESSANTS
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
STIMULANTS
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

S4
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. Amphet-
amines 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., Rit-
alin®, Methylin®) {National Institute on Drug Abuse, 2005).
These drugs are prescribed primarily to treat attention defi-
cit-hyperactivity disorder {ADHD), with 90% of methylpheni-
date 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 teenag-
ers to get high, to stay awake and focused for studying, or
to lose weight (CASA, 2005). The effort to minimize diver-
sion 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 for-
mulations than of immediate-release formulations (Wilens,
Gignac, Swezey, Monuteaux, & Biederman, 2006).
CNS depressants include barbiturates such as phénobar-
bital (Nembutal®) and benzodiazepines such as diazepam
(Valium®), clonazepam (Klonopin®), and chlordiazepoxide
HCI (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
prescnbed 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. Uninten-
tional 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 depen-
dence does not always result from misuse, it is a potential
outcome (O'Brien, 2005). The greatest danger with benzo-
diazepine misuse occurs if these drugs are used in combina-
tion with other CNS depressants, such as opioid analgesics
or alcohol (National Institute on Drug Abuse, 2005). The
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 2 1 % ,
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) medi-
cations, such as diet pills, sleep aids, cough medicine, and
motion sickness aids, are being abused as well. Adoles-
cents 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 hal-
lucinogens. 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. Ado-
lescents have several names for dextromethorphan-con-
taining medicines, such as "dex," "DXM," and "skittles,"
and the act of getting high on products such as Robitus-
sin is often called "robotripping" (James, 2006; Johnston,
O'Malley, Bachman, & Schulenberg, 2007b). OTC medica-
tions 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 Wash-
ington, 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 pre-
scription 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 medi-
cation 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 con-
tinued 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, Ciasen,
Toga, Rapoport, & Thompson, 2004).
55
MYTHS CONTRIBUTING TO people metabolize many drugs, including antidepressants
INCREASED MISUSE and opioid analgesics. Those who metabolize a drug rapidly
may need higher doses to achieve an effect, whereas those
Several common misconceptions among adolescents and
who metabolize the same drug slowly may experience toxic-
their families contribute to the high rate of prescription
ity at a similar dose of that same drug (Caraco, 2004; Merck
medicine misuse. These include, but are not limited to, the
& Co., 2003). in other words, what can help one person may
following:
have no effect on another and could be lethal to a third,
MYTH: There is no such thing as "abuse" of prescription
MYTH: If drugs are used only occasionally, they can't hurt
drugs-after all, they're legal; also, if it's legal, it's safe.
anybody
In the PATS survey, about half of the more than 7,000 ado-
A common impression is that there is little risk in occasional
lescents, grades 7 through 12, surveyed saw no great risk in
use of medications (Friedman, 2006). Many of the adoles-
nonmedical use of prescription drugs. A majority of teens
cents responding to the PATS survey believed that prescrip-
surveyed also believed that prescription medications, even
tion pain relievers are not addictive. About one third of
when prescribed for someone else, are safer to use than are
these adolescents believed that occasional nonmedical use
illegal drugs (Partnership for a Drug-Free Amenca, 2005).
of others' prescription medications is not harmful or addic-
The principle of "good medicine, bad behavior," meaning
tive (Partnership for a Drug-Free America, 2005). Teenag-
that drugs that can be very helpful when used appropriately
ers frequently do not understand the variation in addiction
can be extremely harmful when misused, clearly needs fur-
potential from user to user of a medication.
ther reinforcement.

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

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

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

nied by an increase in potential adverse effects. exposures

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

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

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

Adolescents and frequently their parents need to be

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

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

S6
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. Mis-
use of prescription medication, however, is not limited to
lower socioeconomic or undereducated groups, as illustrated
in Figures 4 and 5 (Manchikanti, 2006; Office of Applied
Studies, 2006c; Wu, Pilowsky, & Patkar, 2008). In fact, teens
from affluent families may have more access to prescription
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'
Ol
c with prescriptions for stimulant medications to manage
Ethnicity Education
• White • Some High school
• Black D High School Graduate
• Asian • Some College
• Native American • College Graduate
•Note. Based on 2002-2004 statistics.
From Office of Applied Studies 2005c,
Figure 5.
Lifetime Prevalence of Non-prescribed Use of
Pain Relievers Among Adolescents Aged
12-17 Years (Unweighted N=18,678)
$20,000- $40,000- $75.000
$39,999 $74,999 or more
Family Income
Note. From Wu, Pilowsky & Patkar, 2008. 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 dan-
ger of accumulating and overdosing on that ingredient, even
if each drug is used within its indicated limitations (Mercóla,
2004).
OTHER FACTORS CONTRIBUTING TO
INCREASED MISUSE
Many factors contribute to the increasing prevalence of pre-
scription drug abuse. Among these are the increasing acces-
sibility of drugs and information on their use, the way that
misuse of prescription medications is interwoven into the
social life of many U.S. adolescents, and general ignorance
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 reliev-
ers (Office of National Drug Control Policy, 2007), More
than 65% of respondents reported friends or relatives as
sources of prescription medications. A recent Canadian
study reported that more than one fourth of adolescents
ADHD had given or sold some of their medication to peers
(Poulin, 2007). Clearly, the majority of teenagers are obtain-
ing 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 fam-
ily members' homes. The ready availability of prescription
S7

