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. Author manuscript; available in PMC: 2025 Oct 15.
Published in final edited form as: J Affect Disord. 2024 Jul 20;363:72–78. doi: 10.1016/j.jad.2024.07.078

Opioid Misuse and Mental Health in College Student Populations: A National Assessment

Christina E Freibott 1, Samantha G Auty 1, Michael D Stein 1, Sarah Ketchen Lipson 1
PMCID: PMC11348281  NIHMSID: NIHMS2014271  PMID: 39038626

Abstract

Background:

Despite growing concern about opioid misuse and mental health of college students, little is known about this population who are at high risk of co-occurrence and unmet needs. This national study aims to estimate the prevalence of opioid misuse, examine correlates with anxiety and depression symptoms, and quantify help-seeking behaviors among U.S. college students.

Methods:

Data come from students in the Healthy Minds Study between 2017 and 2020 (n=176,191). Validated screening tools assessed mental health symptoms (PHQ-9, GAD-7). Marginal effects of logistic regression models estimate the effect of opioid misuse on mental health symptoms, help-seeking and academic performance.

Results:

782 students indicated past month opioid misuse. Student opioid misuse was associated with 24.1 percentage point increase in the probability of screening positive for anxiety/depression (p<0.001) and 3.6 percentage point increase in the probability of informal help-seeking (p=0.017). Less than half of students with opioid misuse and a positive depression/anxiety screen received any treatment in the past year.

Limitations:

Limitations to this study include: possible non-response bias, as it is unknown whether students with opioid misuse may be differentially-likely to respond to the survey; differing time frame for opioid misuse and mental health questions; and data was collected prior to the COVID-19 pandemic.

Conclusions:

This large, multi-campus study underlines the need for more partnership between substance use and mental health services on campus. It also highlights that college peers could receive training in ways to best help students who misuse opioids, directing them to on- or off-campus care.

Keywords: opioids, young adults, higher education, mental health, treatment-seeking

Introduction

Postsecondary education represents an important transition and a time of newfound autonomy for the roughly 20 million young adults enrolled in U.S. colleges and universities (Hussar et al., 2020). Substantial developmental changes experienced between the ages of 18 and 25 coincide with a period of initiation and intensification of substance use (Lipari, 2015; NCES, 2019). Prior research has shown that young adults are more likely to engage in substance use behaviors compared to older adults (Casey et al., 2008; Uchitel et al., 2019). For example, 67% of college students report binge drinking (Johnston et al., 2019), while 38% report cannabis use in the past 12 months (Johnston et al., 2019). Similarly, nicotine vaping has increased in recent years, with 28% engaging in vaping in the last 30 days, more than double the rates in 2017 (12%) (SAMHSA, 2020). Substance use among young adults is a concern as it can disrupt key periods of cognitive and emotional development, which can have lifelong effects on health and wellbeing (Degenhardt et al., 2016).

While a large body of research has focused on alcohol, cannabis, and nicotine use in the college setting, comparatively fewer studies have examined opioid misuse in this population (Association of Governing Boards of Universities and Colleges, 2020; Bae & Kerr, 2020; Jackson et al., 2020; Kerr et al., 2017; Koval et al., 2019; Krieger et al., 2018; Reid & Carey, 2015; SAMHSA, 2020; Ward & Guo, 2020). Opioids and their synthetic versions, pose a greater health threat due to heightened risk of overdose (Roberts, 2014). By sophomore year, 50% of college students report being offered an illicit opioid for nonmedical use (Daniels-Witt et al., 2017; Hedegaard et al., 2015). A recent systematic review of prescription opioid misuse among university students reports a lifetime estimate of 4% to 19.7%, with higher rates of opioid misuse reported among students with psychological distress, depression, and suicidal ideation (Weyandt et al., 2020).

