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. Author manuscript; available in PMC: 2018 Sep 1.
Published in final edited form as: Drug Alcohol Depend. 2017 Jun 29;178:372–379. doi: 10.1016/j.drugalcdep.2017.05.038

High-intensity drinking and nonmedical use of prescription drugs: Results from a national survey of 12th grade students

Sean Esteban McCabe 1,2, Philip Veliz 2, Megan E Patrick 3
PMCID: PMC5580264  NIHMSID: NIHMS891890  PMID: 28704765

Abstract

Background

Nearly 10% of U.S. 12th graders report high-intensity drinking (10+ or 15+ drinks in a row), but the extent to which these drinkers also engage in nonmedical use of prescription drugs (NMUPD) is largely unknown. This study examined the associations between different thresholds of past two-week high-intensity drinking and past-month NMUPD among U.S. 12th graders.

Methods

The sample consisted of eleven nationally representative cross-sections of 12th graders in the Monitoring the Future study (2005–2015) who answered questions on past two-week drinking behaviors and past-month nonmedical use of prescription opioids, sedative, stimulants, and tranquilizers (N = 26,502 respondents).

Results

High-intensity drinking during the past two-weeks was associated with an increased risk of past-month NMUPD. The odds of NMUPD were four times larger among 12th graders who indicated drinking 15 or more drinks on at least one occasion (AOR = 4.43, 95% CI = 3.18, 5.01) relative to those who had 0 to 4 drinks during the past two-weeks, after adjusting for relevant covariates. These associations were similar across different classes of prescription drugs and tended to be stronger among non-white respondents. A sub-analysis revealed simultaneous co-ingestion of alcohol and NMUPD was more prevalent among high-intensity drinkers.

Conclusions

More than 1 in every 4 U.S 12th graders who engage in high-intensity drinking (15+ drinks in a row) also report NMUPD. Given the greater likelihood of simultaneous co-ingestion of alcohol and prescription drugs among high-intensity drinkers, adolescent substance use interventions need to address the risks associated with mixing alcohol and prescription drugs.

Keywords: High-intensity drinking, binge drinking, heavy drinking, Nonmedical use, prescription drugs, adolescents, substance use, epidemiology

1.0 Introduction

High-intensity drinking is a major public health concern among adolescents and young adults due to the heightened risk of experiencing adverse consequences such as blackouts, traffic accidents, or alcohol-related overdoses (Hingson and White, 2013; Jackson, 2008; Read et al., 2008; SAMHSA, 2013a). High-intensity drinking is defined as consuming at least twice the level as the standard cutoff for binge drinking (i.e., 10+ drinks or higher; Patrick et al., 2013; Patrick, 2016). Among 12th graders in the U.S., roughly 10% have indicated consuming 10 or more drinks and roughly 6% have indicated consuming 15 or more drinks in a row (Patrick et al., 2013).

Although recent trends show that alcohol use, standard binge drinking, and 10+ high-intensity drinking have declined among high school seniors over that past several years, trends in 15+ high-intensity drinking have not significantly declined over the past decade (Miech et al., 2016; Patrick et al., 2013). Problematically, alcohol-related overdoses among young adults (i.e., age 18 to 24) have increased in recent years with a 76% rise in hospitalization rates for combined alcohol and drug overdoses between 1999 and 2008 (White et al., 2011). In particular, many of these hospitalizations among adolescents and young adults involve nonmedical use of prescription drugs (NMUPD), and frequently involve simultaneous co-ingestion of alcohol and NMUPD (SAMHSA, 2004a; 2004b; 2012; 2013b, 2014).

Studies of adolescents and young adults have found that alcohol use and NMUPD are highly correlated (Inciardi et al., 2004; Barrett and Pihl, 2002; Barrett et al., 2005; Egan et al., 2013; Garnier et al., 2009; McCabe et al., 2004; 2006; 2007a; 2012; 2015; Schepis et al., 2016). In fact, more than half of nonmedical users of prescription opioids, sedatives/anxiolytics and stimulants co-ingested these drugs with alcohol and had a higher likelihood to screen positive for substance-related problems than nonmedical users who do not engage in simultaneous co-ingestion with alcohol (McCabe et al., 2006). Furthermore, a national study of 12th grade students in the U.S. found that among past-year nonmedical prescription opioid users, approximately 70% indicated simultaneous co-ingestion of another substance, with a little more than half indicating simultaneous co-ingestion with alcohol (McCabe et al., 2012). The findings from these studies are troubling given that simultaneous co-ingestion of prescription drugs and alcohol are linked to lower blood alcohol concentrations required for fatal overdoses, increases the risk for liver and heart damage, and increases the risk of impaired driving and traffic accidents (Jones et al., 2011; Dassanayake et al., 2011).

