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Published in final edited form as: Addict Behav. 2022 Dec 21;139:107594. doi: 10.1016/j.addbeh.2022.107594

Early-Onset Prescription Drug Misuse in Indiana Youth

MA Parker a, TC Zapolski b, I Carson c, M Waldron d
PMCID: PMC10506418  NIHMSID: NIHMS1924171  PMID: 36566680

Abstract

Background:

Based on 2018 national estimates, approximately 5-10% of youth between the ages of 12-17 report past year prescription drug misuse (PDM) in the United States. PDM among adolescents is associated with negative health outcomes and risk behaviors. The current study examined both the prevalence of PDM among diverse groups of adolescents and the association of alcohol and cigarette use with early PDM.

Methods:

Data came from the cross-sectional state-based 2018 Indiana Youth Survey of students from grades 6-12, ranging in age from 10-17 years (n=80,926). Lifetime PDM, alcohol, and cigarettes were assessed by self-report, including ages at first use. A series of analyses were conducted separately for non-Hispanic Black, non-Hispanic White, and Hispanic students. We estimated the prevalence of PDM. Likelihood of PDM was estimated using the Kaplan-Meier survivor function. Cox proportional hazards regression models estimated age at first PDM from ages at first use of alcohol and cigarettes.

Results:

Three percent of non-Hispanic Black, 4% of non-Hispanic White, and 5% of Hispanic students reported PDM. Onset of smoking was associated with first PDM across adolescence for all groups. Onset of drinking was associated with first PDM among Hispanic students across adolescence. For Non-Hispanic Black and Non-Hispanic White students, likelihood of PDM was most pronounced during very early adolescence.

Conclusions:

Onset of alcohol and cigarette use were associated with of PDM among Indiana youth, suggesting that interventions aimed at preventing early smoking and drinking may also reduce PDM among youth.

Keywords: Opioid Use, Youth, Race/Ethnicity, Cigarettes, Alcohol

1. Introduction

Concern surrounding prescription drug misuse (PDM) has traditionally focused on opioids and adult populations despite alarming rates of PDM among adolescents. In 2018, according to data from the National Survey on Drug Use and Health (NSDUH), the past-year prevalence of PDM (i.e., pain relievers, tranquilizers, stimulants, and sedatives) was 5% for 12-17 year olds, with misuse as high as 21% for those who used any prescription psychotherapeutic drugs in the past year (United States, 2019). Data from the Monitoring the Future (MTF) study indicates past-year PDM use at 10% among 12th graders (Johnston et al., 2019). Moreover, PDM during adolescence is associated with numerous adverse health outcomes, including drug overdose, substance use disorders, suicidal ideation, delinquency and violence, sexual risk-taking behavior, and STDs (Clayton et al., 2019; Gaither et al., 2016). Thus, understanding risk factors associated with PDM among adolescents is critical.

Several models have been constructed to illuminate the multi-factorial nature of risk for adolescent substance use (e.g., Dodge et al., 2009; Petraitis et al., 1995; Schulenberg & Maggs, 2002). Common across all models, and consistent with the gateway drug theory (Kandel & Kandel, 2015), is the recognition that prior substance use is a risk factor for using other substances. A significant body of research has been conducted examining gateway models within the context of adolescent alcohol and cigarette use. Data from MTF (Kirby & Barry, 2012) and the National Longitudinal Study of Adolescent to Adult Health (Add Health; Nkansah-Amankra & Minelli, 2016) suggest increased likelihood of using other drugs in older adolescence as a function of earlier alcohol and cigarette use. There is also evidence consistent with gateway models of PDM (Griesler et al., 2019; Hermos et al., 2008; Osborne et al., 2017). Utilizing state-level data, alcohol, cigarette, and cannabis use were observed risk factors for PDM, specifically the later use of stimulants, central nervous system depressants, opioids, and over the counter (OTC) drugs (Jayawardene & YoussefAgha, 2014). In data drawn from the NSDUH, Yockey et al. (2020) found that youth who previously used cannabis, alcohol, and cigarettes were also more likely to engage in prescription opioid misuse.

