Pills, Thrills and Bellyaches: Case Studies of Prescription Pill Use and Misuse among Marijuana/Blunt Smoking Middle Class Young Women

Abstract

Recent survey research has documented important increases during the 2000s in the misuse and abuse of several prescription drugs (Vicodin, Percocet, Codeine, Dilaudid, Xanax, Klonopin, Valium, Ativan, Adderall, Ritalin, among others). This article focuses upon the patterns of pill use and misuse among young women who are middle-class white and college-educated, and they are also experienced marijuana users who report recreational consumption of other illegal drugs. The ethnographic data provides insights about various ways and reasons that such prescription pill misuse occurs among 12 college-educated, (upper) middle-class, white/Asian women in their 20s who were involved in a major ethnographic study of marijuana and blunts. Three patterns of pill use were observed: recreational; quasi-medical; and legal medical; shifts among these patterns of pill use was common. Few reported that their pill use interfered with their conventional jobs and lifestyles; they concealed such use from their employers and coworkers, and from non-using friends and family members. None reported contacts with police nor seeking treatment specifically for their pill misuse. Many reported misusing prescription pills in conjunction with illegal drugs (marijuana, cocaine, ecstasy) and alcohol. Pills were used as a way to enhance the euphoric effects of other drugs, as well as a way to avoid the negative side effects of illegal drugs. Some reported pill use as a means for reducing expenditures (and use of) alcohol and cocaine. The implications suggest a hidden subpopulation of prescription pill misusers among regular users of marijuana and other illegal drugs. Future research should include users and misusers of various pills to better understand how prescriptions pills interact with illegal drug use patterns.

Introduction

Several major national surveys have documented important increases during the 2000s in the misuse and abuse of several prescription drugs. Of special concern in this paper is a pattern of misuse among young women, especially those who are college-educated, white, and experienced in recreational consumption of illegal drugs. Despite important and numerous surveys documenting pill misuse among this population subgroup, relatively few scientific articles provide insight(s) about the reasons why and how such relatively privileged women come to engage in such misuse. This paper provides ethnographic data about various ways that such prescription pill misuse occurs among 12 college-educated white women in their 20s who were involved in a major ethnographic study of blunts and joints. The emphasis here is upon those who use these prescription pills for euphoric purposes (“thrills”) as well as for perceived quasi-medical symptom relief (“bellyaches”). Another explanation for the term “pills, thrills, and bellyaches”¹ are the feelings associated with a long night of partying, followed by the “pill-hangover” the next day. This would include taking prescription pills, as well as drugs such as cannabis, cocaine powder, or ecstasy at a party, dancing all night, and feeling the side effects of them the next day.

Literature Review

The National Survey on Drug Abuse and Health (NSDUH) reports “new users of tranquilizers have been increasing since the mid-1980s, but the largest increase has been recently, from more than 700,000 new users in 1999 to almost 1 million users in 2000. The number of new users of sedatives remained around 100,000 per year between 1988 and 1994. Starting in 1995, the number rose from 111,000 to 175,000 in 2000.” (SAMHSA 2003)

The DAWN Report (Drug Abuse Warning Network) reported in April 2004 that Benzodiazepines (common brands include Valium, Xanax, Klonopin, and Ativan) that are used to treat anxiety, insomnia and seizures were responsible for many ED (emergency department) visits, and increased 41 percent from 1995 to 2002. Further, alcohol was the substance most frequently reported with benzodiazepines in these visits to the ED. (OAS/SAMHSA 2004).

The National Survey on Drug Use and Health (NSDUH) reported in 2005 that a total of 19,686 people age 12 and older used Benzodiazepines nonmedically, compared to 18,643 in 2004. Of all of the users, 14,939 were age 26 and older. Valium was the most used, with 14,914 reported users, followed by Xanax, Alprazolam, Ativan and Lorazepam, with 10,291 reported users. Klonopin or Clonazepam had 3,129 reported users. (NSDUH/SAMHSA 2005)

Many consumers are under the impression that taking prescription pills is safer than taking other illegal drugs recreationally (Klein, Elifson & Sterk 2003). The truth is that just because something is “prescribed” to a patient does not mean that it is not highly addictive or ultimately damaging to the person. Meadows (2001) told the story of a 46 year-old woman named Lynn Ray, who was prescribed tranquilizers after the death of her infant son 15 years ago, but became addicted soon after. Ray would seek out different doctors to write her prescriptions. “Ray had convinced herself that abusing prescription drugs was safer than abusing heroin, marijuana, and other ‘street drugs’. ‘I would never do those’, she says. ‘I figured I had a prescription for what I was doing, which made it OK.’”(Meadows 2001) Such rationalization is not uncommon, based on the belief that products made by regulated legitimate manufacturers must not be harmful.

There is a significant lack of literature that focuses entirely on women's shared experiences and what may bring them to turn to the misuse and abuse of prescription pills. Additionally, the relationship between marijuana use and prescription pill use is often overlooked. There is a gap in the literature as far as the “voice of women” is concerned, and as far as their documented experiences go. Much has been written about what pills are being used (McCabe et al., 2006) and what the health implications of such use may be (Compton et al., 2005) but very little research is available that actually documents the lived experience of these young women, and about their stated reasons for using pills for euphoric purposes, or for relief from what troubles them, both psychologically and physically. Even less information is available about women's transitions in their prescription pill use and its relationship to other illicit drugs (primarily marijuana, cocaine, and ecstasy).

Prescription pills became commonplace for many women as early as the 1970s. Eakman (2004) observes, “As far back as the 1970s, shortly after the feminist movement was launched, it was estimated that as many as 30 million American women were taking tranquilizers. That was almost half of the female population at the time. In 1975 alone, more than 103 million prescriptions for tranquilizers were written.” A NIDA (2001) report on prescription-drug abuse and addiction stated that studies indicate that “women were more likely than men to be prescribed an abuse-prone prescription drug, particularly anti-anxiety drugs—in some cases 48 percent more likely.”

Additionally, “in 2001, almost 3 million youths aged 12 to 17 and almost 7 million young adults aged 18 to 25 had used prescription-type drugs non-medically at least once in their lifetime.” (SAMHSA 2003). The pills-marijuana relationship was also substantial. The National Household Survey on Drug Abuse (NSDUH 2001) found that “Among persons aged 12 to 25, the rate of past year marijuana use was much higher among those who had used prescription-type drugs nonmedically in the past year (63 percent) than those who did not (17 percent).”

Understanding substance use and misuse among young women is critical for understanding an important subpopulation in America. Yet capturing “the female experience” is difficult to do (Beckwith 1992). Women are seen as being doubly deviant in their drug and alcohol use when the norms of appropriate femininity and masculinity are considered. “It becomes apparent that an addicted or alcoholic woman is doubly deviant: she has transgressed not only the law or general social convention, but she has specifically violated the norms of being a ‘good woman’. Her drinking and drug use opens her to suspicion of sexual promiscuity or prostitution and incompetence as a mother and wife.” Addiction or alcoholism among males is more acceptable, while in women, they are viewed as a threat to society. (Broom & Stevens, 1990)

Since women are more likely to be prescribed anti-depressants and anti-anxiety medications than men are (Baker et al, 1999), some researchers have made a connection between topics such as depression, bipolar disorder, anxiety, stress/tension and the use and misuse of these medications (Klein et al, 2003). Klein (2003) also found that not being married seemed to be statistically significant as a predictor of women's drug use. Women's age, race, educational background, childhood maltreatment history, psychosocial profiles, exposure to substance abusers, and interpersonal relationship qualities had no significant impact upon the amount of drugs they used, when marital status and other control variables were taken into account. All of the women interviewed for this paper are not married, and most of them stated that the opinions of the men they were with were not a factor in their drug use. They viewed their use of prescription pills as a personal experience in which they did not disturb or harm anyone close to them in their decision to use them. It is important to have an understanding of how, for some women, doing pills and drinking alcohol frequently, thus causing a dependence on them, can be due to a woman's need to feel connected to certain people or experiences. Miller (1976) in Toward a New Psychology of Women proposed that women's psychological development differs in fundamental ways from the traditional model of development derived from men's experience.

Covington (1997) discusses Miller's model: “She suggested that for women the primary motivation throughout life is toward establishing a basic sense of connection to others. She wrote that women feel a sense of self and self-worth when their actions arise out of connection to others and lead back into, not away from, connections.” This model could be seen as a background for the behavior of many young women that use various different substances, as well as for the women in this study. For instance, some women in the study would do drugs with their boyfriends in order to feel a connection with them, to be closer to them, and to understand them. They developed a codependence with both the boyfriend and the drug, often blurring the two together, although the extent of dependence on the various drugs used is difficult to establish.

Prescription pill misuse and abuse has been a frequently discussed topic in the scientific literature and in the mass media. Articles in major newspapers and magazines across the country have brought attention to various issues, such as self-medicating, particularly among women. The recreational use (misuse) of prescription pills is often addressed in both television shows and films. A primary difficulty is that no clear line exists between appropriate medical use and misuse (in the minds of many pill consumers). Yet the government and medical/pharmaceutical profession are clear that a three stage process is necessary for “medical use” to occur when: a) a physician diagnoses and provides a written prescription for specific pills and dosage unit(s), b) the patient/consumer purchases such pills from a legitimate pharmacy, and then c) swallows the pills on a schedule as specifically directed by the physician. This definition implies that if any element of this 3-stage process is absent then such consumption would be considered as misuse or abuse (the two terms are often applied as synonyms by government actors). Two of these stages (physician diagnosis and pharmacy purchase) often involve considerable expense to the patient, which those on limited income and/or without insurance wish to avoid. Likewise, the typical retail unit sold contains a specific number of pills in a plastic bottle (often a 30 day supply).