Figure 6.
Sources of Prescription Pain Relievers
for Adolescents
10.0%
47.3%
• other • 1 Physician
• Bought (stranger) • Friend (given)
• >1 Physician • Friend/Relative (stole)
• Internet (0.1%), D Friend/Relative (bought)
Fake Rx (0,1%), Stole* (0.5%)
*from physician's office, clinic, hospital, or pharmacy,
Rx = prescription.
Note. Adapted from Office of National Drug Control Policy, Executive
Office of the President, 2007.
medication in adolescents' own or families' homes highlights
the need for increased educational efforts targeting families
regarding safeguarding and monitoring prescription medica-
tions in the home.
The Internet has hecoTne 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. CaÜfano, Jr., Chairman and President, CASA
A recent survey by Teenage Research Unlimited found that
58% of respondents v^ere aware of the availability of pre-
scription drugs on the Internet (Teenage Research Unlimited,
2006), and more than 7 million respondents in the PATS
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 2006, The number of sites that sell controlled pre-
scription 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 prescnptions, and more than half of the other 16%
did not require original prescriptions but accepted faxed cop-
ies {CASA, 2005). In addition to the Internet's being a source
S8
of drugs, it also is a source of information on their use. Sev-
eral 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 pana-
ceas rather than dangerous substances (CASA, 2005). The
media may contribute to the attraction of prescription medi-
cations to adolescents by fostering an impression that these
drugs are safe to use (McCarthy, 2007). Adolescents who see
adults in their families using more and more prescription and
OTC medications may then go to school and see their peers
using the same drugs for nonmedical purposes, and their
impression of the acceptability of the use of the medica-
tions 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 dan-
gerous effects, as described in Table 3 (National Institute on
Aicohoi Abuse and Alcoholism, 2007; National Institute on
Drug Abuse, 2005; Parents: The Anti-Drug, 2006).
Ignorance Regarding the Problem
If Iget a narcoticfrom a dentist... [Vm guilty]
of not counting them when Iget home, or not
watching them that closely, or not disposing
ofthem properly when I am, through with
them, andVm 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
 disposing of pills safely when they are finished using them
Table 3. or the period of highest potency of the pills has expired
Drug Interactions (MSNBC.com, 2007). In fact, it is reasonable to assume that
Drug Type Mixed With parents would be unaware if their children stole prescription
Possible Adverse
medicine from them.
Interactions
OpioJd Alcohol, Increased respiratory Adolescents are frequently more experienced in using the
antihistamines, depression, impaired Internet than their parents are. The survey by Teenage
barbiturates, motor control Research Unlimited (2006) noted that the majority of teen-
benzodiazepines agers interviewed had bought or knew someone who had
CNS
bought alcohol on the Internet and stated that their par-
Alcohol, Respiratory
Depressant ents could not control their Internet activities. In fact, 68%
prescription pain depression, impaired
medications, OTC reported that their parents never tried to control their Inter-
motor control,
cold and allergy dangerously slowed net activities, and 39% said that their parents knew little or
medications heartbeat nothing about their Internet activities. Only 25% reported
that their parents knew a great deal about their Internet
Stimulant Alcohol Need to drink more to activities. These findings probably are equally applicable to
feel effect of alcohol the accessibility of drugs on the Internet. The discrepancy
OTC Arrhythmia, between adolescents' skill at navigating the Internet and
decongestants^ dangerously high their parents' awareness of this ability likely enhances the
blood pressure ease with which teenagers can obtain drugs on the Internet.
Cold and Alcohol Increased drowsiness, On the other hand, adolescents often are not aware of the
cough dizziness, risk of potent effects on cognition and motor skills some commonly
nrtedicine overdose available drugs can have or of their potential harm, including
*This cJoes not include decongestant sprays. death, even at small doses (Friedman, 2006). This is not sur-
CNS = central nervous system prising considering that adults in one study ranked NSAIDs
Note. From National Institute on Drug Abuse, 2005; National Institute on among the safest prescription medications and, overall,
Alcohol Abuse and Alcoholism, 2007; Parents: The Anti-Drug, 2005.
underestimated the rates of adverse reactions possible with
several prescription medications (Cullen, Kelly, & Murray,
ill equipped to deal with teens' abuse of prescription drug 2006). If parents are not aware of the risks, their children
use, a behavior that was probably not on their radar when should not be expected to be aware either.
they were teenagers. They find it hard to understand the
scale and purposeful ness with which today's teens are abus-
ing medications, and it's not immediately clear to them that RECOGNIZING THE PROBLEM
the pnme source of supply for abusable prescription drugs
IS likely to be their own medicine cabinet. Further, many
Because ofour unique position within the
parents themselves are misusing, or perhaps abusing, pre-
scription drugs without having a prescription. In our study..., schools, students trust and confide in school
28% of parents said they had used a prescription drug with- nurses. We need to be prepared to respond
out having a prescription for it, and 8% of parents said they
had given their teenaged child an Rx drug that was not pre-
accordingly when we hear about the misuse
scribed for the teen" (United States Senate Committee on of prescription drugs, including drugs being
the Judiciary, 2008). mixed with alcohol or stimulant drinks. It is
important to keep abreast of current trends, as
One pill makes you larger, and one pill students have access to so much information
makes you small, and the ones that mother on the Internet that can be potentially lethal.
gives you don't do anything at all. Paula Apa-Hall
Past-President. Oregon School Nurses Association
Grace Slick, "White Rabbit" Board of Directors, National Association of School Nurses

