Rx for a Party: A Qualitative Analysis of Recreational Pharmaceutical Use in a Collegiate Setting

Abstract

Objective

To examine the socio-recreational use of pharmaceuticals in a collegiate setting using a qualitative methodology.

Participants

Ninety-one college students from a public, four-year institution for higher learning in the Southwest participated in this study.

Methods

Semi-structured interviews conducted between May 2004 and December 2005 were audio recorded, transcribed, and examined for themes related to the socio-recreational use of prescription drugs.

Results

A variety of prescription drugs are used for a number of purposes, including to experience pleasure, to manage the duration or intensity of another drug’s effects, to “party” or socialize with friends and peers in leisure settings, to facilitate socio-recreational activities, and to help structure free time.

Conclusions

Pharmaceuticals appear to be well integrated into the recreational drug use practices of college students and prescription drug misuse presents a significant prevention challenge.

The non-medical use of prescription drugs among college students is an emerging public health concern and while the misuse of pharmaceuticals is not a new problem recent trends and incidents have brought about increased attention to this practice.^1-6 The National Survey on Drug Use and Health, for instance, indicates that in 2005 just over 12 percent of the young adult population (18-25 years of age) misused a narcotic analgesic (typically Vicodin), making this class of pharmaceuticals the second most popular illicit drug in this age group, behind only marijuana.⁷

Increases in prescription drug misuse are particularly pronounced among college students. Observers note a dramatic 342 percent increase in the 30-day prevalence rate of pharmaceutical misuse among college students in the United States between 1993 and 2005.⁸ This is in line with other studies reporting significant increases in last 30-day illicit use of several drugs, including barbiturates, tranquilizers, and opiates between 1993 and 1999.⁹ Data from the National Survey on Drug Use and Health also reflect these trends. The non-medical use of psychotherapeutics, including the use of prescription pain relievers, tranquilizers, stimulants, and sedatives, has increased steadily in recent years among young people. The lifetime non-medical pain reliever prevalence rate among youth aged 12 to 17, for instance, increased from 1 percent in 1989 to 11 percent in 2002. Among young adults aged 18 to 25, the rate increased from 7 to 22 percent between 1992 and 2002.¹⁰ More recent data indicates continuation of these trends - approximately one in five teenagers (4.3 million nationally) report using hydrocodone within the last year to get high, making this class of pharmaceuticals the second most popular illicit drug in this age group, behind only marijuana.^7,11

Although these patterns of use have received a great deal of play in the popular news media and among law enforcement authorities and drug abuse preventionists, systematic qualitative examination of the emerging practice of recreational prescription drug misuse is scant. In this paper we hope to address this lacuna by examining the recreational use of prescription drugs in a collegiate setting. First, we offer an overview of recreational pharmaceutical use patterns among a group of college students. We then describe the risks these young adults associate with these practices along with the strategies they utilize in an attempt to address and avoid these perceived negative outcomes. We conclude by discussing the implications these data hold for prevention efforts directed at collegiate socio-recreational prescription drug use and underscore important areas for future research in this area.

METHODS

The analyses presented here derive from an exploratory study funded by the National Institute on Drug Abuse (DA016329). The overall goal of this study was to explore socio-cultural factors related to pharmaceutical misuse among college students, including the risks and negative outcomes associated with this practice.

Two approaches were utilized to recruit research participants: advertisements and snowball referrals. Recruitment ads were placed in a student newspaper and local entertainment magazine, and handbills and flyers were distributed and posted at student social venues (e.g., bars). In addition, at the conclusion of the interview participants were asked if they knew other likely research candidates. If they responded positively they were asked to notify up to three other individuals and provide them with business cards that had a telephone number they could call to learn more about the project. Each card was assigned a unique identification number so that referral chains could be documented to control the types of chains recruited and number of cases in any particular referral chain. Individuals who called in response to the ad or snowball referral were screened systematically for eligibility utilizing a purposive sampling procedure. In order to meet participation criteria an individual had to be 18-25 years old, an enrolled college student, and a prescription drug misuser (defined as past year use of one or more prescription drugs without a prescription from a doctor or use that was contrary to a doctor’s direction).