Besides being easy to acquire a prescription from a physician, many young women can pay for their prescriptions through their health insurance. Many college students have health insurance through their college, or they have their health insurance covered by their parents. Young employed working women usually have health insurance coverage for their prescription pills. Therefore, a prescription that would ordinarily cost $50-$100 or more (if self-paid) would usually be reduced to anywhere from $5-$25, depending on the co-payment that the individual has on her health plan. Thus, young women willingly share their prescription pills with their friends, often handing them out at parties or bars, or giving them to a friend in need, knowing that it will cost them very little, and will take only a few dollars to get a new refill. Moreover, the patient may only use a fraction of those pills to “feel better” or “normal” and then cease using them. The unused pills are available for what we call “informal diversion”—the prescription recipient can give away, trade, re-sell, or lose the pills, or they can be outright stolen. (Examples are given below.) Most of the 12 women report regular involvement in informal diversion of pills, most often “giving” or “receiving” them without cash payment. These women rarely reported reselling their prescription pills for money. In many respects, informal exchanges of pills are similar to cigarette consumers who “bum” or “share” their cigarettes with those without a pack.

Moreover, neither the federal government (thru the Drug Enforcement Administration or the Food and Drug Administration) nor local law enforcement specifically targets this informal diversion of prescription medications – rather they target persons possessing, selling, or transferring the major illegal drugs (e.g. marijuana, heroin, cocaine/crack). Furthermore, all the subjects in this study present a persona and set of observable characteristics (20-something white women, college educated, typically employed, residentially stable) that conceals their illegal behaviors (marijuana use, prescription pill misuse, and informal diversion) so as to be nearly invisible to police and law enforcement. None reported any lifetime arrests associated with their drug use.

During the past 20 years, both the medical and pharmaceutical professions have also expanded the range and specificity for which different drugs are prescribed. “Pills” are often prescribed by physicians for a widening range of symptoms and medical conditions. Moreover, the pharmaceutical industry has created a wide range of “pills” (with different trade names for a given generic compound, and a wide range of very similar generic compounds). Sizable proportions of the American population receive prescribed medications.

A recent article has brought attention to the use of prescription pills among young children that attend summer camps across the U.S. It states that, “within the American Camp Association, a trade group with 2,600 member camps and three million campers, about a quarter of the children at its camps are medicated for attention deficit disorder, psychiatric problems or mood disorders.” At 100 of these summer camps, the private company, CampMeds, provides a summer's worth of prepackaged pills to 6,000 children. The founder, Dana Godel, reported, “40 percent of the children regularly took one or more prescription medications, compared with 30 percent four years ago. Eight percent used attention deficit medications last year; 5 percent took psychiatric drugs.” (Gross 2006)

Harmon (2005), writes about young people trading and giving prescription pills to their friends (often self-diagnosing each other and themselves), “The behavior, drug abuse prevention experts say, is notably different from the use of drugs like marijuana or cocaine, or even the abuse of prescription painkillers, which is also on the rise. The goal for many young adults is not to get high but to feel better -- less depressed, less stressed out, more focused, better rested. It is just that the easiest route to that end often seems to be medication for which they do not have a prescription.”

It is common for general practitioners to be unfamiliar with many of the new psychiatric drugs on the market, so patients see themselves as providing a service to their physicians when they suggest what drugs they think they need, or should be prescribed to them.

For many young people, having been prescribed various “pill cocktails” is what they are used to. It is not unusual that they would not only be skeptical of a physician's choice in what anti-depressants or other prescription pills to prescribe, but that they would be able to pick out a pill they think would work for them. This is illustrated by one of the women in Harmon's (2005) article. Casey Greenfield, a writer in Los Angeles, had been put on almost every SSRI (selective serotonin reuptake inhibitor) by the time she was out of college. Ms. Greenfield has no compunctions about telling her doctor what prescriptions she thinks she should be put on and this is illustrated in her own words, “I would never just do what the doctor told me because the person is a doctor. I'm sure lots of patients don't know what they're talking about. But lots of doctors don't know what they're talking about either.”

Ms. Greenfield is not alone in her view of psychiatrists and other medical professionals. Many of the women in the this study felt the same way, often being wary of doing “just what the doctor ordered,” thus altering the dosage of their medication to fit their needs. In addition, they felt informed enough to hand these pills out to their friends whom they help “diagnose” as having similar symptoms or medical issues to their own. Many of the women in the study also felt that some psychiatrists and/or pharmacists were freely prescribing mind-altering prescription medications, perhaps because they were using/misusing the medications themselves. (Hollinger 2002)

Using prescription drugs to work a little harder, sleep a little better, and relax a little faster, has become commonplace in the U.S. and especially in New York City. Not that long ago, the only people that used prescription drugs for their mental health had “obvious issues.” Levy (2003) writes, “At that time (the crack epidemic still raged), you wouldn't have talked to your colleagues about what you took for insomnia, you bummed cigarettes off your friends instead of Ativan, and it might not even occurred to you to take a pill for your garden-variety depression or anxiety. Now the question is not ‘Should I take something?’ It's ‘Am I taking enough?’ Or ‘Am I taking the right one(s)?’ It is not uncommon to talk about prescription pills over dinner, since the negative stigma has been somewhat removed. It is no longer embarrassing to talk about what prescription drug you are taking, because chances are that the person you are talking to is either on one (or more) as well, or at least knows what you're talking about.” Levy (2003) also describes a “hierarchy of cool within the world of prescription pills. No one wants to admit to taking Prozac, Zoloft, or any sort of mood-stabilizing drug for depression, bi-polar disorder, or schizophrenia. If they are popping a Xanax, Ativan, or Valium, however, that is acceptable behavior. It's those pills that are being traded amongst friends at parties, not those that have to be taken long term for depression (like SSRIs).”

A sizable literature documents that women, especially middle class white women, are most likely to approach physicians, to be prescribed a wide range of pills, and to share them with others. Recent data has shown a relationship between women, alcohol, marijuana, and prescription pills. (McCabe et al., 2005). While the literature suggests this, relatively little is known about the reasons and experiences that young women have with their legitimate use and misuse of prescription pills, and how those experiences fit within their patterns of illicit drug use.

Raves, Club Drugs, and Pills

In addition to their marijuana use, several subjects below were participants in the “raver” subculture. They were involved in the “rave scene”—a group of young people who would go to late night parties and dance to techno and other electronic music, often taking various drugs including ecstasy (MDMA), acid (LSD), crystal meth (methamphetamine), nitrous oxide, ketamine (K or Special K), mescaline, PCP (dust), mushrooms, as well as smoking marijuana, doing cocaine and using prescription pills. Ravers participated in this behavior from the late 1980s on throughout the 1990s. “Raves” have been observed within the U.S. and other parts of the world, but in New York City, their heyday was in the mid-1990s, quickly fading in the beginning of the new millennium. Kelly (2005) observed that “club drugs”, which include MDMA (ecstasy), methamphetamine, cocaine, ketamine, LSD, and GHB (gamma-hydroxybutyrate) are still widely being used by young people in club subcultures in New York City.

While the rave culture may have declined in popularity, a post-rave culture seems to have flourished, with ex-ravers in their mid to late 20s looking to other drugs of choice to mix with their marijuana smoking: prescription pills. It has been observed that young people in their late teens and early 20s, who were too young to participate in the rave culture (post-ravers), have found prescription pills to be a regular part of their college experience. Pills are commonly found and used at fraternity and sorority parties, are mixed with alcohol, and are used to stay up late and study. Students find them on campus, being traded and sold, and oftentimes given out for free. In this study, young women, who are middle to upper class and all hold bachelor degrees or higher, use prescription pills such as Xanax, Klonopin, Valium, Codeine, Vicodin, Ativan, Adderall, Ritalin and Ambien for reasons such as relaxing and relieving stress, escaping from their troubles, legally medicating and self-medicating. These women also use pills recreationally. Many of these women used to be a part of this “rave culture” in their teens and early twenties, yet have “grown out” of the lifestyle of taking a mixture of drugs and going to raves. As further explored in this paper, they prefer to take pills irregularly for recreational or quasi-medical reasons, or regularly for medical reasons.