Despite the clear link between alcohol and NMUPD, and the major acute consequences (e.g., fatal overdoses) and chronic risks (e.g., substance use disorders) associated with mixing these substances, no research to date has examined how NMUPD is associated with high-intensity drinking among adolescents. Based on this gap in the literature and the current need to increase our knowledge of the potential risks associated with high-intensity drinking (Patrick, 2016), the main objective of this study is to assess different thresholds of high-intensity drinking (i.e., 10 to 14 drinks, and 15+ drinks) and determine how these thresholds are associated with past-month NMUPD (i.e., opioids, sedative, stimulants, and tranquilizers) and past-year co-ingestion of alcohol and NMUPD, and whether these associations vary by sex and race.

2.0 Methods

2.1 Study design

The present study uses eleven cross-sections (2005–2015) of the Monitoring the Future (MTF; Miech et al., 2016) study. Based on a three-stage sampling procedure, MTF has surveyed nationally representative samples of approximately 15,000 U.S. high school seniors each year since 1975, with response rates ranging from 79% to 85% between 2005 and 2015. The project design and sampling methods are described in greater detail elsewhere (Miech et al., 2016).

2.2 Sample

Measures of high-intensity drinking were added to one of six questionnaire forms in 2005; data for the current analysis included 12th graders who were randomly assigned to complete this form. The analytic sample included 26,502 (weighted n=26,499) 12th graders, 48.4% boys (51.6% girls; see Table 1). The racial/ethnic distribution was 10.9% Black, 13.6% Hispanic, 55.7% White, and 19.9% other race.

Table 1.

Sample characteristics (weighted estimates are provided n = 26,502)

(n = 26,502) Multiple Imputation (10 imputations) (n = 17,234) Full sample (listwise deletion)
High intensity drinking (past two weeks) % SE % SE % Missing
0 to 4 drinks in a row (ref.) 80.9% 0.003 82.2% 0.003
5 to 9 drinks in a row 9.1% 0.002 9.2% 0.003 6.10%
10 to 14 drinks in a row 4.7% 0.002 4.5% 0.002
15 or more drinks in a row 5.3% 0.002 4.1% 0.002
Nonmedical Prescription Drug Use (past month)
Any Nonmedical Prescription Drug Use 6.6% 0.002 5.8% 0.002 12.4%
Nonmedical Opioid Use 3.5% 0.002 3.0% 0.002 9.80%
Nonmedical Sedative Use 2.2% 0.001 1.8% 0.001 8.20%
Nonmedical Stimulant Use 3.0% 0.001 2.4% 0.001 7.60%
Nonmedical Tranquilizer Use 2.4% 0.001 1.7% 0.001 8.80%
Control Variables
Male (ref.) 48.4% 0.004 46.6% 0.004 9.2%
Female 51.6% 0.004 53.4% 0.004
White (ref.) 55.7% 0.004 64.7% 0.004
Black 10.9% 0.002 9.4% 0.003 0.00%
Hispanic 13.6% 0.002 12.8% 0.003
Other race 19.9% 0.003 13.1% 0.003
Both parents do not have a college degree (ref.) 50.1% 0.004 47.0% 0.004 8.8%
At least one parent has a college degree 49.9% 0.004 53.0% 0.004
2005–06 (ref.) 19.1% 0.003 19.8% 0.003
2007–08 18.8% 0.003 19.0% 0.003
2009–10 18.5% 0.003 18.3% 0.003 0.00%
2011–12 18.3% 0.003 18.5% 0.003
2013–14 16.6% 0.003 16.1% 0.003
2015 8.7% 0.002 8.3% 0.003
Lives in the North East (ref.) 18.4% 0.003 17.1% 0.003
Lives in the Midwest 23.3% 0.003 25.2% 0.004 0.00%
Lives in the South 36.3% 0.003 34.6% 0.004
Lives in the West 21.9% 0.003 23.1% 0.004
Lives in a Non-MSA (ref.) 20.9% 0.003 21.5% 0.004
Lives in a other MSA 48.5% 0.004 49.5% 0.004 0.00%
Lives in a Large MSA 30.6% 0.003 29.1% 0.004
Did not skip class during the past month (ref.) 68.5% 0.004 70.4% 0.004 13.3%
Skipped class during the past month 31.5% 0.004 29.6% 0.004
Average grade is a B- or higher (ref.) 83.2% 0.003 85.4% 0.003 11.2%
Average grade is a C+ or lower 16.8% 0.003 14.6% 0.003
Does not work (ref.) 37.6% 0.004 36.2% 0.004 12.70%
Works 1 to 20 hours during a typical week 41.6% 0.004 44.0% 0.004
Works 21 or more hours during a typical week 20.8% 0.004 19.8% 0.004
Indicated first time being drunk during the 9th grade or later/never drunk (ref.) 89.1% 0.002 90.2% 0.003 16.40%
Indicated first time being drunk before the 9th grade 10.9% 0.002 9.8% 0.003
Indicated first daily cigarette use during the 9th grade or later/never smoked (ref.) 95.7% 0.002 96.5% 0.002 11.1%
Indicated first daily cigarette use before the 9th grade 4.3% 0.002 3.5% 0.002
Indicated first marijuana use during the 9th grade or later/never smoked marijuana (ref.) 88.8% 0.002 90.5% 0.003 10.90%
Indicated first marijuana use before the 9th grade 11.2% 0.002 9.5% 0.003
Number of friends who get drunk at least once a week (none, a few, some) (ref.) 80.2% 0.003 81.5% 0.003 8.30%
Number of friends who get drunk at least once a week (Most, All) 19.8% 0.003 18.5% 0.003
Number of friends who smoke cigarettes (none, a few, some) (ref.) 86.7% 0.003 87.9% 0.003 8.10%
Number of friends who smoke cigarettes (Most, All) 13.3% 0.003 12.1% 0.003
Number of friends who smoke marijuana (none, a few, some) (ref.) 75.7% 0.003 77.7% 0.004 8.10%
Number of friends who smoke marijuana (Most, All) 24.3% 0.003 22.3% 0.004
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% = percent; SE = standard error; ref. = reference group in the multiple logistic regression analysis