A total of 91 face-to-face semi-structured interviews were conducted with college students at a public university in the Southwest United States from May 2004 to December 2005. These interviews included questions that focused on a variety of aspects of drug use including types of pharmaceuticals misused, the college drug scene, social settings of use, and outcomes. In addition, interview participants were asked to provide a detailed account of episodes when they had used prescription drugs within the last year, including the context of and reasons for use. All recruitment and data collection procedures associated with this study were reviewed and approved by an Institutional Review Board and all subjects provided written informed consent to participate in this research.

Interview participants averaged 22 years of age and were predominately White (73%). A substantial majority of the participants lived off-campus (91%), most with roommates (75%), and just over half were employed at least part time (53%). Close to a third (31%) of the participants self-identified as being Hispanic and just over half (55%) were upper-division students or graduate students. Nearly equal proportions of men (48%) and women (52%) participated in these interviews. These demographic data are summarized in Table 1.

Table 1.

Participant Background Characteristics (N = 91)

		Frequency	Percentage
Gender
	Male	44	48
	Female	47	52
Race
	American Indian	7	8
	Asian	3	3
	African American	5	5
	White	66	73
	Refused	10	11
College Class
	Freshman/Sophomore	41	45
	Junior/Senior	42	46
	Graduate	8	9
Residence
	Off campus	83	91
Living Arrangement
	Self (alone)	15	16
	Roommate(s)	68	75
	Parent(s)	8	9
Employment Status
	Employed	48	53
	Not employed	43	47
Hispanic
		28	31
Average Age	22 years

Responses to semi-structured questions were tape-recorded, transcribed and then coded using Nvivo.¹² Preliminary coding and analysis focused on examining the range of patterns related to general drug use, prescription drug misuse, and polydrug use. Analysis followed an iterative approach whereby a descriptive coding scheme was developed from transcripts based on specific questions and broader domains from the interview. Analysis then progressed to pattern coding.¹³ In the context of the analysis presented here, pattern coding was employed to highlight examples of socio-recreational uses of prescription drugs in the collegiate setting.

RESULTS

Patterns of Recreational Use

For the purposes of this analysis we define social-recreational use as the intentional utilization of a pharmaceutical in order to get high, have fun and/or socialize with friends and peers. It differs in intention from other types of prescription drug misuse we have identified in this collegiate setting, including self-medication for physiological conditions and states of affect, and functional uses related to academic performance.¹⁴ Fifty out of the 91 participants (55%) reported at least one episode of socio-recreational use of prescription drugs within the last year.

Research participants reported the recreational use of a wide variety of prescription drugs, including narcotic analgesics (e.g., Demerol, Percocet, OxyContin, Vicodin), central nervous system stimulants (e.g., Adderall, Dexedrine, Ritalin) and anxiolytics (e.g., Diazepam, Valium, Xanax), as well as anti-depressants (e.g., Amitriptyline, Trazadone, Zoloft). These data are summarized in Table 2. Although some drug use surveillance systems have pointed out that narcotic analgesics and certain classes of sedatives are commonly misused,^7,15 to our knowledge no sources have documented the misuse of anti-depressants for recreational purposes.

Table 2.

Prescription Drugs Used Recreationally

Narcotic Analgesics	Anxiolytics/Sedatives
Darvocet	Alprazolam
Demerol	Ambien
Hydrocodone	Diazepam
Lortab	Flexeril
OxyContin	Klonopin
Percocet	Nembutal
Roxicet	Soma
Tramadol	Valium
Tylenol with Codeine	Xanax
Vicodin
Central Nervous System Stimulants	Anti-Depressants
Adderall	Amitriptyline
Concerta	Trazadone
Dexedrine	Zoloft
Ritalin

Our analysis emphasizes several discernable patterns of pharmaceutical misuse. While our presentation of these patterns may suggest that they are distinctive there is, at times, considerable overlap between some of the examples we provide. In addition, many users describe multiple motivations for use in single specific episodes, which further complicates analytical and presentation procedures. Nevertheless, these categories illustrate the major cultural practices derived from our interview data and point to patterns that may be important to recognize from a prevention standpoint and to examine systematically in future quantitative studies.