The landscape of opioid misuse for adolescents and young adults, and substance use more broadly, is constantly evolving. Available evidence indicates that while adolescent drug use has remained stable in the last decade, adolescent overdoses involving fentanyl, a highly potent synthetic opioid, have tripled since 2019 (Friedman et al., 2022). Recent estimates indicate this crisis has further intensified, with 5.2 deaths per 100,000 adolescents attributed to overdoses in 2022 (Friedman & Hadland, 2024). There is also emerging evidence that fentanyl is being added to non-opioid drugs, such as stimulants (e.g., amphetamine, cocaine), and counterfeit pills; this shift in fentanyl distribution may impact a much broader range of adolescents and young adults, beyond those who knowingly use opioids (National Institute on Drug Abuse, 2021).

In addition to the strong evidence of health consequences relating to young adult substance use, the connection between substance use and learning, development, and success in college is also well established in the literature (W.-L. Chen & Chen, 2020). One study reports that 25% of college students endorsed academic difficulties, such as missing class or getting behind in schoolwork, as a result of drinking (National Institute on Alcohol Abuse and Alcoholism, 2023). Another found that college students exhibited lower academic effort (i.e., skipping class) after heavy episodic drinking or high intensity drinking days (Allen et al., 2022). Cannabis use has also been shown to adversely affect college academic outcomes, leading to less frequent class attendance and reduced levels of academic achievement (Arria et al., 2015). Further, in a study conducted among patients entering opioid treatment programs in the US, approximately 70% indicated that drug-seeking behavior was prioritized over academic performance, thus negatively impacting their education (Ellis et al., 2020).

Opioid misuse in college populations is further complicated by concomitant increases in anxiety and depression over the past decade (Auty et al., 2022; Lipson et al., 2019). The prevalence of co-occurring mental illness and substance use disorders among young adults has increased 22% in the past three years, and more than one-third of today’s college students meet clinical criteria for anxiety or depression (Lipari, 2018; Lipson et al., 2019). Despite these risks, less than half of all college students with clinically-significant symptoms receive any treatment for anxiety, depression, or substance use (Eisenberg et al., 2011). Importantly, there are disparities in help-seeking, diagnosis, and treatment of mental health conditions within college student populations(Lipson et al., 2018; Liu et al., 2019). A recent study found that among college students of color with a mental health concern, African-American students had 73% lower odds of being diagnosed, while Asian students had 51% lower odds of receiving therapy (Lipson et al., 2018). Another study assessing prevalence and predictors of mental health diagnoses among US college students reported that both transgender and sexual minority students (lesbian, gay, bisexual, queer) had higher rates of mental health disorders and suicidality compared to their heterosexual or cisgender peers (Liu et al., 2019).

While a recent report indicates around 40% of college students screen positive for anxiety or depression, less than half of those students received counseling or therapy in the past year (The Healthy Minds Study, 2021). This delay in help-seeking has been reported for substance use treatment as well. One study assessing reasons for avoiding treatment among students misusing prescription opioids for emotional pain reports that more than half of students were fearful that others would find out if they sought help (Kenne et al., 2017). Similarly, 47% were too embarrassed to seek treatment, while a third were afraid of what would happen if they were seen by a doctor (Kenne et al., 2017). Given the frequent co-occurrence of opioid misuse and mental illness, identifying and addressing the mental health treatment gap among students who use opioids is of critical importance. The Andersen Behavioral Model of Health Services Utilization is a framework for understanding how and why people use healthcare services, emphasizing the importance of an individual’s predisposing characteristics, enabling factors, and need for services (Andersen, 1995). Predisposing characteristics reflect the likelihood or intention of using health services when in need, typically referring to demographic characteristics or health beliefs (C. Chen & Gu, 2020). Enabling factors are what allows individuals to use available services, such as health insurance. Need denotes factors relating to demand for health services, often based on perceived need (perception of health status) or evaluated need (medical diagnosis).The Andersen model has been used to predict how health impacts academic performance among college students, finding that while predisposing and need factors were important, enabling factors were the best predictors of health impacts on academic performance (Vernet & Sberna, 2022).