Methods

The data provided in this article was collected as part of a NIDA-funded study, entitled “Marijuana/Blunts: Use, Subcultures and Markets.” This project is primarily an ethnographic study designed to examine the differences and similarities among blunt smokers (who consume marijuana in a cigar shell) and marijuana-only smokers (who consume marijuana in a pipe, bong, joint, vaporizer, one-hitter, or bubbler). The ethnographic study was designed to provide a much richer understanding of the intersections of blunts and marijuana-using subcultures and analyze the effective conduct norms, settings, rituals, beliefs, language and practices that followed. Subjects were largely recruited in Harlem and the Lower East Side (including the East Village and Chinatown) neighborhoods of Manhattan, New York City. These two general uptown/downtown areas of Manhattan were appropriate neighborhoods to recruit respondents who were ethnically and economically diverse. Harlem is primarily African-American and Latino, while the larger Lower East Side (LES) encompasses residents who are predominantly White, Latino, and Asian. Some subjects were located and initially recruited in Harlem or the LES because they worked and/or socialized there. Several subjects were interviewed where they lived in Brooklyn, Queens or other Manhattan neighborhoods. Further details about the study are provided in other publications (Dunlap et al 2005; Sifaneck et al 2007; Ream et al 2006) as are findings about marijuana argot (Johnson et al 2005), and contacts with police and law enforcement (Johnson et al 2006; Golub, Johnson, Dunlap 2006, 2007).

During their fieldwork, ethnographers were involved in observation with over 500 individuals of different ages, ethnicities, occupations, educational levels, etc. In-depth qualitative interviews focused upon their marijuana practices were conducted and tape-recorded with over 120 subjects, then narrowed down to 97. During the interviews, it was clear that some young women in the study were using prescription pills as an addition to smoking marijuana and/or blunts. Twelve young women were chosen from the larger study as case studies to be further examined and interviewed. These women were by and large white and Asian, middle to upper class, educated young females.

An additional qualitative instrument was developed, and these twelve young women were reinterviewed with specific questions focused upon their past and present history of prescription pill use. They were asked questions about whether they currently have or ever have had a legal prescription for any of the pills they used, whether they mix the pills with any other substances (such as alcohol, marijuana, and other drugs), and other questions that portrayed their experiences. This data was collected and further analyzed. A brief description of the pills mentioned by the women and their medical/pharmaceutical uses are provided in the Appendix.

The women use and misuse prescription drugs and self-report the use of various illegal drugs. All of these women were currently employed at legal jobs that were appropriate to their education and skill levels. Few reported that their pill use (or illicit drug use) interfered with the performance of their legal jobs; they concealed such use from their employers and coworkers, and often their families. These women use prescription pills for various reasons, fitting into one of three use patterns, and often shifting between them. The patterns of use are: recreational use, quasi-medical use, and legal medical use. Since these women were initially recruited as marijuana users, their pill use was often intertwined with their marijuana and illicit drug use—as the case studies show.

Reports from middle class women

All of the women in this sub-study reported use of one or more prescription pills, often mixing them with alcohol, marijuana, and harder drugs. Their introductions to these pills are quite varied, ranging from an actual medical diagnosis, to a discovery at a party in a warehouse, to asking a friend for a couple of pills to help sleep at night. Regardless of their method of accessing these prescription pills, these young women felt that they had a legitimate reason to be using them, whether it was for a medical reason or for a recreational one. In several cases, they recognized clear transitions in their reasons for use (e.g. from medical only to recreational) that are described below.

Initiation

All of the women in the study reported different experiences with the manner in which they were first introduced to prescription pills. For some, such as Ginger, Jada, and Doll, it was an injury that led them to use certain pills for pain relief. For others, such as Veronica, Maya, Nina and Holly, it was experimentation with drugs, something to do out of boredom, or at a party. Yet for others, like Ava, Kayla, and Julia, it was not an injury, but a condition such as anxiety or depression, that led to their seeking pills to make them feel better, whether or not they had a prescription for the drug. Each woman has an individual experience that, although it may be somewhat similar to the experience of another woman, is still very much her own.

Doll is a 25 year-old vivacious blonde originally from upstate New York. She is a currently a chef at one of New York City's top restaurants, although she worked as an office assistant for a paint company for three years. Doll's first experience with prescription pills came as a result of an injury at work. She was filing paperwork in front of a large metal filing cabinet. The entire cabinet fell on her head and left her lying on the floor almost unable to move. She suffered a minor concussion and some scrapes and bruises. She went to the doctor and got a prescription for codeine to help ease the pain, along with some very strong ibuprofen tablets. She liked the effect that the codeine had on her, especially when she mixed it with smoking marijuana. Her discovery of prescription pills then led her to try Percocet that she had gotten from a friend who had a prescription for it. Doll stated that she kept her pill use to a level of “purely recreational,” thus not actively seeking out pills to try or use. She describes her pill use as being “of a certain time”, meaning that after suffering her injury at work, she experimented with one new pill (Percocet) and cut it off there. She didn't feel the urge to try anything new such as Xanax, Vicodin, Klonopin, or Valium.

Holly is a tall model-esque 26 year-old Caucasian woman originally from Chicago. She works as a personal assistant to the owner of a hedge fund in New York City. Holly was first introduced to pills at raves in the early 1990s. She may have been a gawky and unpopular girl at school, but in the rave scene, she felt like the prom queen.

I had tons of friends, some that I would only see on the weekends, but friends nonetheless. Name it, I tried it. E (ecstasy), dust, acid, weed, mushrooms, nitrous, GHB, coke, crack, k (ketamine), opium, roofies, and tons of pills. I didn't get into heroin until my college years. What can I say? I have an addictive personality. My dad was a raging alcoholic, well, my real dad. I had lots of dads.

When asked about her prescription pill initiation, Holly stated that when she went out to dance all night at a party, she did not like to be high on pills. They were used more as a way to come off of other drugs. She spoke about how she never got the drugs from a complete stranger, because she could never trust what was being given to her. She did, however, purchase a Xanax or a Klonopin occasionally for $2 each in “desperate times when I was so coked out all I wanted to do was pass the fuck out. I didn't care where it came from, as long as it made me relax and sleep.” She expanded on her willingness to use pills, without a fear of them harming her.

You know, it was also the reputation that pills had, as opposed to other drugs. They were legal. They were ‘safe’. Or so you were led to believe. Therefore no one I knew was really afraid of OD'ing on pills in the same way you could on coke or heroin after a night out.

Kayla is a 26 year-old Caucasian female originally from a small affluent town in Connecticut. She works in public relations for a toy company. She lived in Connecticut until the age of 13, when her parents decided to send both her and her younger brother to boarding school in the mountains in western Massachusetts. Kayla was first introduced to prescription pills at the age of 14, when her parents put her on Ritalin for A.D.D. (Attention Deficit Disorder). She used it as directed, for medical purposes, yet when she discovered that she could crush the Ritalin pills and snort them for a different effect (much like the effects of cocaine), she began to do that as well. She would also sell some of her Ritalin prescription to those seeking it on her campus in boarding school in order to make some extra money. When Kayla was introduced to Adderall, she began to use that as well, for many of her friends had a prescription for it, therefore making it easy to obtain without much effort.

Kayla's prescription use soon moved to Xanax, Klonopin, Valium, Codeine, Vicodin, Percocet and Ambien. She would often mix these substances with alcohol in order to get drunk faster, much like Ginger and Veronica reported doing (below). She took Ritalin for 12 years with a prescription, from the ages of 14 to 26. Kayla took herself off the Ritalin at the age of 26, when she had been out of college for five years, because she did not feel the need to use it anymore.

Jenny is a 22-year old Jewish woman who was born and raised in downtown Manhattan. She is soft-spoken yet very opinionated, and very well educated, having gone to an Ivy League university. For Jenny, her introduction to prescription pills came at a very young age when her parents, both psychiatrists, put her on anti-depressants, Ritalin, and eventually Adderall in order to combat her depression, anxiety, and inability to concentrate in school. She was in junior high school when her father decided that she was not working to the best of her ability and put her on Ritalin.

I just remember feeling really speeded out, but feeling a sense of clarity at the same time. I was grasping ideas and learning things that I had never showed an interest in before, but I knew that it was just a matter of time that I had to give it (Ritalin) up.

Jenny was aware that she would most likely not be on Ritalin for the rest of her life, and that her parents had put her on it for a short amount of time so that she could be productive in her studies. She was also put on a variety of anti-depressants and anti-anxiety medications such as Celexa, Prozac, Zoloft, Paxil, Ativan, and Wellbutrin throughout high school and college. Jenny explained why she was so educated about prescription pills.

My parents are both psychiatrists, and they have been on every prescription pill imaginable. That's how they knew what would most likely work for me. I am going to school to become a therapist and in a weird and twisted way I am keeping the cycle going. It will soon be my turn to medicate those in need, and I will know what I am talking about based on my own experiences.

She is currently still using some of the medications, but has learned what combination works best for her.

Julia is a 30 year-old White woman of English descent. Although she was born in England, she was raised in San Francisco from infancy. She works as an assistant to a photographer in Manhattan, and bartends in the evening in order to pay her bills. Julia's knowledge of drugs and alcohol came at a very young age. She candidly speaks about her initiation to them.

Um, my parents were really open to communicate with us about what different drugs do. You know, we had like, you know, openly asked them about things. It also made it more disenchanting for me to try or do, just because I didn't necessarily have the desire because now I was more informed about it. But I would say that they were pretty open about discussing that kind of stuff. Just based on the fact that they wanted us to feel like home was safe and that we could, you know, talk to them. We wouldn't have to have like a secret habit, you know. They were openly letting us be open about that so that we were not having some secret, you know, undercover habit. So, that was good, I guess.