Finally, it should be noted that a sub-analysis of the MTF data using the samples from 2005 and 2006 were used to assess high-intensity drinking and simultaneous co-ingestion of alcohol and prescription drugs (n = 5062; weighted). Questions on high-intensity drinking and simultaneous co-ingestion of alcohol and prescription drugs appeared on only one of six forms in 2005 and 2006, thus limiting the sample size. The analytic sample for this sub-analysis was similar to the sample that extends to 2015.

2.3 Measures

2.3.1 Past Two-Week Drinking

This was based on three questions that asked respondents to report on the number of occasions during the last two weeks they had “five or more drinks in a row,” “10 or more drinks in a row,” and “15 or more drinks in a row.” Respondents could select from six response categories that ranged from “None” to “10 or more times.” For the purposes of this study, these three questions were combined into a variable with four mutually exclusive categories to assess different thresholds of past two week drinking: (1) 0 to 4 drinks in a row, (2) 5 to 9 drinks in a row, (3) 10 to 14 drinks in a row, and (4) 15 or more drinks in a row at least once during The past two weeks.

2.3.2 Past-Month Nonmedical Use Of Prescription Drugs (NMUPD)

This was based on four separate questions that asked respondents to report whether they used prescription opioids, sedatives, stimulants, or tranquilizers during the past 30 days on their own “without a doctor telling you to take them.” For each prescription drug class, respondents were told that drugstores are not supposed to sell them without a prescription. In addition, specific examples were listed for each prescription drug class such as prescription opioids (e.g., codeine, methadone, opium, morphine, Vicodin®, Demerol®, OxyContin®, Percocet®, Percodan®, Ultram®), prescription sedatives (e.g., Ambien®), prescription stimulants (e.g., Adderall®, Dexedrine®, and Ritalin®) and prescription tranquilizers (e.g., Ativan®, Klonopin®, Librium®, Valium® and Xanax®). Respondents could select from seven response categories that ranged from “0 Occasions” to “40 or more occasions.” Four binary measures were constructed from these questions that indicated whether respondents engaged in nonmedical use of opioids, sedative, stimulants, and tranquilizers during the past-month. Moreover, a general binary measure was constructed to capture any NMUPD during the past-month across the four prescription drug classes.

2.3.3 Past-Year Co-Ingestion Of Alcohol And Prescription Drugs

This was based on three separate questions measuring simultaneous co-ingestion of alcohol and prescription opioids, alcohol and prescription stimulants, and alcohol and prescription tranquilizers. Respondents were ask to report on past-year simultaneous use of alcohol and three classes of prescription drug in which “their effects overlapped”. Three binary measures were constructed from these questions that indicated past-year co-ingestion of alcohol and prescription opioids, alcohol and prescription stimulants, and alcohol and prescription tranquilizers. In addition to these three measures, a general binary measure was constructed to capture any past-year co-ingestion of alcohol and prescription drugs.

2.3.4 Control Variables

Control Variables were also included in the analyses to account for potentially confounding factors that are known to be associated with NMUPD and high-intensity drinking within the MTF sample (e.g., Barret et al., 2005; Egan et al., 2013; Garnier et al., 2009; McCabe et al., 2006, 2014; Patrick et al., 2013). These variables include sex, race, skipping class, average grades in school, work status, parental education, urbanicity (e.g., does respondent live in a metropolitan statistical area [MSA]), region of the country (e.g., does respondent live in the Northeast), cohort year, early onset of substance use (i.e., drunkenness, daily cigarette use, and marijuana use before the 9th grade), and peer substance use (i.e., number of friends who get drunk, number of friends who smoke, and number of friends who smoke marijuana). Table 1 includes greater detail on these control variables.

2.4 Analysis

Descriptive statistics were used to examine prevalence of high-intensity drinking and NMUPD. Multiple logistic regression was used to examine the odds of past-month NMUPD among the four mutually exclusive thresholds of past two-week high-intensity drinking when controlling for potentially confounding factors. The additional sub-analysis of the sample of respondents for 2005 and 2006 assessed past-year prevalence rates of simultaneous co-ingestion of alcohol and prescription drugs across the different thresholds of high-intensity drinking when control variables were included. Finally, additional analyses tested for differences by sex and race by examining interaction effects within the multiple logistic regression analyses with control variables.