Although important information has been gained through studies examining PDM based on prior substance use, they are limited in two ways. First, most studies examine the gateway hypothesis based on past year use or use by a certain age rather than age of onset. Age at first use is a significant predictor of future engagement in substance use, as well as related problems into adulthood (DeWit et al., 2000; Wagner & Anthony, 2002). Of note, early initiation of PDM is also associated with faster transition to substance use disorders (Volkow et al., 2021).

A second limitation is that much research on adolescent PDM has been conducted with predominately White samples or with data pooled across racial/ethnic group and, thus, ignoring potential variation in risk based on racial/ethnic group membership. Among few studies to examine PDM by racial/ethnic group, differences have been observed. For example, analyzing NSDUH, Ford and Rigg (2014) found that prior cigarette use and binge drinking were associated with PDM only among White youth, with misuse of prescription stimulants increasing risk for both White and Hispanic youth, and the use of other illicit drugs increasing risk for both White and Black youth. Yet, cannabis use and the misuse of prescription sedatives/tranquilizers increased risk of PDM across all racial/ethnic groups. Although limited in the number of published studies, such findings suggest that risk for PDM may vary across racial/ethnic groups based on substance class or type, which is critical to understand given evidence of higher PDM among Black youth (Carmona et al., 2020), with some evidence of elevated risk also for Hispanic youth (Yockey et al., 2020).

To expand on this body of research, the current study aimed to examine both the prevalence of first PDM among three racial/ethnic groups of adolescents and the association of timing of first alcohol and cigarette use on the timing of first PDM.

2. Methods

Study Sample

Data came from the cross-sectional 2018 Indiana Youth Survey of students from grades 6-12, ranging in age from ≤10-18+ years. This survey provides data for state and local planning on substance use and other behaviors. Invitation letters were sent to all 1,448 public and nonpublic Indiana schools in May 2017. Schools obtained parental consent for student participation and had a choice of administering an in-person or online survey. A total of 119,991 students from 407 schools completed the survey from January through April 2018. In total, 112,240 surveys were usable (32.4% of all 6-12th grade students enrolled in Indiana schools during the 2017-2018 school year) (Gassman et al., 2018). We did not have access to data from grade 6 students (n=18,285), 6,999 students self-identified as Asian, Native American, more than one race, or other, and another 1,989 did not answer the questions on race or ethnicity (n=8,988). The present analysis focused on non-Hispanic Black (NHB), non-Hispanic White (NHW), and Hispanic students from grades 7-12 (n=84,967) who answered questions on prescription drugs, alcohol, and cigarettes (n=80,926).

Measures

Lifetime use and age at first use of non-prescribed prescription drugs, alcohol, and cigarettes were assessed by self-report similar to the NSDUH (NSDUH 2018 Methodological Resource Book (MRB) ∣ CBHSQ, 2017). The survey asked, “How old were you when you first used… [Prescription drugs (like OxyContin, Xanax, Vicodin, Adderall, etc.) not prescribed to you; Alcohol (beer, wine, liquor, wine coolers); Cigarettes]?” with the following response options: never used, ≤10, 11, 12, 13, 14, 15, 16, 17+. For analytic purposes, students initiating at ages ≤10 were coded as having first used at age 10. Likewise, students initiating PDM at age 17+ were coded as having first used at age 17 (n’s≤1%). Students were also asked about their sex (male/female), race (White, Black or African-American, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaskan Native, Race not known or other, More than one race), ethnicity (Hispanic, Non-Hispanic), and current age (11, 12, 13, 14, 15, 16, 17, 18+ years old). Race/ethnicity was combined into three categories based on a priori hypotheses: NHB, NHW, and Hispanic.

Analyses

We first estimated the prevalence of PDM separately for NHB, NHW, and Hispanic students. Using the Kaplan-Meier method, we estimated likelihood of PDM with log-rank tests of differences by racial/ethnic group. Next, Cox proportional hazards regression models were estimated separately for NHB, NHW, and Hispanic students, estimating age at first PDM from ages at first use of alcohol and cigarettes while adjusting for sex. The Huber-White robust variance estimator was employed to compute confidence intervals (95% CI) and the Efron method was used for when drinking or smoking and PDM were initiated the same year. In Cox analyses, the Grambsch and Therneau test of Schoenfeld residuals examined the proportional hazards assumption (Grambsch & Therneau, 1994). Age interactions were modeled to correct for observed violations and selected based on best correction. All analyses were conducted in STATA Version 17 (StataCorp LP, College Station, TX).