Hedonistic Patterns of Use: Achieving and Managing Highs

The first general pattern presented involves what we will refer to as hedonistic uses of prescription drugs and emphasize experiencing pleasure. Individuals’ descriptions of this type of use emphasized taking a pharmaceutical in order “to feel good,” to experience “enjoyment,” or simply “to get high.” Although similar to other patterns we will discuss below, such as partying and experimentation, responses within this category consistently focused on personal individual pleasure and did not emphasize the social, interactive character found in these other examples. In fact, some respondents, like the one quoted in the following passage, explicitly avoided using certain pharmaceuticals (in this case OxyContin), when they would be involved in social interactions: “There’d be times that I wouldn’t want to do it [OxyContin]. If I was going to hang out with a bunch of people that I wanted to carry on a conversation with, or if I was going to go out to the clubs and try to talk to girls or just try to be social. If I’m going to take it I’d rather be sitting there, staring at the TV or not have to do a whole lot.”

Other reports suggest the calculated use of pharmaceuticals in an attempt to manage or modify the high the user experienced. Individuals described several distinguishable strategies within this pattern. For some, this type of use was directed toward achieving a new high that they had not experienced before by combining a prescription drug with another substance, most often alcohol. One interviewee noted: “A lot of times that I was taking a Percocet or an OxyContin I would drink. I would mix it up just to get more of the high. The high would be different or it would last longer. It wouldn’t just be the same old high. If I mixed it with alcohol it would get a different effect. I would have different feelings, different highs.”

This type of simultaneous polydrug use involving prescription drugs and alcohol was fairly common in our sample – it accounted for 57 percent of all polydrug use episodes that were reported for the last year.

Individuals already familiar with the high produced by these sorts of polydrug combinations also reported taking pharmaceuticals for the sequential management of the duration or intensity of another drug’s effect. In other words, these persons utilized prescription drugs in a purposeful manner to modulate the effects of other non-prescription drugs. At times, users relied on these mixtures to produce what they characterized as a more thrifty high. One 23-year old woman conveyed this particular pattern of use by describing her combination of Valium with beer: “If you take a Valium and have a beer, then you’re pretty much good for the rest of the night, instead of buying seven or eight beers. It’s just a really great money saver.”

Finally, another hedonistic use involves taking pharmaceuticals as substitutes for other recreational drugs. A 25-year-old male described this pattern of use in the following way: “If I didn’t have alcohol, I would take a pill instead, and get the high off of that.”

Social Patterns of Use: Partying, Experimenting and Structuring Free Time

Other subjects focused less on intoxicating effects and instead emphasized social interchange and personal experimentation in a range of contexts. These narrative descriptions typically centered on utilizing pharmaceuticals to “party,” i.e., to consume intoxicants while socializing with friends and peers in leisure settings. Although alcohol and marijuana were the drugs most commonly used at parties, many individuals reported feeling compelled by the social aspects of these settings and the easy availability of prescription drugs to experiment with pharmaceuticals for recreational purposes. These uses were often described in casual terms. Individuals were offered medications in party settings, usually by friends, and simply took the drug because, as one 25-year-old woman summarized her recent recreational use of Lortab, “It was there.” Several interviewees made a point of indicating that this was not a type of use that they would normally engage in, but suggested that they did so only because a pharmaceutical was available in a party context. Thus this type of use was presented as opportunistic and circumstantial. A 22-year-old male noted: “If there are people taking some Vicodin then I might take some, but I don’t go around looking for it. I’m not trying to find it off the street or anything.”

Narrative accounts suggest that a number of interrelated attitudes and experiences specific to prescription drugs underpin this type of experimental use in collegiate social settings. When speaking about pharmaceuticals informants commonly noted that standard dose dependent effects make these drugs predictable, especially when compared to adulterated street drugs. Individuals reasoned that reputable companies manufacture pharmaceuticals and comply with federal safety regulations. These drugs have legitimate purposes and individuals see them used widely to no apparent ill effect. Personal knowledge and experience of pharmaceuticals, either through direct means or vicariously through secondhand knowledge of friends and relatives regarding dosages and effects, also adds to the perception that prescription drugs are known, safe substances. In addition, because of the ubiquity of these drugs and the social acceptability surrounding their use, several informants noted that pharmaceuticals were not “really drugs.”