The Andersen model provides the theoretical grounding through which to consider the relationships between predisposing characteristics (age, gender, race, sexual orientation), enabling factors (insurance, knowledge of campus resources), need (perceived need for help, mental health diagnosis), and use of mental health services among college students who misuse opioids. Further, the relationship between Andersen domains (predisposing, enabling, and need factors) and academic performance highlights the importance of understanding the factors that may affect use of mental health services among college students, which can directly or indirectly affect student success and retention (Vernet & Sberna, 2022). The purpose of this paper is to: (1) quantify the prevalence of opioid misuse in a large, national sample of college students, (2) estimate the prevalence of depression and anxiety among students reporting opioid misuse, (3) document the mental health help-seeking behaviors of students reporting opioid misuse and (4) describe the academic performance of students reporting opioid misuse. Overall, this knowledge can inform both population-level prevention efforts as well as tailored initiatives to reach students at high-risk for substance use and untreated mental health problems.

Methods

Data

Data come from three waves of the Healthy Minds Study (HMS), an annual cross-sectional survey of college students (Eisenberg & Lipson, 2020). HMS examines mental health, substance use, service utilization, perceived need for services, help-seeking intentions, help-seeking behaviors, and barriers to utilization in student populations across the United States.

All colleges and universities are eligible to participate in HMS. The institutional sample is large and diverse, including public and private universities, specialty schools (i.e., colleges of art and design), of differing academic rank (i.e., highly competitive), located across all six geographic regions with varying student body sizes (<1,000 to >20,000). At each participating campus, a random sample of students is selected from the full population and invited to complete the survey. Data are collected via Qualtrics and all research is approved by relevant institutional review boards.

This analysis includes data collected from 375 campuses from 2017–2020. Response rates were as follows: 24% in 2017–2018, 16% in 2018–2019, 15% in 2019–2020. To account for survey non-response bias, the HMS research group constructs sample probability weights using administrative data on student characteristics (i.e., sex, race, academic level, and grade point average) from participating institutions. Sample weights were applied in all analyses. Further details about the HMS study design have been reported extensively in prior publications (Eisenberg & Lipson, 2020; Healthy Minds Network & American College Health Association, 2020; Lipson & Eisenberg, 2018).

Sample

Students between 18 and 25 years of age with complete demographic, substance use, and health service utilization data were included in the study cohort. The final analytic sample included 176,191 participants. The average age was 20.52 (±1.94), with 67% identifying as female, 31% as male, and 2% identifying as TGNC. 64% of the cohort were white and 10% identified as Latinx. Within this cohort, 79% were heterosexual and 21% identified as lesbian, gay, bisexual, queer, questioning, or other (LGBQ). The majority of students (74%) have insurance through their parents, while 9% were covered under student-based insurance.

Measures

Opioid misuse was measured using the following survey question, “Over the past 30 days, have you used any of the following drugs (select all that apply).” Students who selected the option “Opioid pain relievers (such as Vicodin, OxyContin, Percocet, Demerol, Dilaudid, codeine, hydrocodone, methadone, morphine) without a prescription or more than prescribed” were included in the study cohort as indicating opioid misuse. Respondents were stratified by past month, non-prescription opioid use (i.e., any past month opioid use vs. no past month opioid use).

Symptoms of depression were measured with the Patient Health Questionnaire-9 (PHQ-9), and a score of 10 or greater constitutes a positive screen (Kroenke et al., 2001). The PHQ-9 is widely used for identifying those at risk for major depressive disorder in the general population. Prior validation studies demonstrate a sensitivity of 88% and specificity of 88%, with a Cronbach’s α reliability coefficient of 0.89 (Kroenke & Spitzer, 2002). Anxiety was measured with the Generalized Anxiety Disorder-7 (GAD-7) survey, where a positive screen is a score of 10 or greater (Spitzer et al., 2006). The GAD-7 is widely used for identifying those at risk for generalized anxiety disorder. Prior validation studies demonstrate a sensitivity of 89% and specificity of 82%, with a Cronbach’s α reliability coefficient of 0.91 (Dhira et al., 2021; Spitzer et al., 2006).

Mental health diagnosis was determined from the question, “Have you ever been diagnosed with any of the following conditions by a health professional (e.g. primary care doctor, psychiatrist, psychologist, etc.)?” Response options were depression, bipolar, anxiety, obsessive-compulsive or related disorders, trauma and stressor related disorders, neurodevelopmental disorder or intellectual disability, eating disorder, psychosis, personality disorder, substance use disorder, none of these, don’t know. These responses were coded as a binary yes/no variable, with yes to any of the mental illnesses indicating a positive response, where as “none of these” was coded as a negative response.