Ginger is a 21 year-old young woman of Greek descent, the child of two immigrants. She is very well put together, with her long, black pin straight hair and her makeup always perfectly done. She works in finance, in midtown Manhattan. She was raised in a traditional Greek home, having to abide by the strict rules of her parents. It was not until Ginger graduated high school and moved to Connecticut to go to college there, that she was introduced to the recreational use of prescription pills.

Everyone was doing them. I had never been around them in high school because everyone back then smoked weed, drank, and once in a while did some coke. When I got to college it was like everyone was a pill head...I mean, I understand the pressures of school, and I especially get it cause I was going to an Ivy (League school), but I mean, c'mon, everyone was all fucked up on pills.

During her freshman year in college, Ginger had been introduced to (and tried) Xanax, Ritalin, Adderall, Vicodin, Codeine, Ambien, and Vioxx. The Codeine and Vioxx had been prescribed to her for an injury she had suffered from diving off a high cliff into the ocean when she was on spring break freshman year.

Veronica is a 22 year-old Irish-American female originally from New York City. She is a short and curvy young woman, with light brown hair that falls to her shoulders, and big brown eyes. She has a very pale complexion, with freckles covering most of her face. She grew up in Manhattan's Upper East Side neighborhood as an only child, with her mother and father, and family dog. When Veronica turned 13, her father left her mother one evening and never came home. After waiting around for him to come back for a week, then a month, then 6 months, Veronica realized that he was probably never coming back. It was then that she became involved in drinking alcohol and smoking marijuana with her friends in junior high school.

Veronica was very candid about her first experience with prescription pills. It was in her senior year of high school that Veronica was introduced to them: Adderall being the first one that she had come in contact with. A friend of hers from high school had a prescription for it and had been using it in order to focus on her schoolwork and get better grades. However, one night when Veronica had a party at her house, her friend brought over some Adderall, crushed it up and dispensed it amongst Veronica and a few other friends. Veronica remembered the rush it gave her, reflecting on it fondly.

I was so psyched to have that feeling, that rush. It was like I had been wasting so much time just drinking, smoking weed and blunts. All of a sudden, with Adderall, I was wide-awake and ready to stay up all night. It's a wonder drug.

Nina, a 26 year-old woman originally from a small but affluent town in New Hampshire, shared her memories of her initiation to prescription pills that occurred at a rave in Boston. As soon as she stepped foot into the abandoned warehouse in Boston's “Southie” neighborhood, she was hooked. “People were having the best time, staying up ‘til all hours of the night and dancing their faces off, and tripping their faces off too.” It was there that she had her first hit of acid, her first tab of ecstasy, her first bump of coke, her first taste of mushrooms, and her first experience with prescription pills.

I knew what Xanax was ‘cause my mom had a prescription when she was sick (with cancer, which eventually took her life). I just automatically associated it with sickness so I never wanted to take it. But when people were doing it at the parties, that changed my view on it. It suddenly didn't seem so scary anymore.

Nina would go to these parties every single weekend with her friends from New Hampshire, and they would often take pills recreationally to get high. If they had nowhere to stay the night, they would often sleep in the Boston Common. Nina used pills such as Xanax, Percocet, Vicodin, and Valium. She reported recreational use of them throughout high school. For Nina, her prescription pill use was much less serious than the habits that some of her friends had developed, such as taking LSD at lunchtime during school or in between classes.

I only used them on the weekends. I never became addicted and I sure as hell didn't have a prescription for any of ‘em. It was just another way to have fun I guess. Everyone was getting even more fucked up around me, on things like ecstasy and heroin, and I never really messed with any of that. Ecstasy yeah, heroin, oh hell no.

Ava, a 22 year-old Jewish woman, grew up in an affluent suburb of New York City, in Westchester County. She is a very pretty and thin brunette with green eyes, often found wearing all vintage 1960s clothing. She had a comfortable upbringing, and went to a prestigious all-girls' private school in her hometown. When she graduated high school, she immediately went on to college at an Ivy League school located in upstate New York. It was there that Ava's first experience with drugs other than marijuana occurred.

Everyone was getting fucked up on campus. If they weren't doing coke to go out all night or stay up to study, then it was Adderall. If it wasn't that then it was some other drug. You could get your hands on whatever you wanted to, and that's dangerous for a girl like me.

During her freshman year of college, Ava used marijuana, cocaine, mushrooms, ecstasy, ketamine, and various prescription pills. Among those pills mentioned were Xanax, Vicodin, Ritalin, Adderall, Quaaludes (or “lemons”), “other anti-anxiety pills” and “pain killers”. When further probed about what pills she was referring to as “other anti-anxiety pills” and “pain killers,” Ava mentioned Valium, Codeine, Percocet, and Ativan. She also mentioned that she had been put on anti-depressants as a teenager in order to treat her bipolar disorder, and that she had tried Prozac, Zoloft, Wellbutrin, Celexa, and Paxil. Her increased use of cocaine, however, interfered with the anti-depressants, thus causing them to have a weak effect, therefore causing a cycle of increased depression and more use of cocaine and other prescription pills in order to combat the depression.

Gabby is a 28-year old white woman with long dread locks originally from New Jersey. She is very much a tomboy in the way she carries herself, as well as in the way she dresses. She had a great deal of insight into the world of prescription pills, particularly the ones that were commonly used around her when she was in her late teens and early 20s.

I was a fixture in the rave scene, and you know how that goes. There were tons of drugs everywhere, but I wasn't doing pills all that much back then. I mean, don't get me wrong, they were around me all the time, but I wasn't really into them. I was smoking a ton of weed. That was my drug of choice.

It was not until Gabby had a back injury that she had her first real experience with pills, when she was prescribed Codeine and Vicodin. She tried both of them and decided that she was missing out on having a hazy, feel-good high that was reminiscent of her marijuana high. Gabby continued to use the pills recreationally, often mixing them with marijuana and alcohol, after her injury had healed.

Maya is a 30 year-old 2^nd generation Chinese-American woman. Her parents were émigrés from Taiwan in the 1970s. They settled down in New Hampshire, where Maya was their first-born. Maya was raised in a strict household, where she was not permitted to stay out late on weekends, not to mention on school nights. She reports that the ways of her strict parents led her to rebel against them, starting to go out late as a teenager. It was at the age of 16, a sophomore in high school, that Maya discovered “raves” or “parties” as they were called among those who were in the know.

It was at these “parties” that Maya was exposed to a world of drugs she had perhaps heard about, but had never seen, nor done before. Everyone around her was experimenting with ecstasy, cocaine, angel dust (PCP), nitrous oxide, k (ketamine), mushrooms, GHB, roofies, heroin, crack, opium, acid, crystal meth, marijuana, and prescription pills. She would attend these parties as a nonuser of these drugs, often wondering what it would be like to experiment with them, yet not ever involving herself with them. Maya became curious and it was at a party in New York City that she tried her first drug.

Someone gave me this little white pill and told me to try it. He said it would make me feel at one with the room and the music. So I tried it. It gave me this blasting feeling of euphoria. I just remember really loving it. It made me thirsty though, and everyone told me to keep on drinking orange juice.

“Things really changed when I graduated high school and got accepted to college in Boston”, Maya said of her discovery of pills. “My parents are both scientists, so it was clearly planned out that I was going to be going to pharmacy school.” Maya had seen prescription pills at parties, but did not start taking them until she was about 19 years old, a pharmacy school sophomore.

I learned all about ‘the benzos’ (benzodiazepines) and I knew they were always at parties, these little pink, blue and yellow pills, but I was always apprehensive about trying them. I had a Klonopin one morning after suffering from ‘post-E depression’ and the rest is history. It just felt so good. My anxiety was gone. My depression was gone. I wondered why I had waited so long to try this little miracle pill. I knew that I would have easy access to pills by staying in pharmacy school, and I really loved the feeling these pills gave me, so I decided that I needed to drop out. I knew I would become one of those pharmacist drug addicts that would end up scamming from the pharmacy. I couldn't and wouldn't allow myself to go down that road. So I dropped out and went to art school instead, obviously disappointing my parents in the process, but knowing it was what I had to do for my well-being.

The post-E Depression Maya mentions is the period of acute depression in the hours and days that follow the ecstasy high. It seems to be unpredictable, with many youth experiencing it more frequently than others. (Kelly 2005) Maya then tried other pills such as Xanax, Ritalin, roofies, Quaaludes, Valium, and Vicodin. She would often take pills recreationally when her friends were drinking because she didn't like to drink alcohol, citing alcohol's affects as being “not fun. I would turn really red in the face and get bad tunnel vision. Alcohol's not for me. But pills were.”

Jada is a 25 year-old woman of Native American and Scottish descent. She was born and raised in a blue-collar town outside of Boston, MA, the only female out of six children. She would often skip school in order to take a bus to Boston to hang out with her older friends who had already graduated high school. It was these friends that introduced Jada to the world of raves and drugs, including prescription pills.

I got into everything. I did every single drug you can imagine: E (ecstasy), nitrous, coke, K (ketamine), heroin, all sorts of pills, GHB, roofies (Rohypnol), acid (LSD), and I even tried crack. I am sure I am forgetting to name a few drugs, but trust me, I was a garbage can when I was young. I put any and every drug into my body. The thing about it, though, was that I did all of these drugs at such a young age that I got it out of my system. These days, I like to smoke a good joint, have a couple of drinks, and take a couple of Vicodin here and there. I don't mess around the way I used to.