3. Results

About half of the sample was male (49%). The approximate mean and median age was 14 years old. Most of the sample identified as NHW (82%), 12% as Hispanic, and 6% as NHB. Three percent of NHB, 4% of NHW, and 5% of Hispanic students reported PDM, among whom age at first use ranged from 10-17 (Mage of onset=13.7, SD=2.2). About a quarter of the sample also reported alcohol use: 22.6%, 26.1%, and 30.4% of NHB, NHW, and Hispanic students (Mage of onset=13.5, SD=2.1). For cigarettes, 6.3%, 10.9%, and 10.8% of NHB, NHW, and Hispanic students reported having smoked (Mage of onset=13.1, SD=2.2). See Table 1 for additional estimates by race/ethnicity.

Table 1.

Background characteristics of Indiana youth by race/ethnicity. Indiana Youth Survey, 2018.

Non-Hispanic Black
(NHB)
n = 4,653		 Non-Hispanic
White
(NHW)
n = 66,052		 Hispanic
n = 10,221
Age (years), M (SD)a 14.0 (1.7) 14.0 (1.7) 13.9 (1.7)
Sex, n (%)
 Male 2,221 (47.7) 32,369 (49.0) 5,017 (49.1)
 Female 2,432 (52.3) 33,683 (51.0) 5,204 (50.9)
Substance Use
 Prescription drug misuse, n (%) 157 (3.4) 2,515 (3.8) 500 (4.9)
  Age at first use, M (SD)a 13.4 (2.3) 13.8 (2.2) 13.7 (2.1)
 Alcohol use, n (%) 1,015 (22.6) 16,969 (26.1) 3,034 (30.4)
  Age at first use, M (SD)a 13.6 (2.2) 13.6 (2.1) 13.1 (2.1)
 Cigarettes, n (%) 293 (6.3) 7,210 (10.9) 1,105 (10.8)
  Age at first use, M (SD)a 12.1 (2.0) 13.2 (2.2) 12.9 (2.2)
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a

Ages are approximate as categories were ≤10, 11, 12, 13, 14, 15, 16, 17, 18+ years old.

In Kaplan-Meier models, likelihood of PDM was associated with timing of first cigarette and alcohol use, with log-rank tests of equality suggesting differences as a function of race/ethnicity (p-value<0.001). Figure 1 and Supplemental Table 1 summarize results of Cox models. Across adolescence, onset of smoking was associated with first PDM for all racial/ethnic groups, with HRs ranging from 2.95-4.42. Across adolescence, onset of drinking was associated with over 8 times increased likelihood of PDM for Hispanic students. For NHB and NHW students, onset of drinking was associated with PDM, with the highest HRs during very early adolescence. For NHW students, through age 11, drinking was associated with over 6 times increased likelihood of PDM, with HRs ranging between 2.86-3.98 from age 12 onward. For NHB students, within each risk period, the relationship between alcohol use and PDM was non-significant. Sex was non-significant in all Cox models.

Figure 1.

Figure 1.

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Hazard ratios (and 95% CIs) from Cox proportional hazards estimates between age of first alcohol/cigarette use and age at first prescription drug misuse by race/ethnicity.

4. Discussion

We examined likelihood of PDM in a diverse state sample of secondary school students, including associations between age at first alcohol or cigarette use and age at first PDM. Although relatively few students initiated PDM, the past-year prevalence of PDM among the current sample appears to be similar to national data collected on adolescent opioid misuse during the same year at approximately 3% for NHB, NHW, and Hispanic youth (United States, 2019). A limitation of this comparison is that prevalence was not consolidated across substance type and did not report lifetime prevalence.