Perceived need for mental or emotional help in the last year was determined from the following survey item, “In the past 12 months, I needed help for emotional or mental health problems such as feeling sad, blue, anxious or nervous.” Consistent with prior operationalization of this survey item, the present analyses include a binary variable of perceived need (agree/disagree).

Knowledge of campus mental health resources was determined from the following survey item, “If I needed to seek professional help for my mental or emotional state, I would know where to go on my campus.” These responses were coded as a binary yes/no variable.

Informal help seeking was assessed from the survey question “In the past 12 months, have you received counseling or support for your mental or emotional health from any of the following sources?: roommate, friend, significant other, family member, religious counselor/contact, support group, other non-clinical source, none.” These responses were also coded as a binary yes/no variable.

Receipt of counseling or therapy in the last year was determined with the following survey questions, “Have you ever received counseling or therapy for mental health concerns?” and, if yes, “How many total visits or sessions for counseling or therapy have you had in the past 12 months?” Responses were coded into a binary variable indicating any/no counseling in the past 12 months.

Academic performance was determined with the following survey question, “In the past 4 weeks, how many days have you felt that emotional or mental difficulties have hurt your academic performance?” with response options none, 1–2 days, 3–5 days, or 6+ days. This was coded to binary variable indicating yes/no severe impact on academic performance due to emotional or mental difficulties (6 or more days).

All measures were assessed within their respective HMS survey waves (2017–2018, 2018–2019, 2019–2020).

Statistical Analysis

Descriptive analysis, adjusted with survey response propensity weights, were conducted to characterize the study sample. Demographic comparisons assessed differences between opioid misuse groups using weighted t-tests for continuous variables (i.e., age) and chi-square tests for categorical variables (i.e., gender). Frequencies of help-seeking intentions and mental health service utilization were examined between groups using bivariate statistics. Weighted logistic regression models assessed the association between opioid misuse and the following primary outcomes: perceived need for help, informal help-seeking behaviors, receipt of counseling or therapy in the last year, and academic performance. Models were adjusted for student characteristics including age, gender (male, female, transgender or gender non-conforming (TGNC)), sexual orientation (heterosexual, lesbian, gay, bisexual, queer, questioning, other), race (White, Asian, Latinx, Black, Middle Eastern, Alaskan Native/Pacific Islander (ANPI), Other), health insurance status (uninsured, student, parent, individual/employer, government, other), living place (on campus vs. off campus), degree type (undergraduate vs. graduate degree), and mental health indicators (i.e., PHQ-9 and GAD-7 summary scores). Marginal effects of opioid use were calculated separately to report risk-adjusted predictions for each outcome variable. Marginal effects are risk-adjusted predictions which report the difference in probability of the binary outcome when it changes from 0 to 1, while all other covariates are held at the sample mean. Models included institution fixed-effects to account for clustering at the college/university level and year fixed-effects to account for time-invariant confounding.

Results

Descriptive and Bivariable Results

Of the total sample, 782 (0.44%) reported opioid misuse while 175,409 (99.56%) did not. Complete demographic data, stratified by opioid-use status, are reported in Table 1.

Table 1:

Demographic Characteristics of Students by Opioid Use Status

Opioid Use No Opioid Use
(N=782) (N=175,409)
Age (mean) 20.57 20.52
N % N %
Gender
 Male 292 38.07 53,242 30.58
 Female 445 58.02 117,730 67.61
 TGNC 30 3.91 3,159 1.81
Race/Ethnicity
 White 522 66.84 111, 729 64.00
 Asian 58 7.43 23,653 13.55
 Latinx 73 9.35 17,684 10.13
 Black 51 6.53 11,728 6.72
 Middle Eastern 16 2.05 3,690 2.11
 Alaskan Native/Pacific Islander 42 5.38 3,566 2.04
 Other 19 2.42 2,532 1.45
Sexual Orientation
 Heterosexual 500 64.10 137,923 79.21
 Lesbian 11 1.41 2,390 1.37
 Gay 27 2.18 3,142 1.80
 Bisexual 147 18.85 15,991 9.18
 Queer 42 5.38 4,436 2.55
 Questioning 29 3.72 5,545 3.18
 Other 34 4.36 4,699 2.71
Degree
 Associates 58 7.57 12,595 6.69
 Bachelor 641 83.68 138,505 73.59
 Graduate 67 8.75 37,138 19.72
Living Place
 On Campus 285 36.45 70,072 36.67
 Off Campus 323 41.30 80,685 42.22
 Parents 127 16.24 32,251 16.87
 Other 47 6.01 8,106 4.24
Insurance
 Uninsured 59 6.52 5,026 3.23
 Student 67 5.57 13,440 8.67
 Parent 544 73.78 114,983 74.14
 Individual/Employer 71 5.30 6,696 4.32
 Government 55 5.03 7,392 4.77
 Other 28 3.80 7,551 4.87
Other substance use
 Alcohol
 Cannabis
 Tobacco		 643
568
421		 82.23
72.63
53.84		 94,371
33,948
25,202		 58.66
19.35
14.37
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Mental Health Need, Help-Seeking Behaviors and Academic Performance

Of the 782 students reporting opioid misuse, 503 (64.3%) screened positive for anxiety or depression (p<0.001) and 453 (57.9%) reported a mental health diagnosis (p<0.001). While 82.8% of students reporting opioid misuse indicated a need for mental or emotional help in the last 12 months, only 48.0% reported counseling or therapy in the same time frame. Over one quarter (26.2%) of students using opioids indicated not knowing where to seek professional help for mental or emotional health on their campus. Relative to students without opioid use, a lower percentage of students with opioid misuse indicated that they would go to a family member or religious contact if they were in distress, and more likely to go to a peer source. More than 1 in 10 students with opioid misuse reported that they would go to no one if they were experiencing serious distress. Just under half (44%) of students with opioid misuse indicated that mental/emotional difficulties severely hurt their academic performance, compared to 20% of students who do not misuse opioids (p<0.001). Complete mental health need, help-seeking and academic performance data, stratified by opioid use, are reported in Table 2.

Table 2:

Mental Health Needs, Service Utilization and Academic Outcomes by Opioid Use Status

Opioid Use No Opioid Use
(N=782) (N=175,409)
N % N % χ2 p-value
Positive Screen for Anxiety or Depression
Yes 503 64.32 63,628 36.27 264.56 <.001
Mental Health Diagnosis
Yes 453 57.93 52,771 30.08 286.29 <.001
Needed help for emotional or mental health in the past 12 months?
Agree 636 82.81 97,467 61.44 147.51 <.001
Any counseling or therapy in the past 12 months?
Yes 343 48.04 45,958 30.51 102.87 <.001
Who would you talk to when experiencing serious emotional distress?
Professional clinician 40 5.25 5,387 3.41 71.30 <.001
Peer source 260 34.12 46,185 29.23
Family member 289 37.93 76,69 48.59
Religious counselor/contact 27 3.54 10,141 6.42
Support group/other 55 7.22 6,573 4.16
No one 91 11.94 12,929 8.19
If I needed to seek professional help for my mental or emotional state, I would know where to go on my campus.
Yes 549 73.79 123,731 79.37 14.05 <.001
How many days mental/emotional difficulties impacted academic performance in the last 4 weeks
None 82 10.50 35,770 21.05 302.71 <.001
1–2 days 153 19.59 57,253 33.69
3–5 days 204 26.12 42,727 25.14
6+ days 342 43.79 34,197 20.12
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Multivariable Results

Controlling for age, gender, race, sexual orientation, insurance status, degree level, housing type, and institution, student opioid misuse was associated with a 24.1 percentage point increase in the probability of screening positive for anxiety or depression as compared to those not using opioids (p<0.001). Additionally, opioid misuse was associated with an 8.7percentage point increase in the probability of indicating a need for help with emotional or mental health problems in the past year (p<0.001). Opioid misuse was associated with a 3.6 percentage point increase in the probability of informal help seeking as compared to students not reporting opioid use (p<0.05). Students who misused opioids had a 7.7 percentage point higher probability of receiving any therapy or counseling in the past year (p<0.001). Opioid misuse was associated with 6.1 percentage point increase in the probability of mental or emotional difficulties severely hurting their academic performance (p<0.001) Marginal effects of opioid use for main outcomes are reported in Table 3.