Jada's use of prescription pills was a part of her poly-drug use pattern. She liked to experiment with a variety of different drugs, but keeping it at a level where she could not fall into becoming addicted.

Shifting Patterns of Use

The relationship between marijuana and other drugs has been well recognized in the literature, yet the relationship between these substances and the way they fit into the user's life has often been misunderstood, particularly when it comes to prescription pills. A typology of initial use patterns has been created in which each woman may begin her use of prescription pills under one circumstance, and one use pattern, yet may move or transition to another. These patterns of use are described below:

All 12 women demonstrated one of three fundamental patterns of use, although shifts between two or more of these categories was commonly observed:

1. Legal Medical users: Women who have a legal prescription for the prescription pills they use. These women have an actual diagnosed injury or a psychological disorder that they are being treated for. They obtain their prescription pills either from a physician or a psychiatrist. Examples of this are taking Vicodin for a back injury, or Xanax for an anxiety disorder. In addition, they report nothing wrong with informal diversion. They often provide others with pills from their prescription, either giving them away to friends and family or selling them to others.

2. Quasi-Medical users: Women who do not have a prescription for the prescription pills they use. They may obtain them from a friend or family member who has a legal prescription, or through an illegal purchase. They may also purchase them on a single pill basis from someone who has a prescription. These women are not presently diagnosed with any injury or psychological disorder, yet they may take them for what they perceived to be a medical reason. An example of this is taking a Xanax for insomnia, a Klonopin to relax after fighting with a boyfriend, or Adderall to stay up all night to study for an exam.

3. Recreational users: Women who do not have a prescription for the prescription pills they use. They may obtain them from a friend or family member who has a legal prescription. They may also purchase them from local sellers or the internet illegally. They may also purchase them on a single pill basis from someone who has a prescription. They do not claim any quasi-medical reason for use and report primarily using the pills to get high or as an adjunct to their illegal drug use (sometimes as a means to counteract the unpleasant side effects of other drugs). These women may take prescription pills sporadically, often mixing them with alcohol or other drugs. An example of this is taking Codeine and drinking alcohol with it, or crushing up and snorting an Adderall before going out to the clubs or bars.

It is fairly common to find transitions between these three patterns of prescription pill use (legal medical use, quasi-medical use and recreational use), and they my also occur nearly concurrently. Furthermore, while each woman in the study fits into one or more category, they also report moving from one type to the next, and sometimes back to the original type. Some of the more common transitions are discussed below.

Legal Medical Use Only

Jenny's use of prescription pills was primarily medical, as she got prescriptions from physicians for all of the medications that she was taking. These medications were usually given to her by her parents, who were both doctors in the field and who felt that they knew what was “best” for their daughter. Jenny remembers being given different psychotropic medications when they were virtually unheard of, just when they hit the market. She shared her feelings about the situation.

It was like I was a medical guinea pig. My parents would test different medications out on me to see if I would react positively to them. It was both positive and negative: sometimes they worked well with my chemistry, but sometimes it was a nightmare. It was like, ‘Here, try this, sweetie.’ It was pretty normal for me to be taking some sort of pill with my Frosted Flakes in the morning.

Legal Medical to Recreational Use

Doll provides an example of legal medical prescription pattern of pill use moving into recreational use. The need for pain relief that she found in taking codeine led to a curiosity for something else. When Percocet was readily available to her, she decided to try it. She never reported any quasi-medical use, always making it a point that she took the Percocet on a weekend evening “just for kicks”. Doll remembers her last experience with Percocet as being a very enjoyable one.

I felt really light and airy. That's what I wanted to do with my Friday night after working my shitty job, so that's what I did. It's not like I had anything better to do, and honestly, I don't think it is that big of a deal. It's not like I am popping these pills to get me through the day. It's a once in a while thing. Fuck it.

She made it very clear that she did not take any prescription pills since that night, and that she really has not wanted to either. “I smoke weed all the time. That's my medicine,” Doll said.

Gabby first began her use of prescription pills legally, obtaining a prescription for Codeine and Vicodin from her physician for a back injury that she had suffered. Her use then became recreational, when she realized that her injury was healed, yet she had a surplus of the pills in her possession. Once she began using the pills in a recreational manner, often taking them on a Friday night before going to the movies or out to a club, Gabby was open to trying other pills that she had never been exposed to before. She took an Adderall that a friend of hers had given to her, and described the feeling it gave her which was the ability to concentrate on a task that she ordinarily would have been loathing, “Yeah, I was chilling. I organized my entire room. It was like color coordinated. Yeah dude, I got my laundry done.”

Quasi-Medical to Recreational Use

For Veronica, her use of Adderall was both quasi-medical and recreational. There were times when Veronica would use the Adderall that was given to her in order to stay up late and study for an exam. She would also use it to concentrate when she had to write a paper. Even though she did not have a prescription, she used it part of the time the way it was supposed to be used: to enhance studying and concentration. The other part of the time she used it recreationally: crushing it and snorting it up her nose in order to stay out late partying. Her friends would use it as a cheap alternative for cocaine. It had similar effects, yet Veronica liked the feeling it gave her when she mixed it with alcohol, as opposed to the feeling cocaine gave her.

With coke, I felt more tweaked out. With Adderall, it was like a smoother high, it was almost like you wanted to stay up late but didn't even notice you were on drugs. And when I mixed it with alcohol, I would have to drink less in order to get drunk, but I rarely got to be a sloppy drunk. I don't know...I can't really explain it, but I know that I like it.

Recreational to Quasi-Medical Use

Holly reported her pill use as being solely recreational, meaning that she only used pills when she was out at a party, or soon afterwards in order to quickly induce sleep. She never had a prescription for these pills, and always obtained them from her friends at the parties. At a later time in college, she would know who to seek out in order to find the pills she wanted, and those were usually Xanax and Klonopin. What began as recreational use for Holly soon transitioned into quasi-medical use. She began to take Xanax more often in order to fall asleep. Her boyfriend supplied her with them for free so it was a “no-brainer” for her. She continued taking Xanax, as well as an occasional Vicodin or Klonopin on the weekends throughout high school and into her freshman year of college. “I kept on taking the pills when I left Chicago ‘cause I broke up with my boyfriend and I was having a hard time adjusting to college life in Boston. It was such a different scene there, as far as music and culture in general are concerned. It was boring.”

Legal to Quasi-Medical to Recreational Use

Ava's use of prescription pills moved from legal medical use to quasi-medical use, and then to recreational use. She did not have a prescription for any of the pills she used, besides her anti-depressants. Her doctor refused to give her a prescription for such pills as Xanax or Ativan in order to curb her anxiety, for she had a history of alcohol, cocaine, and other drug use, and he did not want to prescribe anything that could be addictive. Since she could not legally obtain these drugs, Ava sought them out by other means, often asking her friends or acquaintances. They were very easy to come by, and she would always get them for free, for many of her friends had legal prescriptions. She began to take Xanax, Ativan, Vicodin and Valium in order to make herself feel better. The quasi-medical use of these prescription pills continued for about a year.

Ava's use of prescription pills went from quasi-medical to recreational, as she would get prescription pills from friends and acquaintances on her college campus, never having a legal prescription from a physician. She would use these pills in order to treat her condition (depression and anxiety), often mixing them with other substances such as marijuana, alcohol, and cocaine. When the effects of the pills became less pronounced, she would ingest them in more recreational ways, snorting them in order to get more of a high. The rest of Ava's three years at school were spent battling a cocaine problem and taking Xanax, Valium, and Vicodin in order to combat the effects of the cocaine. She could rarely fall asleep without using these pills to bring her down from her cocaine or Adderall high.

Ginger started with a prescription for codeine and Vioxx for an injury she suffered during spring break, but this turned into recreational use, with Ginger mixing her leftover codeine pills with alcohol, liking the effects, and thus increasing her recreational use of the prescription. Ginger also noticed that mixing the pills with alcohol made her get intoxicated faster. Later on in her college years, Ginger began to use her roommate's prescription for Xanax in order to help her get over the panic attacks that she was suffering. She had been smoking more marijuana in order to self-medicate, and realized that perhaps it was the marijuana that increased her anxiety levels.

Ginger's psychiatrist increased the dosage of her antidepressants; the Zoloft was actually used to treat panic attacks over time, as opposed to Xanax, which worked as a quick fix. Ginger cut down on smoking marijuana (she went down from smoking daily to smoking 4−5 times a week) and saw a significant decrease in panic attacks in conjunction with an increase in her prescription dosage. Although she no longer had a medical use for the Xanax, Ginger still called on her roommate for a few pills here and there. She had noticed that when she would take the Xanax (even if it was a half of a .5 mg pill, or .25 mgs),² it would increase the effects of alcohol, thus causing her to get very drunk at a faster rate. “I liked it ‘cause I wouldn't have to spend as much money on drinks at the bar. I could drink a lot less and get more fucked up. It was great!” Therefore, her use of Xanax shifted from quasi-medical use to recreational use. Ginger's use of Ritalin and Adderall was first quasi-medical, as she would use it in order to discipline herself to study for exams and write papers. She would then use the two drugs recreationally, sometimes crushing and snorting them, using them as a substitute for cocaine when she would go out to bars and clubs and would want to stay out late.