Across adolescence, onset of smoking was associated with earlier PDM for NHB, NHW, and Hispanic students, as was onset of drinking for Hispanic youth. In contrast, for NHB and NHW students, HRs associated with alcohol use were highest during very early adolescence. However, estimates within individual risk periods, which were necessary to correct proportional hazards violations, were non-significant for NHB students where cell sizes were especially small.

Findings on cigarette use and PDM are broadly consistent with prior research (Griesler et al., 2019; Hermos et al., 2008; Osborne et al., 2017), as are findings specific to the relationship between alcohol use and PDM (Kirby & Barry, 2012; Yockey et al., 2020). Such studies rarely examine use specific to race/ethnicity, nor utilize a survival-analytic framework taking into consideration that many adolescents who have yet to initiate use may do so in the future. For alcohol use, results from survival models highlight both racial/ethnic and developmental variation. Although onset of smoking was associated with earlier use of PDM across race/ethnicity, and regardless of age, likelihood of PDM associated with drinking was highest through ages 11-12 for NHW and NHB students. Family structure, parental relationships, and monitoring may account for some of the variation across race/ethnicity groups (Harrell & Broman, 2009).

Among strengths of this study, we examined a large state-representative sample of students, who self-reported a range of substance use behaviors, including ages at onset of PDM. However, there are also limitations of this study. As noted, the sample was predominately NHW, representing one US state in one year (2018), which may limit generalizability and statistical power for some comparisons, including those specific to NHB students. In addition, those reporting first use prior to age 10 or after age 17 were pooled with those initiating at ages 10 and 17, respectively, a consequence of the assessment. Given the goal of our study was to document previously undocumented associations focusing on timing of onset, we did not examine potential mechanisms underlying observed relationships. There are likely numerous unmeasured factors that may influence onset of alcohol and cigarette use and, in turn, onset of PDM, beyond gateway causality (e.g., birthplace (Parker et al., 2018)).

The current study provides further evidence to suggest that early smoking and drinking are risk factors for PDM during adolescence, with indication that this risk pathway (i.e., earlier prior use) is evident across race/ethnicity with variation in timing of risk also important. Moreover, given that other forms of tobacco use, such as e-cigarette use, are associated with PDM use among adolescents (Evans-Polce et al., 2020) more research is warranted to better understand the types of substance use that pose risk for PDM among adolescents. Additionally, future research may also build from this study by examining the hypothesized relationship across nationally representative samples of adolescents studied prospectively over time into younger and older adulthood. Moreover, given the multi-factorial structure of risk for adolescent substance use (e.g., Dodge et al., 2009; Petraitis et al., 1995; Schulenberg & Maggs, 2002) that includes sociodemographic risk as well as personality, behavioral risk, family, peers, and the community (Donovan, 2004), additional factors can be examined beyond prior substance use and variation in risk based on race/ethnicity. It may also be important to investigate the association between alcohol and/or cigarettes and specific PDM (e.g., opioids, benzodiazepines, stimulants) considering the dynamic changes in youth drug use (Johnston et al., 2019).

In conclusion, in a state-wide sample of middle and high school students, onset of alcohol and cigarette use were associated with earlier PDM across three race/ethnicity groups. Findings suggest programming at both primary and secondary school levels may help prevent PDM with focus on early smoking and drinking. For alcohol use, targeting of very young adolescents may be especially efficacious.

Supplementary Material

1

Highlights.

  • We estimated the prevalence of prescription drug misuse (PDM) among diverse youth.

  • We examined the association between alcohol and cigarette use and early PDM.

  • Onset of alcohol and cigarette use was associated with PDM among Indiana youth.

  • Interventions aimed to prevent early smoking and drinking may reduce PDM for youth.

Acknowledgements

The authors would like to thank Dr. Erik S. Parker for his help with the statistical analysis and developing the figure for this paper.

Role of Funding Source

This work was supported by Indiana University start-up funds (MAP).

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Credit Author Statement

Maria Parker: Conceptualization, Writing – Original draft, Reviewing, & Editing, Formal Analysis; Tamika Zapolski: Writing – Original draft, Reviewing, & Editing. Ian Carson: Writing – Original draft; Mary Waldron: Conceptualization, Methodology, Reviewing, & Editing;

Conflict of Interest

No conflict declared.

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