One 20-year old woman pithily summarized many of these perceptions: “I think prescription drugs sound safer, even if they’re not, just because they came from a company, and they were prescribed to someone for a legitimate reason. I don’t know the laws regarding illegal pharmaceutical use, but it seems safer. Plus if you actually know the kid who has the prescription, they can’t really get in trouble for having a prescription in their name, or at least that’s the perception. It’s prescribed to them, why would it be illegal? So, I think that has a lot to do with it. It comes from a standard source. I think that’s one of the big advantages over the non-prescription drugs. Also, I don’t know how long they stay in the body but it seems like it’s less than Marijuana. I’ve heard they leave your body faster and are easier to get out with things like drinking a lot of water and that sort of thing.”

A 19-year old woman noted: “Some people think prescription drugs aren’t as harmful as street drugs because they were made by somebody who knows what they’re doing. They were made in a lab. They weren’t made in somebody’s house and they were tested and FDA approved. It just kind of makes it seem better. And they’re legal.”

The distinctions underscored in these passages are important in a social context where some individuals wish to achieve altered states of consciousness and experiment with particular identities without incurring the stigma of being seen as a “real” drug user. These perceptions, however accurate they may or may not be, contribute to a cognitive framework that classifies pharmaceuticals as something safe to experiment with on both physical and social levels.

In contrast to the somewhat haphazard experimentation noted above, other individuals indicated that they use pharmaceuticals in a more deliberate manner. In these cases interviewees report the calculated use of prescription drugs in order to ease social interactions and activities. This type of use was directed toward facilitating relaxation and extroversion in specific non-party social contexts. It was along these lines that a 21-year old woman noted: “I knew we were going out to a bar and I just wanted to be ‘dancy’ and a little bit more excited than I was, but not be sloppy. You know, if you’re drinking you get sloppy, but not with Dexedrine. You’re very controlled.”

A different 21-year old woman expressed a similar outlook: “Recreationally I would take Vicodin and drink. When I get drunk I get kind of loud, and so when I take a Vicodin, I can still be functional but be a little more mellow, and my body just feels looser and relaxed. I am more aware of my senses, as opposed to alcohol when I just feel really numb to things that happen.”

At times, pharmaceuticals were used to facilitate interactions with the opposite sex. One 25-year old man described activities he would typically engage in after consuming Xanax: “I like to go to bars and talk to people. Hit on girls. It kind of loosens the tongue. You become a smooth talker.”

A third type of social use was associated with less structured time periods and not tied to specific social events such as parties or going out to clubs or bars. Individuals reported using prescription drugs to organize their free time by giving them and their friends a common leisure activity to participate in. This pattern of use was typically explained by noting that there was “nothing else to do” or that an individual was simply “hanging out” and wanted to use a pharmaceutical. Often this type of use was brought up in the context of alleviating boredom. A 20-year-old woman, for instance, explained her use of Ritalin in the following way: “It was something to do. I was really bored. This was before school started so I wasn’t doing much with my time.”

Each of these patterns of use, along with selected exemplary quotes from informants, is summarized in Table 3.

Table 3.

Major Patterns of Socio-Recreational Prescription Drug Use

Pattern	Selected Interviewee Comments
Hedonistic
Getting high	“I took it (Ritalin) just to get high.”
Managing highs	“You can smoke one bong or one joint or something and you’re high. A little while later you smoke more. It’s kind of like the same thing with the pills. I would do it the same way. Once I was high at a certain level, I was comfortable at that level. And once I started coming down it was like, ‘Oh no, don’t want it to come down yet,’ you know. I still like want to be out of reality a little bit.”
Substitution	“If I didn’t have alcohol, I would take a pill instead, and get the high off of that.”
Social
Partying	“If I’m partying or whatever I’ll use Xanax, but I don’t go out of my way to find them or anything.”
Experimentation	“I took it (Vicodin) just to try it. I figured I might as well see what it was like for myself.”
Facilitating other social interactions  and activities	“Valium makes me feel happier. Like you know if you have a little bit to drink and you’re out with your friends and your having a good time and you’re not drunk, you’re not buzzed, you’re just happy? That’s kind of like how it makes me feel. I feel more outgoing because I relax more. I’m more open. I’m not so tight with a situation.”
Structuring free time	“Last time I took OxyContin, we were just hanging out at my buddy’s apartment, didn’t drink that night, didn’t smoke that night, just hung out and played some board games and it was there.”