When speaking about her prescription pill use, Ginger would comment about how her use would fall into all three categories of legal medical use, quasi-medical use, and recreational use, although she put a great amount of stress on the idea that most of her use was recreational in the most recent years.

I got a prescription for Vioxx and Codeine freshman year, so taking those doesn't really count, right? I mean that was totally legal. The Xanax, well, that started off as being, I guess, medical for all the panic attacks, but then I liked how they made me feel if I drank a little or smoked a little (marijuana). So I would say it then became recreational.

Her use of Ritalin and Adderall in college was for studying at first, and then simply recreational when she did not need it to stay up all night to do school work. She did not use Vicodin and Percocet until this past year, when she and her friend were given the pills by two young college boys in Mexico when she was there on spring break.

I know it was probably really stupid of me to do, especially since I was given them by two strangers in Mexico, but I trusted them for some reason. I really liked the way the Vicodin made me feel. The Percocet was a little too strong for me, especially since I mixed it with alcohol.

Recreational to Quasi-Medical to Legal Use

As far as her prescription pill use is concerned, Julia spoke of how she tried “Xanax, Vicodin and Codeine, and with the Codeine and the Vicodin, maybe experimented twice in my life when I was like 23. I took it and then drank on it, just to see what it would feel like, but I don't experiment with that at all anymore.”

At the time of the interview where she spoke of her prescription pill use, and of not using them anymore, Julia was mainly just smoking marijuana. It was soon after the interview that she began to experience anxiety attacks and discomfort with taking the subway. She then got a prescription for Xanax, a bottle of sixty .5 mg pills, which was supposed to last her at least a couple of months. Julia had been instructed to take them “in an emergency”, that is, only when she was feeling an anxiety attack coming on. She would take them almost everyday, to get her through a subway ride, or through a night at work. When she realized that she began to feel chronic anxiety and it was almost impossible for her to get through the day without her “xani (pronounced zani)”, as she called it, (her term for a Xanax) she decided to go into therapy. The anxiety attacks began to come less frequently, yet Julia still popped a Xanax anytime she felt a bout of anxiety coming on. She would also carry around her bottle of pills with her everywhere, as a “band-aid”, as she called it.

Julia got the prescription for the Xanax from her general practitioner, rather than a psychiatrist. She chose to get it from him because she had a thyroid imbalance, which would give her symptoms that felt like an anxiety attack was coming on (i.e. shakiness, irritability, fear, loss of control). She felt like it was legitimate to get the prescription from him because he was a medical doctor, who told her that she had an actual medical condition. It was easier for her to treat it like a physical issue, rather than a mental one.

Another reason for going to a general practitioner rather than a psychiatrist was that Julia felt that she did not want to be reprimanded by a psychiatrist and treated like a “patient that had problems.” She knew that she could be denied the prescription pills because of her history with cocaine, marijuana and alcohol. She has had friends that have been to psychiatrists in order to get medications, and have been denied because “they are drinkers or (weed) smokers, or do coke here and there.”

I feel like I have my life under control, and if I want to smoke weed here and there I don't think it's a psychiatrist's business. They want to medicate everyone for one reason or another. Either that, or put you in rehab.

When Julia changed her diet by eating better, exercising more, sleeping better, and generally treating her body well, she thought that the anxiety would disappear. When it did not, however, she decided that perhaps the issue ran deeper, and that is when she decided to go into therapy. She did not want to rely solely on medication to make her feel better, and she believed that cognitive therapy would help her as well.

Julia has been in treatment for about a year now, and has expressed that although she is still experiencing bouts of anxiety, she feels that she has a better handle on it. She is more in tune with herself, thus being able to deal with situations where she experiences episodes of anxiety. Julia still pops a “xani” here and there, when she needs it, but she has learned to live without relying on them so much for instant relief.

Recreational Use Only

For Nina, pill use was always recreational. She never had a prescription for anything, and she did not report any quasi-medical use, such as trouble sleeping, anxiety or undiagnosed depression. For her, it was always about fighting boredom, and pills helped her do that, just like smoking marijuana, cigarettes, or drinking a beer or two. It was not uncommon for her to take a pill before she drank some beer while watching a movie.

In 2004, her aunt (her mother's sister) developed the same form of ovarian cancer that Nina's mom had. She would often go up to Massachusetts on the weekends in order to spend time with her sick aunt and her uncle at the farmhouse they lived in. Her aunt battled the illness for months, but she didn't make it. She passed away in late 2004. On a trip up to see her uncle, Nina discovered something when she was helping him pack her aunt's things away. She discovered a whole medicine cabinet filled with prescription pills such as Vicodin, Xanax, Valium, Percocet, and Dilaudid. They were given to her aunt by her doctor in order to help her deal with the pain. Although Nina hadn't used any pills in over two years, she decided to throw the prescriptions in a bag and take them back to New York with her. “I didn't really need to be doing any of these pills, but sometimes shit gets boring, and I am always broke so I can't really go out all that much. That's when I have my friends over, we smoke weed, drink beers, and take pills. It's better than Friday night out in Williamsburg!”

Maya reported her prescription pill use (Klonopin being her drug of choice) as being recreational: she would only take them when going out to parties, bars, or clubs, where other people were either using other drugs or drinking alcohol. “I couldn't bring my bong to the club, so I would pop a pill instead”, she said of those specific situations. Maya moved to New York City in the summer of 2000. She has reported taking a Klonopin “here and there” in the last six months recreationally. She gets them from a friend of hers who is diagnosed with General Anxiety Disorder, and has a legal prescription. She reported no quasi-medical use, and has never been given a prescription for any pill for legal medical use. She states that she will probably continue to do them recreationally if they are offered to her, and she has no plans to stop “because it's not like I have a problem or anything. I take them once in a blue moon.”

Legal, Quasi-Medical and Recreational Use Simultaneously

Kayla's patterns of use varied and moved throughout all three categories. When she couldn't afford to buy cocaine, or could not get any for some reason, she would crush up Adderall and Ritalin and use them as a substitute. She never got a prescription for Adderall, but many of her friends were on it so that they could keep up their good grades and balance a social life with an academic one. Kayla would often mix her prescription pills with alcohol because she liked the effect it gave her. She would mix the Xanax, Valium, codeine, Ritalin, Adderall and Vicodin with alcohol, because she felt that “I would get drunk faster, so I didn't have to spend that much money on alcohol. I could buy one drink, take a codeine and feel like I had six drinks instead of one. It was great.”

Kayla reported quasi-medical use of pills as well as recreational and legal medical.

I would take a Xanax or Klonopin in order to zone out or get away from my problems and away from reality. If I was feeling bummed out or something, I would take a Xanax and everything would suddenly be alright. It was better than taking all those anti-depressants that everyone around me was on. I mean...those take a while to kick in and work. And then even then, you need to take them everyday for maintenance. Who wants to do that? Not me. With a Xanax, it's like instant gratification.

Kayla stated that she took these prescription pills for 12 years off and on. She would often use pills alone in her room in college, and lock herself away from her friends for hours. She would also use pills in more of a social setting, meeting up with friends and going out and drinking with them in bars. The third scenario that she talked about with her pill use was taking them to stay up late and study.

Jada was prescribed codeine twice: once for a bad toothache and once for a bad bike accident she was in. She did not like the effects both of the times she took it, reporting that the drug nauseated her each time. She was also prescribed Vicodin for severe bronchitis that she suffered when she was on a cross-country trip. She never took these two drugs outside of having a prescription for them. Her use shifted to quasi-medical use, when she would take a Xanax or Valium on a long flight to ease her fear of flying and help her get some sleep. She also reported recreational use of Xanax and Klonopin when she was younger (in her “rave years”) when they were around when everyone else around her would be taking them. She would also take Xanax, Klonopin, and Valium in order to help her sleep after staying up all night doing cocaine.

Pills, Alcohol, & Marijuana

In interviewing the youngest women in the study, Ginger and Veronica, both age 21, a common theme began to arise. Both women had mentioned that they had used prescription pills for drug and alcohol substitution. It was relatively common for them to both talk about how they would take a pill, usually a codeine or a Xanax before going out to the clubs or bars in order to increase the effects of the alcohol. They would do this because the pills made them feel good and it made sense economically for them to do so.

As college students, Ginger and Veronica had limited disposable incomes. Their parents would help support them, paying their tuition and giving them spending money for food, books, and some clothing, yet it was never enough to support their partying lifestyle. Ginger recounts using the couple hundred dollars her parents gave her for books on a night out at the local college pub, “I remember one semester my parents gave me like $250 to spend on my textbooks, but I bought rounds of shots for my friends at the bar and a bag of some really nice weed. I took the books out of the library for the semester, not like I actually used them.”

It was somewhat an economic matter that young women like Ginger, Veronica, and their friends would take a Xanax before heading out to the bars. Veronica stated, “Instead of paying for 5 or 6 drinks at the bar, or even more than that, the combination of 2 drinks and a Xanax was the perfect combo for achieving that happy drunk feeling. It was the same thing with Codeine, although Codeine would make me more nauseous here and there. It totally made sense and saves you a lot of money on drinks.” This method especially made sense for Ginger and Veronica, who would drank anywhere from 5 to 7 times a week during their 4-year college experience.