Unfortunately, the statement in the Jefferson Airplane song
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 medi-
cations by counting pills periodically, locking up prescrip-
tion 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 m the school nurse

S9
without risking consequences such as being judged, hav-
ing their privileges revoked or curtailed, or receiving lower
marks in classes. With the exception of information regard-
ing potential harm to the student or others, the school nurse
can offer confidentiality to students in discussing any prob-
lems 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, shouid initiate an
investigation into potential problems. A straightforward con-
versation 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 bet-
ter results than a more open question.
Teachers, administrators, and other school personnel need
to be educated by the school nurse to recognize medica-
tion misuse problems among students (Manchikanti, 2006).
Teachers should become familiar vwith 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 prescnption medication misuse
among students, school nurses play a pivotal role in man-
agement 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
SIO
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 pri-
mary recipients of education by the school nurse. The infor-
mation 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 advis-
able. Although high school health classes often address use
of illicit drugs, the majority do not cover misuse of prescrip-
tion 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, Direc-
tor of the Center for Substance Abuse Treatment of the U.S.
Substance Abuse and Mental Health Services Administra-
tion, has stressed the importance of physicians and phar-
macists 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 lock-
ing 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 impor-
tant that they establish an ongoing dialogue regarding the
dangers of drug abuse. See page SI 5 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 teenag-
ers 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 state-
ment 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
 Figure 7.
States That Have Developed Policies or Regulations
Regarding Medication Administration in Schools
Map not drawn to scale
policies with which students must comply. They further advise
that all medication brought to school should be in appropri-
ately 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). Fig-
ure 8 (page SI2) 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 adoles-
cents 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 con-
trolled drugs, preventing their diversion, or identifying abuse
of or addiction to these medications {CASA, 2005; National
Institute on Drug Abuse, 2005).
Note. From Enotes.com.
School nurses should be aware of the options for treat-
ing prescription drug misuse or dependence. Primarily,
these comprise behavioral and pharmacologie approaches.
Depending on the drug of abuse and the extent of a stu-
dent's involvement with or dependence on the drug, the
treatment may consist of counseling alone, detoxification
along with counseling, or, if necessary, medications to coun-
ter 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 offic^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
Sil