Risk Perceptions Regarding Socio-Recreational Prescription Drug Use

Individuals predominately characterized the risks associated with these patterns of use in two ways – by emphasizing the possible physical harms they might experience or by not acknowledging any risks at all. Interviewees noted a wide range of physical worries – from relatively benign conditions such as hangovers and nausea to more serious complications such as overdoses, damage to specific bodily organs (e.g., liver, brain), blackouts, unconsciousness and even death. Other less noted negative outcomes included addiction, and more socially oriented concerns, such as damage to relationships, adverse impacts on academic performance and possible legal sanctions.

At the same time, a large proportion of the interviewees (about 42 percent), when queried about the risks or bad outcomes they were concerned about related to specific recreational use episodes they reported, replied simply that they had none. While such responses may be interpreted as a blissful (and perhaps dangerous) lack of awareness, or an indication that individuals were in denial or less than forthcoming in their responses, other data suggest that this lack of concern regarding objective risks associated with pharmaceutical misuse may be related to various “folk” harm reduction measures that individuals utilize to manage risks. In this light it is instructive to note that it was common for interviewees to initially reply that they had no specific worries regarding their recreational use of prescription drugs, only to add that while they recognized that some practices theoretically carried potential risks, they took practical steps which they felt buffered them from these negative outcomes. These strategies and dimensions of risk appraisal will be discussed in more detail in the following section.

Strategies Employed in an Attempt to Address Risks

In response to questions directed at determining what precautions individuals took in an attempt to minimize risks interviewees described deliberate and sometimes elaborate strategies to manage negative outcomes and create a perception of safety. These strategies fell into two broad categories.

First, individuals employed self-control strategies intended to limit the physiological harm caused by ingesting prescription drugs. This took several forms: setting limits on the quantities of drugs taken, spacing the time intervals of drug consumption, taking food and water along with a drug to buffer the intensity of its effects, and not mixing drugs with alcohol, or only with certain types of alcohol (e.g., using Vicodin with beer but not with liquor). Some individuals described how they periodically monitored and evaluated the effects of drugs on their body, behavior, and perceptions, and how they would utilize this information to adjust their drug usage accordingly over a certain time period.

Second, subjects reported a number of more socially oriented strategies to manage risks associated with drug use. This included enlisting trusted friends to assist them in monitoring drug effects and using drugs in social settings that were considered comfortable, controlled and unlikely to produce situations where their drug use would result in serious physical detriment or social liability. These strategies sometimes included using social networks to gather information regarding specific drugs, including effective dosages, the effects of combining a pharmaceutical with other drugs, and the assessment of potential social and physical risks.

COMMENTS

These results suggest several observations regarding the sociocultural factors influencing recreational pharmaceutical use by college students.

First, faced with an emerging trend in drug use, it is worthwhile to consider what factors might be facilitating the integration of pharmaceuticals into recreational use patterns. On a broad level, a number of developments have created a context where prescription drugs are widely available, including medicalization, disease mongering (the effort by pharmaceutical companies to expand the market for a treatment by convincing people that they are sick and need medical intervention), off-label prescribing, and direct-to-consumer advertising.¹⁶ At the same time, this is one of the most medicated generations of young people in history. A study examining trends in Attention Deficit Hyperactivity Disorder treatment among children (aged 3 to 18) from 1987 to 1997, for instance, found significant increases in the rates of treatment across nearly all sociodemographic groups, as well as an increase in the number of stimulant prescriptions.¹⁷ This parallels increases in pharmacological treatment of other mental conditions, including depression and obsessive compulsive disorder, among youth. ¹⁸ It is also worth noting that increases in legitimate prescriptions for medical purposes are associated with rises in misuse rates.¹⁹ It is clear that young people are being exposed to more medications than ever before. What is less clear is how current prescription practices contribute to the diversion of these drugs, and knowledge about taking them, in specific social networks and how this knowledge, in turn, is put to recreational purposes.

On a local level within the context of collegiate sociocultural settings a number of other factors appear to influence recreational pharmaceutical use. Specific pharmacological, social, and cultural aspects of prescription drugs make them ideal for recreational use and to some extent explain the patterns described here. The standard, predictable, dose-dependent effects of prescription drugs, for instance, make them prime candidates for strategically managing highs and producing specific states of mind. On a broader cultural level, these patterns of pharmaceutical use take place within a context where college life and the young adult life phase more generally, are shaped by shared expectations that individuals will actively experiment with a number of aspects of identity and lifestyle, including drug use.^20,21 Within this environment it should come as no surprise that prescription drugs are used recreationally because they are easy to acquire and are associated with fewer physical, legal and social risks, especially in comparison to illicit street drugs. Furthermore, prescription drugs and knowledge regarding their use and effects provide a currency that individuals can utilize to practice social reciprocity in a setting where individuals seek to develop and maintain friend and peer networks.