Veronica reported using prescription pills with both marijuana and alcohol. She got procured a few Vicodin when her friend had some dental surgery. She expressed her interest in the drug by stating that it by far made her feel the best out of all the prescription pills she tried. “There's just no competition. With Vicodin, you don't have a care in the world.” She would mix the Vicodin with marijuana and alcohol, giving her an effect that made her feel really good. She would be able to sleep well at night, especially after having been at the bars all night drinking alcohol and mixing it with the Vicodin and marijuana. It was that ease in being able to fall asleep that was so alluring to Veronica. One of her roommates then introduced her to Ambien, telling her that the effects were like clockwork. “She told me that I could pop one and then 10 to 15 minutes later I would be passed out, without weed, alcohol, or any other pills. I had pretty bad insomnia at one point, maybe from taking so much Adderall, so I was happy to have the Ambien.”

Wilsnack et al. (2004) found that the use of psychoactive medications in combination with alcohol leads to both acute effects and long-term risks. Nearly one-half of women who use psychoactive prescription drugs are concurrent consumers of alcohol (approximately 3.7 million women). The women in our study did show simultaneous use of alcohol and prescription pills, although they reported use in moderation and usually in a recreational manner. They implied that their codeine or Xanax consumption might have reduced their alcohol consumption.

Doll was given three Percocet by a friend of hers who had a prescription for a pulled back muscle. She was curious, and since she knew that she had taken codeine in the past and had liked the effects, she was interested in trying some Percocet as well. Her friend gave her three pills. Doll took the first pill the following Saturday night, when she went out with a few friends of hers to a club to dance and to drink. She reported feeling the same way she had felt on codeine, but that the Percocet was much stronger. When asked why she mixed codeine with marijuana and not alcohol and why she mixed Percocet with alcohol and not marijuana, Doll had an explanation.

I had been taking codeine for a while and felt that I knew the effects it had on me. So I tested it. I mixed it with weed in order to see how it felt. And it felt good. So I kept on doing it. With Percocet...it was new to me, and I had only a couple of pills and it felt a lot stronger so I only had a couple of drinks with it. I didn't wanna mix it with the weed because I was sort of worried about what it would do. I wanted a mellow high, nothing too strong and crazy.

Doll then saved the other two pills for another time. She took the second one the following weekend when she was going out for drinks with a friend, and once again mixed it with alcohol. She reported taking the pill first, waiting about forty-five minutes and then drinking a couple of beers afterwards. Although she liked the feeling she got from it, she made it clear that “There was no room in my life for pills to become a habit. I had too much other stuff going on. It was more like something really fun to do one night out of my weekend, and I knew that keeping it minimal like that was safe.”

Jada reported the recreational use of prescription pills, and the mixing of them with alcohol and marijuana.

My current favorite combination is Vicodin and vodka. I mean, I like to take Vicodin by itself as well, for that woozy feel-good feeling, but when I have a drink with it, it is all the better. Then I'll take a bong hit as I am getting ready to go to sleep, and it's just the perfect combo.

Although she had been given a prescription for Vicodin and codeine in the past, Jada more recently got her pills from friends that had prescriptions for toothaches and other injuries.

Jenny is a daily marijuana smoker who often mixes her prescription pills with both marijuana and alcohol. “I am pretty aware of what my medications do, what the side effects are and how I react to them all. It's totally normal for me to smoke weed while I'm on Ativan and my other anti-depressants cause it just helps me calm down and get out of my head even more. It also helps me get to sleep faster so I don't have to pop an Ambien. I try to keep my drinking at a minimum, but sometimes that's hard to do when I am out on the weekends.”

Pills and Hard Drugs

Ginger explicitly referred to substituting Adderall for cocaine.

And then there is the whole Adderall thing. All my roommates had a prescription for Adderall and you know, anytime they were either broke or couldn't find a dealer, they would crush up the Adderall and snort it. It was a total budget version of coke. I've heard people call Ritalin and Adderall ‘kiddie cocaine’ but we call it ‘bc’, or ‘budget cocaine’. I don't really mess with it up my nose ‘cause I don't really do coke that much, but I will snort Adderall here and there along with every other college student across America. It's way cheaper and if you want to stay up all night, it will not let you down.

Veronica recalled how she thought the cocaine dealers on campus were suffering as a result of Adderall becoming so common:

Everyone I know would stick Adderall up their nose instead of coke. I mean, don't get me wrong, if there was money to be thrown around, we'd all be getting the real thing, but in the meantime, the substitute works just fine. It's crazy that there is a visible difference on campus in coke sales though. I know this because my new boyfriend is a coke and weed dealer and he says Adderall is ruining his life, cause his coke sales were where the money was at. Now he mostly relies on selling weed.

Additionally, many young women find Adderall to be such an attractive drug for the side effects that occur. For them, it is a wonder drug of sorts: it keeps one awake, it allows one to concentrate on schoolwork, and it curbs one's appetite. It is not unusual to find young women around college campuses using Adderall in order to stay thin. According to Veronica,

Adderall is like the new cigarette, only it doesn't give you lung cancer. Instead of chain-smoking cigarettes to stay thin and not eat, we eat Adderall. Besides, smoking to stay thin is something your mom does.

Gabby reported that Vicodin was the only pill she would mix with cocaine, for any other combination would make her feel sick.

I've mixed my pills with other drugs before. I've done a couple lines of coke and then popped a Vicodin here and there. It helps me come down from my high, if I'm trying to get to sleep,” “I remember doing a line and then taking a codeine, and let me tell you, that was not a good combo. So now I stick to Vicodin. That's my wonder drug.

Holly's use of pills was integrated with her use of other drugs. She would take considerable amounts of cocaine in order to stay up all night and would take a Xanax after the party was over (usually at around 4 PM or later the following day) in order to fall asleep. Holly has used prescription pills such as Xanax, Klonopin, Percocet, and Vicodin. She used them mostly through high school in order to counter the effects of the drugs she took at the parties she went to, although she reported some pill use in her college years as well. Her pill use in college was much less compared to in high school because she was using heroin at the time, which allowed her to sleep well after having used cocaine.

Discussion

Prescription drugs are misused by more Americans than any other drug except for marijuana. Approximately 46 million Americans (20 percent of the population) have used prescription drugs non-medically during their lifetimes, including almost 15 million in 2002. (NSDUH 2005) Pain relievers are the most commonly abused prescription drugs, followed closely by tranquilizers and sedatives, and stimulants (McCabe 2006). While men and women are equally likely to abuse painkillers and stimulants, women are more likely than men to abuse tranquilizers and sedatives. The case studies of prescription pill use and informal diversion documented here provide some important insights about young women's thinking and practices with both legal pills and illegal drugs, mainly marijuana and cocaine. Despite reporting often heavy consumption of a wide variety of illegal drugs and different types of pills, especially during high school and college years, all 12 of these women had completed college, often at prestigious universities. When interviewed in their 20s, all had full time employment with health benefits that used their skills and education. They were all attractive and personable young adults. Other than a few friends and co-users, almost no one was aware of their continued use of illegal drugs nor prescription pill misuse. In short, these women managed to present a conventional persona even while engaging in hidden drug use. Several factors appeared to be associated their ability to maintain a conventional persona.

Most of the women appeared and claimed to avoid dependence on their prescription pill use, although some did report being “garbage heads” and having some dependence in their past. Most had become relatively sophisticated consumers of illegal drugs and prescription drugs. The women often knew that taking too many depressants with alcohol was dangerous and could lead to overdose. So they took one or two pills (just a few mgs) and then drank less.

They also believed that asking, obtaining or purchasing pills from others was acceptable, and that they often (mis)used them for appropriate quasi-medical reasons (stay awake to study, deal with anxiety, avoid pain, etc). Moreover, each woman's story about quasi-medical use often mentioned different pills for various symptoms, so that each woman's patterns of use were quite unique—no standard pattern of misuse of a specific drug (or pill) was reported by all the women. All the women indicated that they avoided the use of heroin and crack (although some reported trying them in the past); cocaine powder was the hardest drug several reported consuming with any regularity.

Since the 12 women were originally recruited as experienced marijuana users, they had extensive involvements with various illegal drugs which they often reported using in conjunction with various prescription pills. What they considered as their “recreational” drug use when “going out,” at “raves” or “parties” typically involved several different drugs. Their expenditures upon and use of illegal drugs (especially marijuana and cocaine powder) appeared to dominate their consumption patterns; their pill use was often reported to moderate or offset episodes of heavy illegal drug use. Especially when their cocaine use had been extensive, several women reported using Xanax, Ambien, Percocet, or Vicodin to “come down” or get to sleep—rather than to achieve a euphoric effect.