STATA 14.0 was used to estimate the models outlined above (Version 14.0; StataCorp LP, College Station, Texas). All logistic regression models provide adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) while controlling for confounders. All analyses used the weights provided by the MTF (public use files) to account for the probability of selection into the sample. Finally, given missing data within the MTF sample, multiple imputation was used to impute missing observations (Raghunathan et al., 2001). In particular, sequential regression imputation was used to impute missing values on all the variables used in the analyses; several separate imputations with the full MTF sample used chained multinomial, logistic, and ordered logit models in STATA’s “mi impute chained” procedure (10 imputations, 5 burn-in iterations each; “augment” option was used in the presence of perfect prediction).

3.0 Results

Among all of the 12th grade respondents, 6.6% indicated past-month NMUPD; 3.5% indicated past-month nonmedical use of prescription opioids, 2.2% indicated past-month nonmedical use of prescription sedatives, 3.0% indicated past-month nonmedical use of prescription stimulants, and 2.4% indicated past-month nonmedical use of prescription tranquilizers. With respect to high-intensity drinking, the majority of respondents indicated 0 to 4 drinks on at least one occasion during the past two weeks (80.9%), 9.1% indicated 5 to 9 drinks on at least one occasion during the past two weeks, 4.7% indicated 10 to 14 drinks on at least one occasion during the past two weeks, and 5.3% indicated 15 or more drinks on at least once occasion during the past two weeks.

Table 2 shows the descriptive statistics examining past-month NMUPD by past two-week prevalence of high-intensity drinking. The results show that more than one in every four 12th graders who consumed 15 or more drinks in one sitting also indicated past-month NMUPD (27.2%). Moreover, more than one in every ten 12th graders who consumed between 5 and 9 drinks (14.6%), or between 10 to 14 drinks (18.5%), also reported past-month NMUPD. Across all thresholds of high-intensity drinking, nonmedical use of prescription opioids was the most common type of NMUPD.

Table 2.

High intensity drinking and nonmedical prescription drug use during the past month (2005 to 2015)

Any Nonmedical Prescription Drug Use (past 30 days) Nonmedical Opioid Use (past 30 days) Nonmedical Sedative Use (past 30 days) Nonmedical Stimulant Use (past 30 days) Nonmedical Tranquilizer Use (past 30 days)
High intensity drinking (past two weeks) % OR 95% CI % OR 95% CI % OR 95% CI % OR 95% CI % OR 95% CI
0 to 4 drinks in a row 3.7% 1.7% 1.2% 1.4% 1.0%
5 to 9 drinks in a row 14.6% 4.43***(3.76, 5.21) 7.6% 4.86***(3.86, 6.12) 3.9% 3.42***(2.47, 4.72) 6.6% 5.18***(4.05, 6.62) 5.2% 5.37***(4.04, 7.14)
10 to 14 drinks in a row 18.5% 5.89***(4.84, 7.18) 11.3% 7.56***(5.82, 9.82) 5.8% 5.07***(3.50, 7.33) 9.2% 7.34***(5.59, 9.62) 7.8% 8.32***(6.09, 11.3)
15+ drinks in a row 27.2% 9.68***(8.06, 11.6) 18.0% 12.9***(10.3, 16.2) 11.6% 10.8***(8.24, 14.2) 16.9% 14.9***(11.8, 18.7) 13.7% 15.5***(12.0, 20.0)
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p<.05*, p<.01**, p<.001***

Results presented in Tables 3 examine the associations between high-intensity drinking and NMUPD with control variables. The odds of engaging in any past-month NMUPD was higher among 12th graders who indicated any type of high-intensity drinking when compared to their peers who did not engage in high-intensity drinking. For instance, 12th graders who indicated drinking 15 or more drinks had higher odds of each type of past-month NMUPD when compared to 12th graders who did not engage in high-intensity drinking.

Table 3.

High intensity drinking and nonmedical prescription drug use during the past 30 days (2005 to 2015)