Table 3:

Marginal Effects (dy/dx) of Opioid Use for Main Outcomes1

Positive Screen for Anxiety or Depression Perceived Need Informal Help Seeking Therapy or Counseling Mental/Emotional affect Academics
dy/dx SE dy/dx SE dy/dx SE dy/dx SE dy/dx SE
Opioid Use (Yes) 0.241 *** 0.07 0.087 *** 0.016 0.036 * 0.015 0.077 *** 0.015 0.061 *** 0.012
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*

p<0.05

**

p<0.01

***

p<0.001

1

Complete regression results with coefficients of covariates are reported in the Appendix (Table A1)

Discussion

While substance use among college students is frequently reported, less is known about opioid misuse within this population and how it impacts mental health, help-seeking behaviors, and academic performance. There is a lack of large-scale data to examine students with opioid misuse, and our sample of nearly 800 students makes this the largest known study of this topic and population. The results of this study indicate that students who misuse opioids have significantly higher rates of anxiety or depression compared to students who do not report opioid use. Students with opioid misuse were more likely to indicate a need for mental or emotional help, but less likely to know where to seek help on campus. Students with opioid misuse were more likely to report that mental/emotional difficulties negatively impacted their academic performance.

Prior research has found that adults with mental health disorders are more likely to use prescription opioids (Davis et al., 2019). One study found that mental health disorders are associated with increased risk for long-term opioid use among young adults (Richardson et al., 2012). Another study assessed mental health among college students who reported recreational prescription opioid use, and found that 56% of the study sample screened positive for depression, but did not compare these rates to non-opioid using students (Davis et al., 2019). Our findings highlight the critical need to address mental health concerns among students misusing opioids, as nearly two-thirds of students misusing opioids screen positive for anxiety or depression, compared to around one-third in the non-opioid use student population. For adults with OUD, co-occurring mental health and substance use disorders are common, making comprehensive health care models addressing both mental health and substance use crucial for these populations (Jones & McCance-Katz, 2019).

We also found that a higher percentage of students reporting opioid misuse sought help with peers or a support group, while fewer spoke to a family member or religious contact. College students are more likely to seek help from their peers, and understanding help-seeking behaviors of students reporting opioid misuse can inform future prevention efforts and education campaigns (Andraka-Christou et al., 2020; Auty et al., 2022; Ennett et al., 2006). Further, reluctance to access campus-based services due to stigma may lead to greater reliance on informal help-seeking sources. In an attempt to leverage this avenue for support, there has been an increase in peer counseling training and interventions on college campuses, particularly since the COVID-19 pandemic (Duggan et al., 2022). A survey of 2,011 college students in 2021 indicates one in five already use peer counseling, while 62% are interested in receiving peer counseling. This role of college students as key interventionists has been leveraged for other public health concerns on college campuses, such as suicide and sexual assault prevention (Katz & Moore, 2013; Mo et al., 2018; Rallis et al., 2018). Identifying where and from whom college-age young adults seek help is particularly important in addressing mental health and substance use related need, and college campuses are an optimal setting for prevention, identification, and treatment of both opioid use and mental health problems (Kessler et al., 2005).

Students with opioid misuse were more likely to have received counseling or therapy in the last 12 months. As these students also had a higher prevalence of anxiety and depression, an increase in mental health care utilization can be expected. However, just under half of students with opioid misuse and a positive screen for anxiety and depression did not receive counseling or therapy in the past year. While prior research indicates shame and stigma as barriers to seeking care for college students, this finding underlines an unmet need in an incredibly high-risk group (Kenne et al., 2017). Consequently, it is vitally important for campus counseling centers to screen for both opioid misuse and mental health diagnoses, while ensuring treatment resources are available for those who do seek help and may need further assistance.