Figure 8.
Sample Se If-¡Vied i cation Agreement
(Courtesy of Paula Apa-Hall, RN, MEd, NCSN)
Studeiits 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.
1 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 avail-
able form. This toolkit can be accessed under "Educational
Campaigns" on the right side of the NASN home page
(http://www.nasn.org).
S12
CONCLUSION
Whichever term is used to describe it, misuse/diversion/abuse
of prescription and OTC medications is a present and grow-
ing 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 medica-
tion misuse.
School nurses are in a position to play pivotal roles in con-
trolling 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.
Acknowledgemer)t: 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. 1 f 2(3 Pt
1), 697-699.
Banta, C. (2005). Trading for a high [Electronic Version]. Time, 166.
Retrieved January 22, 2008 from http://www-time.comAime/magazine/
artide/0,9171,1086173,00.html.
Boyd, C. J.. McCabe, S. E,, Cranford, J. A., & Young, A- (2006).
Adolescents' motivations to abuse prescription medications. Pediatrics,
ÍÍS(6), 2472-2480.
Caraco, Y- (2004). Genes and the response to drugs. New England Journal
of Medicine. 3S1{21). 2867-2869.
CASA. (2005), Under tbe counter: The diversion and abuse of controlled
prescription drugs. Retrieved September 19, 2007, from http://www.
medpagetoday.com/Psychiatry/Addictions/tb1/1322?pfc=101&spc=235
Centers for Disease Control and Prevention. (2007). Unintentional
poisoning deaths-United States, 1999-2004. MMWR Morbity and
Mortality Weekly Report. 56(5), 93-96.
Cheng, I 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). 129-132.
Cullen, G., Kelly, E., & Murray, F. E. (2006). Patients' knowledge of adverse
reactions to current medications. British Journal of Clinical Pharmacology.
62(2), 232-236.
 Daniel, K. L., Honein, M. A., & Moore, C. A. (2003), Sharing prescription
medication among teenage girls: Potential danger to unplanned/
undiagnosed pregnancies. Ped/afncs, ; n { 5 P t . 2), 1167-1170.
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 Healtfi Services
Administration-
Enotes.com. Administering medicine. Encyclopedia of Everyday Law.
Retrieved February 14, 2008, from http://www.enotes.com/everyday-law-
encyclopedia/administering-medicine
Friedman, R. A. (2006). The changing face of teenage drug abuse—the
trend toward prescription drugs. New England Journal of Medicine,
354(14), 1448-1450.
Giedd J. (2008). Interview. PBS Frontline. Retrieved February 20, 2008, from
http://vvww.pbs.org/wgbh/pages/frontline/shows/teen bra in/interviews/
giedd.html
Gogtay, N., Giedd, J. N., Lusk, L., Hayashi, K. M., Greenstein, D., Vaituzis,
A. C, Nugent, T. F, 3rd, Herman, D. H., Ciasen, 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
Amenca. /0?(21), 8174-8179.
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 http://wvvw.abcnews.go.com/print?id=2702166
Johnston, L D., O'Maliey, P. M., Bachman, J. G., & Schulenberg, J. E.
(2007a). 2007 Data from in-school surveys of 8th-, 10th-and 12th-grade
students. Retrieved January 28, 2008, from http://vvww.
monitoringthefuture.org/data/07data.htm!
Johnston, L. D., O'Malley, P. M., Bachman, J. G., S Schulenberg, J. E.
(2üO7b). Monitoring the future. National survey results on adolescent drug
abuse. Overview of key findings, 2006. (NIH Publication No. 07-6202).
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 http://vwvw.usatoday.
com/news^ealth/2003-12-29-drug-abuse-cover„x.htm?loc=interstitiaskip
Leshner, A. I. (2005). Oops: How casual drug use leads to addiction.
Retrieved March 3, 2008, from http://www.drugabuse.gov/Published_
Articles/Oops.html
Levine, D. A. (2007). "Pharming" : The abuse of prescription and over-the-
counter drugs in teens. Current Opinion in Pediatría. 19{3). 270-274.
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),
287-321.
Manchikanti, L. (2007). National drug control policy and prescription drug
abuse: Facts and fallacies. Fain Physician, 10{3). 399-424.
McCarthy, M. (2007). Prescription drug abuse up sharply in the USA.
Lancet, 369(9572], 1505-1506.
Merck S Co., Inc. (2003). The Merck manual of medical information—
second edition. Retrieved January 29, 2008, from http://wviMi.merck.com/
mmhe/print/secO2/chO13/chOl 3a.html
Mercóla, J. (2004). Seven common misconceptions about Tylenol and other
OTC drugs. Retrieved January 22, 2008, from http://www.
chattanoogahea!th.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 http://wvvw.msnbc.msn,com/id/17153831/print/1/
displaymode/1098/
National Association of School Nurses. (2007). NASN prescription drug
abuse 4-question survey
National Institute on Alcohol Abuse and Alcoholism. (2007). Harmfui
interactions: Mixing alcohol with medicines. Retrieved January 22, 2008,
from http://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm
National Institute on Drug Abuse. (2005). Prescription drugs: Abuse and
addiction (No. NIH Publication No. 05-4881).
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 http://www.nih.gov/news/pr/dec2007/nida-11 .htm