Any Nonmedical Prescription Drug Use (past 30 days) Nonmedical Opioid Use (past 30 days) Nonmedical Sedative Use (past 30 days) Nonmedical Stimulant Use (past 30 days) Nonmedical Tranquilizer Use (past 30 days)
High intensity drinking (past two weeks) AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI
5 to 9 drinks in a row 2.50***(2.07, 3.00) 2.47***(1.92, 3.20) 1.91***(1.31, 2.77) 2.83***(2.16, 3.71) 2.73***(1.98, 3.77)
10 to 14 drinks in a row 3.99***(2.36, 3.77) 3.31***(2.41, 4.55) 2.68***(1.79, 4.01) 3.57***(2.59, 4.93) 4.06***(2.77, 5.96)
15+ drinks in a row 4.43***(3.18, 5.01) 4.28***(3.19, 5.76) 4.42***(3.05, 6.40) 5.84***(4.41, 7.73) 5.58***(3.92, 7.96)
Control Variables
Female 1.35***(1.17, 1.56) 1.19 (.986, 1.44) 1.61***(1.28, 2.01) 1.36** (1.11, 1.66) 1.47***(1.16, 1.86)
Black .480***(.352, .654) .629* (.416, .951) .721 (.432, 1.20) .495** (.302, .812) .451** (.257, .793)
Hispanic .549***(.432, .698) .543***(.383, .770) .652 (.422, 1.00) .711 (.493, 1.02) .884 (.576, 1.35)
Other race .964 (.816, 1.14) 1.14 (.888, 1.46) 1.35* (1.01, 1.80) 1.18 (.934, 1.50) 1.55** (1.17, 2.07)
At least one parent has a college degree 1.08 (.944, 1.24) 1.02 (.851, 1.22) 1.18 (.932, 1.51) 1.13 (.934, 1.37) 1.18 (.939, 1.48)
2007–08 1.10 (.910, 1.34) 1.18 (.905, 1.54) .924 (.672, 1.27) .946 (.708, 1.26) 1.11 (.802, 1.55)
2009–10 .985 (.799, 1.21) 1.08 (.796, 1.46) .830 (.591, 1.16) .911 (.676, 1.22) 1.25 (.871, 1.80)
2011–12 1.01 (.822, 1.25) .871 (.655, 1.15) .745 (.513, 1.08) 1.01 (.755, 1.35) 1.15 (.784, 1.68)
2013–14 .977 (.786, 1.21) .816 (.600, 1.11) .713 (.501, 1.01) 1.14 (.845, 1.53) 1.24 (.867, 1.80)
2015 .833 (.626, 1.10) .782 (.509, 1.20) .741 (.460, 1.19) .932 (.629, 1.38) .719 (.422, 1.22)
Lives in the Midwest 1.49***(1.23, 1.80) 1.59***(1.21, 2.09) 1.32 (.927, 1.89) 1.10 (.853, 1.43) 1.11 (.796, 1.55)
Lives in the South 1.46***(1.22, 1.76) 1.27 (.943, 1.70) 1.73***(1.27, 2.37) 1.07 (.831, 1.38) 1.75***(1.28, 2.40)
Lives in the West 1.41***(1.15, 1.73) 1.55** (1.14, 2.12) 1.39 (.977, 2.00) .964 (.723, 1.28) .968 (.663, 1.41)
Lives in a other MSA 1.32** (1.11, 1.57) 1.10 (.865, 1.40) 1.25 (.942, 1.66) 1.41** (1.10, 1.81) 1.43* (1.07, 1.89)
Lives in a Large MSA 1.13 (.936, 1.37) .955 (.722, 1.26) .990 (.714, 1.37) 1.30 (.981, 1.73) 1.36 (.992, 1.87)
Skipped class during the past month 1.67***(1.45, 1.93) 1.83***(1.50, 2.24) 1.45** (1.14, 1.85) 1.71***(1.37, 2.12) 1.90***(1.45, 2.48)
Average grade is a C+ or lower 1.06 (.908, 1.24) .982 (.789, 1.22) 1.11 (.844, 1.47) 1.17 (.869, 1.59) 1.15 (.861, 1.56)
Works 1 to 20 hours during a typical week .998 (.851, 1.17) 1.23 (.974, 1.55) .967 (.728, 1.28) .998 (.773, 1.28) 1.09 (.826, 1.44)
Works 21 or more hours during a typical week 1.08 (.911, 1.29) 1.25 (.954, 1.63) .866 (.636, 1.18) 1.27 (.903, 1.80) .993 (.741, 1.33)
Indicated first time being drunk before the 9th grade 1.58***(1.29, 1.93) 1.66***(1.26, 2.19) 1.61** (1.13, 2.30) 1.28 (.973, 1.70) 1.26 (.894, 1.78)
Indicated daily cigarette use before the 9th grade 1.19 (.924, 1.54) 1.30 (.953, 1.78) 2.03***(1.41, 2.91) 1.52 ** (1.13, 2.04) 1.61** (1.13, 2.29)
Indicated first marijuana use before the 9th grade 1.71***(1.40, 2.10) 1.76***(1.39, 2.24) 1.54** (1.13, 2.10) 1.51** (1.15, 1.98) 2.03***(1.50, 2.75)
Number of friends who get drunk at least once a week (Most, All) 1.19* (1.02, 1.40) 1.12 (.905, 1.40) 1.10 (.838, 1.46) 1.27* (1.01, 1.60) .951 (.730, 1.23)
Number of friends who smoke cigarettes (Most, All) 1.85***(1.56, 2.20) 1.79***(1.38, 2.31) 1.48** (1.11, 1.98) 1.77***(1.39, 2.26) 2.14***(1.61, 2.86)
Number of friends who smoke marijuana (Most, All) 2.20***(1.89, 2.56) 2.68***(2.18, 3.30) 2.27***(1.76, 2.93) 2.13***(1.67, 2.73) 2.77***(2.09, 3.65)
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p<.05*, p<.01**, p<.001***