Lastly, students with opioid misuse were more likely to report negative effects on their academic performance due to mental/emotional difficulties. A recent study used the Andersen model to explore the relationship between physical health, mental health, and academic performance among college students (Vernet & Sberna, 2022). The authors found that enabling factors, such as having health insurance and receiving health information from their university, were the best predictors of health impacts on academic performance. However, substance use behaviors were not included in their analysis. Our study expands on these results by finding that students who misuse opioids are not only more likely to screen positive for anxiety or depression, but are also more likely to have mental/emotional difficulties that negatively impact their academic performance. In addition to enhanced screening for opioid misuse and mental health diagnoses, interventions aimed at providing academic support may also be needed to assist these students. For example, Collegiate Recovery Programs (CRPs) offer recovery support for college students and an avenue through which to socialize in a drug- and alcohol-free settings. A national survey of CRPs found that three-quarters of students enrolled were being treated for chronic mental health conditions, highlighting the co-occurring nature of substance use and mental health concerns within this population (Laudet et al., 2015). Further, CRPs typically offer academic support and guidance, and studies have shown encouraging outcomes relating to academic performance of enrolled students (Laudet et al., 2016).

This is the first study to use HMS data to assess prevalence of opioid misuse within the college student population, as well as rates of anxiety, depression, and treatment seeking among those who misuse opioids. The large-scale, multi-campus nature of the study, along with random sampling at the student-level and the use of validated screening tools are key strengths of the present study. Despite many strengths of the study, there are also limitations to consider. While survey weights partially address non-response bias, it is unknown whether students with opioid misuse may be differentially likely to respond to the survey. While the response weights correct for known characteristics, such as demographics and degree program, substance use status is not known for the full invited sample. Academic performance was evaluated through subjective means, with participants self-reporting the number of days emotional or mental difficulties affected their academic performance. Furthermore, the time frame of opioid misuse and of mental health questions are different, and the amount of opioids used by students (e.g., explain what is meant by “amount”) is not known. We do not know the extent of opioid use disorder among those who misuse opioids. Additionally, we do not include in this analysis rates of other substance misuse. Finally, all data for this study was collected prior to the COVID-19 pandemic. Current research reports that substance use among college students generally declined during the pandemic due to decreased socialization, while rates of anxiety and depression generally increased (Freibott et al., 2022). Additionally, due to the evolving nature of drug use patterns, the age of these data are a limitation. However, this is the first large-scale, multi-campus analysis of opioid use and help-seeking among college students, which is a crucial first step in addressing this problem. Future research should consider how COVID-19 may have impacted help-seeking among students who use opioids.

Conclusions

HMS is the largest source of data about mental health topics in college populations, and this project is the first to characterize students misusing opioids and their mental health needs as well as their help seeking behaviors and service utilization. We found that students who misuse opioids have significantly higher rates of anxiety, depression, and perceived need for mental or emotional help. The critical mental health need within the student population points to an urgent opportunity for more partnership between substance use and mental health screening and services on campus. It also highlights the possibility that college peers could receive training in ways to best help students who misuse opioids, directing them to care, on-campus or off. With the increasing presence of fentanyl in both opioid and non-opioid drugs, leveraging substance use and mental health screening on campus is important for the entire student population, not just students who knowingly use opioids. Future research should explore programs that leverage peer interventions for students who misuse opioids and may be experiencing anxiety, depression, or declining academic performance.

Highlights.

  • 782 students (0.44%) indicated past month opioid misuse

  • Opioid misuse associated with 24.1 percentage point increase in anxiety/depression

  • Opioid misuse associated with 3.6 percentage point increase of informal help-seeking

  • <50% with opioid misuse and anxiety/depression received past-year treatment

Acknowledgements:

Christina E. Freibott is supported by National Institute of Drug Abuse grant T32-DA041898-03. Sarah Ketchen Lipson is supported by National Institute of Mental Health grant K01MH121515 and the William T. Grant Foundation scholars program.

Role of funding source:

The funding sources had no involvement in the study design; collection, analysis and interpretation of data; in the writing of this manuscript; and in the decision to submit the article for publication.