For those interested in promoting health in the collegiate setting, the results reported here are worrying given students’ low levels of acknowledging the risks associated with the misuse of pharmaceuticals, as well as their use of prescription drugs with alcohol. Clearly, these results point to an important challenge for health professionals in higher education – to correct the cultural assumption that it is safe to misuse pharmaceuticals. Addressing these perceptions will require a concerted effort by all campus-based health professionals. The results presented here suggest that campus-based student health providers should discuss the risks associated with the socio-recreational use of prescription drugs.

The emerging trend of collegiate prescription drug misuse also underscores the need for rethinking and transforming current prevention research and intervention efforts on college campuses. Drug use practices are dynamic, especially among young people. As a result, prevention programs must change overtime to effectively address new developments. Current campus-based intervention efforts are predominately focused on the prevention of alcohol abuse, particularly binge drinking.²² Drug use practices among young adults, however, appear to be changing rapidly and include a number of substances in addition to alcohol.

It is also important to emphasize that the procedures employed by college students to manage the risks associated with pharmaceutical misuse were no different that those utilized to control risks associated with the use of other drugs in socio-recreational contexts. Individuals reported the same strategies for managing risks associated with other forms of recreational drug use, including drinking alcohol, smoking marijuana and ingesting hallucinogens. The strategies and the risks they were meant to address were complex – they varied by type of drug being discussed, the context of use, and whether they were being used in combination with other drugs or not. The regulatory mechanisms underscored here coincide with observations of drug use in other socio-recreational use settings.^23-25 Although the overall prevalence of the socio-recreational prescription drug use patterns described here is an open question, the strategic, purposeful character of these forms of use, the multiple functions these patterns fulfill, as well as the strategies applied to manage untoward consequences related to this type of use all indicate that pharmaceuticals are well incorporated into existing recreational drug use practices in collegiate social settings.

This integration has taken place with little concerted research or prevention efforts focusing on these emerging practices. The patterns of recreational drug use presented here suggest a line of study that combines analyses of pharmaceutical practice with studies of recreational drug use. This convergence underscores two new interrelated developments represented by socio-recreational prescription drug use that warrant further study. The first concerns the ways in which socio-recreational drug use is becoming pharmaceuticalized. In other words, how do cultural ideas about pharmaceuticals and pharmaceutical practices influence the interactions, information exchange, experimentation and drug-related activities that take place in socio-recreational settings? The second development is a complement to the first and concerns how pharmaceuticals are being recreationalized. Here key issues include how prescription drugs are being put to new recreational uses and to what extent pharmaceuticals replace or complement more traditional recreational drugs.

Finally, these drug use patterns suggest the need for more targeted and relevant health surveys that include items focused on pharmaceutical misuse and polydrug use among collegians. Such surveys would not only provide sound data regarding the prevalence of these practices, but also help to identify any specific sub-groups on campus that participate in these behaviors to a greater extent and that may be in need of specifically tailored prevention programs. Ultimately, these data could be utilized to inform campus-based health programs directed at these practices, and to monitor success.

Limitations

This research has several important limitations. Like other qualitative studies, it provides a great deal of information about individuals and small social groups, but does not allow for making more generalizable conclusions regarding larger populations. This research targeted a relatively small segment of the population and as a result does not offer a great deal of external validity. Therefore, the findings presented here may not apply to other groups. The specific interview methods utilized in this study are also limiting to the extent that they are subject to mode of interview effects. There is a possibility, for instance, that subjects may have felt compelled to offer socially desirable responses.

The average age of the sample, twenty-two, is lower than the average age of the entire main campus enrollment of the institution analyzed here (27), and the undergraduate student body (24). As a result, the conclusions discussed in this paper may not apply to younger sub-groups, such as entering traditional college freshmen.

It should also be recognized that the sample discussed here does not include significant numbers of individuals from higher risk groups, such as dorms, and fraternity or sorority houses.