Several differences were also found between different thresholds of past two week high-intensity drinking (tables not provided). In particular, 12th graders who indicated drinking 5 to 9 or 10 to 14 drinks on at least one occasion during the past two weeks had similar odds of engaging in any past-month NMUPD. This was consistent across all prescription drug classes. However, 12th graders who indicated drinking 15 or more drinks had roughly one-and-a-half times higher odds of any past-month NMUPD when compared to their peers who either drank 5 to 9 drinks (AOR = 1.59; 95% CI = 1.26, 2.02), or 10 to 14 drinks (AOR = 1.34; 95% CI = 1.02, 1.75). This difference was consistent across all drug classes except for a non-significant difference on past-month nonmedical use of prescription opioids and tranquilizers between those who had 10 to 14 and those who had 15 or more drinks.

There were no significant interaction effects between sex and high-intensity drinking with respect to past-month NMUPD (tables not provided). However, there were several statistically significant interactions by race (tables not provided). Black respondents who drank 15 or more drinks on at least one occasion during the past two weeks had higher odds of engaging in past-month nonmedical use of prescription sedatives (16.8%; AOR = 5.15, 95% CI = 1.42, 18.5) and tranquilizers (16.1%; AOR = 7.67, 95% CI = 2.10, 27.9) when compared to White respondents who consumed 15 or more drinks. Hispanic respondents who drank 15 or more drinks during the past two weeks had higher odds of engaging in past-month nonmedical use of prescription opioids (17.6%; AOR = 3.44, 95% CI = 1.53, 7.73) and sedatives (12.1%; AOR = 3.79, 95% CI = 1.47, 9.73) when compared to White respondents who consumed 15 or more drinks. Finally, ‘Other Race’ respondents who drank 15 or more drinks during the past two weeks had higher odds of past-month nonmedical use of prescription opioids (25.1%; AOR = 2.04, 95% CI = 1.05, 3.93), sedatives (19.7%; AOR = 2.40, 95% CI = 1.09, 5.24), and stimulants (24.8%; AOR = 1.86, 95% CI = 1.02, 3.41) when compared to their White peers who indicated drinking 15 or more drinks.

Table 4 provides the sub-analysis of simultaneous co-ingestion of alcohol and prescription drugs using data from 2005 and 2006. The results indicate that respondents who engaged in high-intensity drinking (i.e., 10 to 14 drinks and 15 or more drinks) consistently had higher odds of reporting any past-year simultaneous co-ingestion of alcohol and prescription drugs when compared to their peers who indicated drinking between 0 to 4 drinks during the past two weeks. These results were similar for simultaneous co-ingestion involving alcohol and prescription opioids, alcohol and prescription stimulants, and alcohol and prescription tranquilizers.

Table 4.

High intensity drinking and past-year coingestion of alcohol and prescription drugs (all respondents; n = 5062) (2005 to 2006)

Coingestion of alcohol and any prescription drug (5.6%) Coingestion of alcohol and prescription opioids (3.1%) Coingestion of alcohol and prescription stimulants (2.9%) Coingestion of alcohol and prescription tranquilizers (2.3%)
High intensity drinking (past two weeks) % AOR 95% CI % AOR 95% CI % AOR 95% CI % AOR 95% CI
0 to 4 drinks in a row (77.8%) 2.6% 1.4% 1.2% 0.9%
5 to 9 drinks in a row (10.5%) 9.6% 1.74* (1.08, 2.79) 5.3% 1.76 (.947, 3.28) 4.4% 1.61 (.859, 3.03) 4.7% 2.53** (1.25, 5.15)
10 to 14 drinks in a row (5.3%) 19.7% 3.88*** (2.33, 6.45) 11.8% 3.77*** (1.99, 7.12) 11.2% 4.78*** (2.39, 9.55) 6.1% 2.90** (1.41, 5.95)
15 or more drinks in a row (6.4%) 23.5% 3.87*** (2.27, 6.61) 12.9% 3.69*** (1.87, 7.31) 13.9% 4.87*** (2.48, 9.54) 12.3% 5.96***(2.86, 12.4)
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p<.05*, p<.01**, p<.001***

All models control for the race, parental education, cohort year, region, urbanicity, truancy, average grade, hours of paid work per week, early onset of drunkenness, early onset of daily cigarette use, early onset of marijuana use, number of friends who get drunk, number of friends who smoke cigarettes, and number of friends who smoke marijuana; refer to table 3 regarding how they were included in the logistic regression models (estimates not provided, but are available upon request). Multiple imputation (m = 10) was used to impute missing data. It should be noted that the percent of missing data on the coingestion items ranged from 7.0% (coingestion of alcohol and stimulants) to 9.1% (coingestion of alcohol and opioids).