Appendix:

Table A1:

Logistic Regression Analyses for Main Outcomes

Positive Screen for Anxiety/Depression Perceived Need Informal Help Seeking Therapy or Counseling Mental/Emotional affect Academics
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Opioid Use
 No Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Yes 2.44 *** 2.14, 2.79 1.89 *** 1.57, 2.28 1.26 ** 1.07, 1.48 1.56 *** 1.34, 1.81 0.481 *** 0.31, 0.65
Gender
 Male Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Female 1.62 *** 1.58, 1.66 1.80 *** 1.76, 1.85 2.23 *** 2.18, 2.28 1.71 ** 1.66, 1.75 −0.066*** −0.10, −0.03
 TGNC 2 99 *** 2.75, 3.26 2.63 *** 2.31, 3.00 2.22 *** 1.99, 2.47 2.82 *** 2.58, 3.09 0.280 *** 0.18, 0.38
Race
 White Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Asian 0.954 ** .92, .99 0.73 *** .70, .75 0.69 *** .69, .72 .52 *** .50, .55 −0.038 −0.09, 0.014
 Latinx 1.12 *** 1.08, 1.16 .97 .93, 1.01 0.90 *** .88, .94 .82 *** .79, .86 0.07 *** 0.02, 0.13
 Black 1.04 .99, 1.09 0.91 *** .86, .95 0.60 *** .57, .63 .74 *** .71,.78 0.096 ** 0.03, 0.16
 Other 1.35 *** 1.29, 1.41 .96 .91, 1.01 0.82 *** .79, .87 0.81 *** .77, .85 0.16 *** 0.097, 0.23
Sexual Orientation
 Heterosexual Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 LGBQ 2.35 *** 2.29, 2.41 2.26 *** 2.19, 2.35 1.74 *** 1.68, 1.80 2.20 *** 2.14, 2.26 0.35 *** 0.31, 0.38
Insurance
 Uninsured Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Student 0.69 *** .65, .74 1.21 *** 1.13, 1.31 1.39 *** 1.30, 1.49 1.54 *** 1.42, 1.67 −0.06 −0.16, 0.04
 Parent 0.69 *** .65, .73 1.13 *** 1.05, 1.20 1.38 *** 1.30, 1.47 1.55 *** 1.45, 1.66 −0.13** −0.22, −0.05
 Employer 0.64 *** .60, .68 0.93 .86, 1.01 1.12 ** 1.04, 1.20 1.20 *** 1.11, 1.30 −0.12* −0.23, −0.01
 Other
Living Place 		0.86 *** .81,.91 1.07 1.00, 1.16 1.04 .98, 1.12 .94 *** .89, 1.00 −0.46 −0.14, 0.05
 On Campus Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref
 Off Campus 1.11 *** 1.09, 1.15 1.05 ** 1.02, 1.09 1.03 * 1.00, 1.06 .94 *** .91,.97 0.12 *** 0.08, 0.16
PHQ9 Score N/A N/A 1.11 *** 1.11, 1.12 1.01 *** 1.01, 1.02 1.04 *** 1.04, 1.05 0.18 *** 0.18, 0.19
GAD7 Score N/A N/A 1.12 *** 1.12, 1.13 1.02 *** 1.06, 1.07 1.05 *** 1.05, 1.06 0.06 *** 0.06, 0.07
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OR: Odds ratios; CI: confidence intervals; PHQ-9: Patient Health Questionnaire 9; GAD-7: Generalized Anxiety Disorder 7; ref: reference; TGNC: transgender or gender nonconforming; LGBQ: lesbian, gay, bisexual, queer

*

p<0.05

**

p<0.01

***

p<0.001

Survey weights applied in each model

Footnotes

Author Contributions

CRediT authorship contribution statement:

Christina E. Freibott: conceptualization, data curation, formal analysis, writing – original draft; Samantha G. Auty: review & editing; Michael D. Stein: review & editing, supervision; Sarah Ketchen Lipson: review & editing, supervision

Data statement: Data is publicly available through the Healthy Minds Study.

Declarations of interest: None.

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.

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