Since almost all pills had been obtained via a legal prescription and the true prescription cost (say $100 for 30 pills) was covered by health insurance with the woman only having a $10 co-pay; each pill had an especially low “economic value” (generally under $1) to the purchaser. This made using a pill or two much less expensive than a drink of beer (about $4), wine (about $6), or liquor ($7−8), a bag of low-grade marijuana ($10), or cocaine powder ($20) [typical but low prices of these substances in NYC in 2006]. The two college students on limited budgets, Ginger and Veronica, were especially clear about how taking a codeine or Xanax before going to a bar or club (where drinks were $5−10 each) was intended to “reduce their bar bill” by having fewer drinks (say 2) but having the same happy drunk feeling(s) as 5−6 drinks. Indeed, their pill consumption probably reduced their alcohol inebriation and alcohol intake considerably. Significantly, none of the women reported substituting pill consumption on a long-term basis for marijuana use—even though the latter was more expensive. Their use of marijuana appeared to be quite constant, regardless of whether they used any specific pill(s) or not.

Ginger and Veronica reported that snorting Adderall was clearly a substitute for cocaine (which was also harder to obtain). Both reported using it as “budget cocaine.” Veronica even explained that her cocaine-selling boyfriend did not sell much cocaine due to competition from Adderall. Of course, the college students were probably making three parallel assessments: that snorted Adderall is less harmful (since it is legal) than snorted powder cocaine; Adderall provides enough high to be mildly euphoric; Adderall is much less expensive per dose unit than cocaine powder. In this respect, snorting Adderall may be a common harm reduction approach for persons who report using cocaine regularly.

Especially among those participating in illegal drug use, teenage girls are also at increased risk for prescription drug misuse; they appear more likely than teenage boys to abuse such painkillers, stimulants and tranquilizers. Some girls may be willing to experiment with prescription and OTC drugs because they may believe these drugs are safer than those drugs that are found on the street. Further, prescription drugs are both legal and sanctioned by doctors. The promise of purity and specified dosage amounts may be important factors, for most prescription and OTC drugs are accurately labeled so those who want to use them to get high know exactly what's in them. Illegal drugs, on the other hand, are often adulterated with dangerous substances, and the precise quantities (in mgs) make them more risky to take. Many young adult women have been and are prescribed drugs that can be abused, and insurance pays for expensive drugs, so women have easy access to them. In many cases, prescription drugs are readily available in medicine cabinets in one's own home or the homes of friends.

It was relatively easy for our 12 women to obtain a prescription for just about any prescription pill wanted. It is often not necessary for a woman to see a psychiatrist, since many general practitioners are willing to write a prescription for a psychoactive drug, or a mood stabilizer, often not knowing the effects that they will have on the patient; nor do they inquire deeply about the woman's illicit drug consumption patterns. Indeed, these women reported that psychiatrists would inquire deeply about their illicit drug use and often deny them prescriptions for various pills that could be easily obtained from general practitioners. Additionally, some of the women in the study had parents who were physicians, starting them on these pills at an early age. Prescription pills are informally diverted to friends and associates and commonly distributed among young women, particularly among women on college campuses. These young women share their prescription pills with their friends, often handing them out at parties or bars. They believe that they are “helping” their friends and express no concern about the moral or legal status of such illicit transfers of pills. None of the women reported being formal resellers of prescription drugs in illicit markets. Likewise, these women could afford to purchase their pills and illegal drugs with their legal income, and did not report committing income-generating crimes (e.g. shoplifting, sex work, etc.) to finance their drug consumption. After amphetamines such as Ritalin and Adderall, these women are turning to painkillers such as Vicodin and Percocet, or sedatives and tranquilizers such as Xanax and Klonopin.

Adderall, a prescription stimulant used to treat Attention-Deficit Hyperactivity Disorder (ADHD), is perceived to be misused more often than other prescription stimulants because it is prescribed more often and is easily accessible around campuses. Some students believe Adderall is used more frequently than some other prescription pills because it has a better reputation among students, causes fewer emotional ups and downs, and is believed to work better overall. (Drug Early Warning System [Maryland] 2005)

It is important to understand the implications of prescription pill use in today's society, particularly by young women. Drugs such as Ritalin and Adderall are prescribed for and serve important functions of medicating those with ADD and ADHD. In addition, many middle class parents encourage their children and adolescents to use these drugs to hopefully improve concentration resulting in good grades and entrance into a prestigious college. These pills are often used quasi-medically to stay awake studying for exams, sharpen concentration, and offset the effects of too much alcohol. Yet prescribing children Ritalin or Adderall at a young age and then keeping them on the drug throughout high school and college may predispose the child to years of use of the drug, as well as providing a dependable supply of pills that can be informally diverted to friends.

Opioid drugs such as Percocet, Vicodin and Codeine, if used frequently, may lead to a curiosity to try heroin, although none of our women reported doing so. Mixing benzodiazepines such as Xanax and Klonopin with alcohol can lead to overdose and death, yet many young women still continue to mix the two, enjoying the effects, but usually limiting the amounts. Women need to educate themselves about their prescription medications, and doctors need to be more wary in prescribing these medications, for many things can go wrong if they are not taken properly. Somehow the 12 women reported here have developed such “education” or “expertise” about how to mix and match the various pills with their illegal drug consumption, and yet continue to manage conventional middle class roles, lifestyles, and identities.

None of these women showed signs of dependence, nor expressed that they felt they had “a problem” with the pills consumed. They all reported controlled use, as well as a firm understanding of the effects of the prescription pills as well as the side effects of the pills. This awareness of one's own drug use and its consequences can be compared to the middle-class cocaine users described by Waldorf, Reinarman and Murphy (1991) who managed to desist their use without treatment, with the motivational factor as having “a stake in conventional society”. These young women reported a relatively sophisticated awareness of the addictive qualities of the medications, and often made methodical choices as to whether or not they want to use these medications for recreational, quasi-medical, or legal medical use. Julia was quite eloquent in the way she expressed her knowledge of prescription pills and her desire to use or not use them

I have made it a point to really understand what it is I am putting in my body in order to medicate myself. I used to just take whatever the doctor ordered thinking it is the best thing for me, but these days I am way more wary of both the medicines and the doctors that are out there. I do my homework. I ask questions. I want to know what the drug is used to treat, what the side effects are, and how the drug will help or harm me. I think it is important to know these things and to do your own research on the matter. I mean it's both your body and your mind that you are potentially messing with here, and especially with Xanax, which I have learned is highly addictive, I want to make sure that I am being safe in my choices to use or not use the drug.

This suggests that many women who are prescribed and/or misuse various pills can and do use them with an awareness of the dangers and benefits, and make decisions about pill use that is often based on conscious choices which consider a number of factors. This is true even when used in conjunction with illegal drugs (marijuana, cocaine powder, ecstasy). Moreover, these women who misuse various pills appear to be relatively invisible to law enforcement and treatment practitioners. This suggests a hidden subpopulation of prescription pill misusers exists—who also use marijuana and other illegal drugs—that are not encountered by treatment providers nor law enforcement. Future research should include such users and misusers of various pills to better understand how prescriptions pills interact with illegal drug use patterns. Yet these women have demonstrated that they manage their conventional middle class identities while concealing their pill use from their nonusing family members, supervisors, co-workers, and friends.

Appendix

Description of Pills Consumed

The respondents in the study mentioned many pills. The more common ones and their appropriate medical uses and symptoms are briefly described here. Vicodin, Percocet, Codeine, and Dilaudid are all opioids, and are in a class of drugs called narcotic analgesics. They are used to relieve moderate-to-severe pain. Codeine and Dilaudid are also used as cough-suppressants. Ritalin and Adderall are both stimulants used to stimulate the central nervous system. They are used to treat attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD) and narcolepsy.

Xanax, Klonopin, Valium and Ativan are benzodiazepines. They affect chemicals in the brain that may become unbalanced and cause anxiety, nervousness, and tension associated with anxiety disorders. They are also used to treat seizures and panic disorders. Ativan is often used to treat insomnia. Rohypnol is a benzodiazepine that is used for the short-term treatment of severe sleep disorders. It has been called the “date rape drug” because of its use in sexual assaults. Rohypnol (often called “roofies”) produces a profound, prolonged sedation, a feeling of well-being and short-term memory loss.

Ambien is a sedative/hypnotic or sleep medication. It affects chemicals in the brain that may become unbalanced and cause insomnia. Soma is a muscle relaxant. It works by blocking nerve impulses (or pain sensations) that are sent to the brain, and is used to treat injuries and other painful muscular conditions. Vioxx is an anti-inflammatory drug that is used to reduce pain, inflammation, and stiffness caused by arthritis. It is also used to manage acute pain in adults, to treat migraines and to treat menstrual pain. Vioxx has been withdrawn from the U.S. and the worldwide market for safety reasons, but several women reported its use in the past.

Anti-depressants such as Celexa, Paxil, Prozac, and Zoloft are all serotonin reuptake inhibitors (SSRI's) that affect chemicals in the brain that may become unbalanced and cause depression. Paxil also treats obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, social anxiety disorder (social phobia), posttraumatic stress disorder (PTSD), and premenstrual dysphoric disorder (PMDD). Prozac is also used to treat mood disturbances, eating disorders, or obsessive or compulsive symptoms. Zoloft is also used to treat obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder (PTSD), premenstrual dysphoric disorder (PMDD), and social anxiety disorder, also known as social phobia. Wellbutrin is an antidepressant that is also used to help people stop smoking by reducing withdrawal effects; it is marketed as the drug Zyban.