Several differences were also found between different thresholds of past two-week high-intensity drinking (tables not provided). Respondents who reported drinking 10 to 14 drinks (AOR = 2.23, 95% CI = 1.28, 3.88) and 15 or more drinks (AOR = 2.23, 95% CI = 1.25, 3.96) on at least one occasion had higher odds of indicating any past-year simultaneous co-ingestion of alcohol and prescription drugs when compared to respondents who indicated drinking 5 to 9 drinks on at least one occasion during the past two weeks. This pattern was similar for simultaneous co-ingestion of alcohol and prescription opioids and co-ingestion of alcohol and prescription stimulants. No significant differences in the odds of any past-year simultaneous co-ingestion of alcohol and prescription drugs were found between respondents who indicated drinking 10 to 14 drinks and 15 or more drinks during the past two weeks (along with simultaneous co-ingestion of alcohol and opioids, and simultaneous co-ingestion of alcohol and stimulants). However, respondents who indicated drinking 15 or more drinks had higher odds of past-year simultaneous co-ingestion of alcohol and prescription tranquilizers when compared to their peers who indicated drinking 10 to 14 drinks (AOR = 2.06, 95% CI = 1.00, 4.25) on at least one occasion during the past two weeks.

Finally, the sub-analysis examining simultaneous co-ingestion of alcohol and prescription drugs also tested for interaction effects for sex and race. No interaction effects were found by sex or race. (Note that small sample sizes did not provide adequate power to estimate separate interaction effects for respondents who were Black, Hispanic, or Other race, so a dichotomous race interaction was tested).

4.0 Discussion

High-intensity drinking was associated with an increased risk of past-month NMUPD among nationally representative samples of 12th grade students in the U.S. While prior studies have found strong associations between heavy drinking and NMUPD among adolescents (Inciardi et al., 2004; Barrett et al., 2005; Egan et al., 2013; Garnier et al., 2009; McCabe et al., 2004, 2006, 2007a, 2012, 2015; Schepis et al., 2016), the present study was the first to demonstrate how different thresholds of high-intensity drinking (i.e., 10 to 14 drinks, and 15+ drinks) were associated with NMUPD. In particular, when compared to 12th graders who did not engage in binge or high-intensity drinking (i.e., who had a maximum of 0 to 4 drinks in a row) during the past two weeks, the odds of engaging in nonmedical use of prescription opioids, sedatives, stimulants, and tranquilizers were at least four times higher among 12th graders who indicated drinking 15 or more drinks on at least one occasion. Moreover, when compared to 12th graders who indicated drinking 5 to 9 drinks, or 10 to 14 drinks in a row, the odds of engaging in nonmedical use of prescription sedatives and stimulants during the past 30 days were approximately one-and-a-half times larger for those who drank 15 or more drinks on at least one occasion during the past two weeks. No differences in past-month NMUPD were detected between consuming 5 to 9 drinks and 10 to 14 drinks in a row.

While no differences in the association between high-intensity drinking and NMUPD were found between males and females, significant differences did emerge across different racial/ethnic groups with respect to these associations. The analyses found that among respondents who indicated consuming 15 or more drinks on at least one occasion during the past two weeks, respondents who identified as Black, Hispanic, or other racial/ethnic categories were at higher risk of past-month NMUPD of certain types of prescription drug classes when compared to their White peers. Several national epidemiological studies find that Whites tend to have the highest rates of alcohol consumption (including binge drinking) and alcohol use disorders (e.g., Grant et al., 2015; Miech et al., 2016; SAMHSA, 2016). However, studies have found that historically disadvantaged racial groups are the most vulnerable to negative consequences associated with alcohol consumption (Delker et al., 2016). Results from the current study corroborate that several racial groups who engaged in high-intensity drinking (15+) were more vulnerable to certain types of NMUPD when compared to their White peers. While the current study cannot determine why these racial groups are at greater risk, it may be that social and cultural factors (i.e., racial discrimination) unique to these racial groups elevates the risk for polysubstance use among individuals engaging in these types of risky drinking behaviors (Mulia et al., 2008, 2009).

The sub-analysis examining past-year simultaneous co-ingestion of alcohol and prescription drugs yielded similar results. In particular, high-intensity drinking (i.e., 10 to 14 drinks and 15+ drinks) was associated with the highest rates of past-year simultaneous co-ingestion of alcohol and prescription drugs. About one-quarter (24%) of adolescents who consumed 15 or more drinks also reported simultaneous co-ingestion of alcohol and prescription drugs during the past year. Given these findings, the 15+ threshold appears to be a critical indicator of drinking that substantially increases the likelihood of engaging in any type of NMUPD, especially among non-Whites. This is alarming given that 1 out of 4 (27.8%) high-intensity drinkers who consumed 15 or more drinks co-ingested prescription opioids, sedatives, stimulants, or tranquilizers. The combination of high-intensity drinking and co-ingestion undoubtedly increases the risk for negative consequences including impaired driving and alcohol or drug-related overdoses (Jones et al., 2011; Dassanayake et al., 2011; SAMHSA, 2004a; 2004b; 2012; 2013b; 2014).