New York State Office of Alcoholism and Substance Abuse Services. (2007).
Addiction medicine — ieens and prescription drug abuse. Retrieved
February 12, 2008, from http://vvww.oasas.state.ny.us/Admed/rx/
teenrsabuse.cfm
O'Brien, C. P (2005). Benzodiazepine use, abuse, and dependence. Journal
of Clinical Psychiatry, 66(Suppl 2), 28-33.
Office of Applied Studies. (2006a). Misuse of prescription drugs: Highlights.
Retrieved January 22, 2008, from http.//www.oas.samhsa.gov/prescription/
High.htm
Office of Applied Studies. (2006b). Misuse of prescription drugs:
Prescription drug dependence, abuse, and treatment. Retrieved January 22,
2008, from http://www.oas.samhsa.gav/prescription/Ch6.htm
Office of Applied Studies. (2006c). Misuse of prescription drugs: Prevaience
and recent trends in misuse of prescription drugs. Retrieved January 22,
2008, from http://vwvw.oas.samhsa.gov/prescr)ption/Ch2.htm
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 http://oas.
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 http://wvvw.
mediacampaign.org/teens/brochure.pdf
Parents: The Anti-Drug. (2006). Prescription drug abuse. Retrieved
January 28, 2008, from http://www.theantidrug.com/drugjnfo/
prescriptian_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 http://vvww.drugfree.org/Files/FuIl_Teen_Report
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, W2{5), 740-751.
Substance Abuse and Mental Health Sen/ices Administration. (2008,
January 10). New study reveals more than 3 million adolescents and young
adults have used non-prescript ion cough and coid medicine to get high at
least once in their lifetimes. Retrieved March 1, 2008, from http://vwvw.
samhsa.gov/newsroom/advisories/0801091855.aspx
Teen Drug Abuse. (2008). Over-the-counter drug abuse. Retrieved
January 21, 2008, from http://vwvw.teendrugabuse.us/over_the_counter_
drug_abuse.html
Teenage Research Unlimited. (2006). Research findings: underage alcohol
access & consumption. Internet, phone, and mail. Retrieved September 18,
2007, from http://wvvw.wswa.org/public/media/tru-research/
TRUSun/ey080206.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
http://wvvw.medpagetoday.corn/Psychiatry/Addictions/tbl/1322?pfc=101
&spc=235
United States Senate Committee on the Judiciary, Senate Subcommittee on
Cnme 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
http://judiciary.senate.gov/testimany.cfm?id=3199&wit_id=7033
Wilens, T E., GJgnac, 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), 408-414.
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), 1-11.
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CNE Questions CNE EXAM AND EVALUATION
(2.0 CNE Contact Hours free to the first 2,000 members)
1. Between 2004 and 2005, the rate of emergency
department visits related to nonmedical use of To receive CNE credit and a certificate, please complete the
prescription drugs increased by post-test and evaluation online at www.nasneducation.org.
a. 4% b. 15% c. 21% d. 35% Your CNE certificate will be automatically generated upon
completion.
2. In 2003, about adolescents misused
prescription drugs. If you are unable to complete the post-test and evaluation
a. 100,000 c. 2.3 million online, please mail the below form to:
b. 1.7 million d. 5.6 million
National Association of School Nurses
3. Prescription psychotropics are abused 8484 Georgia Avenue, Suite 420
Silver Spring, MD 20910
a. less than any other class of drugs Attn: Marianne Engle
b. more than any other drug except marijuana
Processing will take approximately 6-8 weeks.
c. more than any other drug, including marijuana
d. about as often as cocaine
4. Most teenagers who misuse prescription medications CE REGISTRATION/POSTTEST
also use other drugs, including alcohol. ANSWER FORM/EVALUATION FORM
a. True b. False
Record your posttest answers by filling in the blank with
5. In one survey, about % of adolescents said that the letter from the correct answer to the corresponding
they would share prescription medications with their
peers,
a. 25 b. 96 c. 8 d. 4 1. 2. 3. 4. 5. 6. 7.
6. Americans use about % of the world's opioids.
a. 20 b. 40 c. 60 d. 80 8. 9. 10. 11. 12. 13.
.. ..
7. "Pharming" refers to:
a. growing one's own marijuana COURSE EVALUATION
b. sharing multiple prescription drugs at parties
c. buying drugs on the Internet We hope this program has provided information that will
d. selling drugs at school be useful in your practice. Your evaluation will help us pian
future programs. May we have your comments? Please
8. "Robotripping" refers to: evaluate this publication by circling your response(s).
a. getting high on OTC cough/cold medicines
b. getting so high that one loses coordination 4 = Strongly Agree N/A = Not Applicable
c. getting high and playing video games 3 = Agree
d. going through the school day without paying 2 = Disagree
attention 1 = Strongly Disagree

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

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