Many adolescents underestimate the perceived harmfulness associated with heavy drinking and NMUPD (Meich et al., 2016) and may not fully understand the dangerous interactions from simultaneously co-ingesting alcohol and NMUPD based on the high rate. For example, mixing prescription stimulants and alcohol can override the protective mechanism of passing out when drinking and approaching dangerous blood-alcohol concentrations which can lead to life-threatening consequences (SAMHSA, 2006). In addition, there is evidence that alcohol increases the subjective effects (e.g., drug liking and euphoria) of prescription opioids, which may partially explain why alcohol and prescription opioids are often simultaneously co-ingested (Zacny and Gutierrez, 2011). Notably, central nervous system depressants (e.g., prescription opioids, sedatives and tranquilizers) are much more toxic and associated with more severe consequences when they are taken with other drugs that depress the central nervous system, such as alcohol, as compared to when they are taken alone (Cone et al., 2004; McCabe et al., 2006; SAMHSA, 2014).

The present study has several limitations that should be addressed. First, the study was cross-sectional and measures of simultaneous co-ingestion of alcohol and prescription drugs were only available for two survey years and did not specifically assess simultaneous high-intensity drinking and NMUPD. Future longitudinal studies should include measures that assess polysubstance use involving more than two substances, dose of NMUPD, and order of substance use involved during simultaneous co-ingestion of prescription drugs and high-intensity drinking. Second, there are some important subgroups of the U.S. youth population, such as students who were home-schooled, dropped out of school, or were absent on the day of data collection, who are not included. Third, the number of racial minorities were too small to examine potential racial interactions in simultaneous co-ingestion of alcohol and NMUPD between individual racial minority groups and future research should consider such racial interactions with larger samples based on the present study. Finally, all measures were based on self-reports. While prior work has found that measures in the MTF study are reliable and valid, studies on youth suggest that misclassification and under-reporting of sensitive behaviors such as high-intensity drinking and NMUPD can occur (e.g., Harrison and Hughes, 1997; Johnston and O’Malley, 1985; Johnston et al., 2016; Miech et al., 2016; Morral et al., 2003; O’Malley et al., 1983), and there are particularly challenges with assessing high-intensity drinking that should be considered in future research (Patrick et al., 2016; White, 2017).

Taking into consideration the results from this study, interventions may need to target certain subgroups regarding the potential risks of co-ingesting alcohol and prescription drugs. For example, given that males have been found to be more likely to receive diverted medication from their peers (McCabe and Boyd, 2005; McCabe et al., 2007b), interventions may want to focus on minimizing peer-to-peer diversion in social contexts that are favorable to excessive drinking. We found that most adolescents who reported each type of past-month NMUPD also engaged in binge drinking or high-intensity drinking in the past two weeks. Prevention efforts must take into account the evidence indicating that each type of NMUPD is largely associated with other high-risk health behaviors rather than solely self-treatment with minimal health risks. Moreover, interventions may target certain social groups (i.e., athletes) within secondary school settings whose members are known to be more likely to engage in both high-intensity drinking and NMUPD (Veliz et al., 2013a; 2013b; 2016). Information regarding the risks associated with mixing alcohol with prescription medications (e.g., fatal overdoses) could occur during yearly physicals or discussed in team meetings by coaches. Accordingly, an increased effort within secondary schools to provide information regarding the hazards of mixing alcohol and prescription drugs may be able to reduce alcohol and drug-related overdoses among adolescents.

Highlights.

  • High-intensity drinking was associated with an increased risk of nonmedical use of prescription drugs (NMUPD).

  • Co-ingestion of alcohol and NMUPD was more prevalent among high-intensity drinkers.

  • These findings were similar across different classes of prescription drugs.

Acknowledgments

The development of this manuscript was supported by research grants R01DA001411, R01AA23504, R01DA031160, L40DA042452 and R01DA036541 from the National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health. The National Institutes of Health had no role in the study design, collection, analysis, or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, or the National Institutes of Health. The Monitoring the Future 12th grade data were collected under research grant R01DA001411, and the work of the third author on this manuscript was supported by research grants R01DA001411 and R01AA23504. For the first and second authors, work on this manuscript was supported by research grants R01DA031160, R01DA036541 and L40DA042452. The authors would also like to thank the respondents, school personnel and research staff for their participation in the study.

Footnotes

Contributors

Sean E. McCabe, Philip T. Veliz, Megan Patrick: Dr. McCabe conceptualized the study and discussed the study design with all co-authors, reviewed and revised the manuscript, added comments to the first draft and approved the final manuscript as submitted. Dr. Veliz interpreted the data, drafted the initial manuscript and all subsequent drafts of the manuscript, and approved the final manuscript as submitted. Dr. Patrick helped analyze and interpret the data, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Conflict of Interest

The authors have no conflict of interest.

Role of Funding Source

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health. The National Institute on Drug Abuse had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

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

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