University student perceptions about the motives for and consequences of nonmedical use of prescription drugs (NMUPD)

Abstract

Objective:

The purpose of the current study was to increase qualitative understanding of student motives for and consequences associated with nonmedical use of prescription drugs.

Participants:

Sixty-one students participated in eight focus groups between April and November 2013.

Methods:

Students described prescription drugs commonly used for nonmedical reasons, as well as the motives for and consequences associated with their use. Data were analyzed using thematic content analysis.

Results:

Students reported stimulants as the most commonly used prescription drug for nonmedical reasons, least expensive, and easiest to obtain on campus, followed by benzodiazepines. Opioids were less commonly used, more expensive, and difficult to acquire. Motives and consequences varied by prescription drug class.

Conclusions:

Our qualitative findings extend previous research by suggesting differences in students’ perceived motives for using and consequences associated with the different classes of prescription drugs. These findings provide implications for the development of preventive interventions.

Nonmedical use of prescription drugs (NMUPD) has become a growing public health concern on university campuses over the past 20 years.¹ The findings from the 2016 NCHA data indicate that 12.5% of students reported any NMUPD.² Using 6 years of data from the College Student Life Survey, McCabe et al.³ found that rates of past year nonmedical use of prescription stimulants significantly increased from 2003 to 2013. These increases are noteworthy given that a number of negative consequences and individual characteristics have been associated with NMUPD.

While the prevalence of NMUPD may be increasing on college campuses and evidence for negative consequences associated with their use is growing, a limited amount of qualitative research has been conducted to assess the perceptions of prescription drug (PD)–using university students about their motives for using these drugs nonmedically,^4-6 and the negative consequences students experience as a result of using these drugs.⁵ To gain a better understanding of these experiences, we conducted eight focus groups at a large university in New York State with students who reported current NMUPD, to explore: (a) the most common classes of PD being used, as well as the availability, and cost of PD being used at the university; (b) their motives for using the different classes of PD; and (c) the negative consequences they experience associated with the different classes of PD. This appears to be the first qualitative study that assessed student perceptions about both motives for using and negative consequences associated with using the different classes of PD (ie, stimulants, benzodiazepines, and opioids). We defined NMUPD broadly as the use of one’s own prescription in a manner other than prescribed (ie, medical misuse) and as the use of a PD without a doctor’s prescription (eg, someone else’s medication). We chose this broader definition given the exploratory nature of our research focus on discriminating motives for and consequences of use among different PD classes.

University student nonmedical use of prescription drugs

The majority of studies that have assessed university student NMUPD indicate that the most commonly used of these PDs are stimulants (eg, methylphenidate “Ritalin,” dextroamphetamine “Adderall,” “Dexadrine,” and “Concerta”) and opioid analgesics “opioids” (eg, oxycodone “Oxycontin,” “Percocet,” Hydrocodone “Vicodin,” “Lortab,” and “Tylenol with Codeine”).^7,8 Individual characteristics of users vary slightly by class of PD used; however, both stimulants and opioids are most likely to be used by university students who are white, fraternity or sorority members, have lower GPAs, and report higher rates of other substance use and risky behaviors.^9,10 Stimulant users are more likely to be men, but there is no gender difference among opioid users. These characteristics of nonmedical prescription drug (NMPD) users have been corroborated by additional studies (eg,¹¹). NMUPD also varies by institutional characteristics; for example, stimulant use is higher at universities located in the northeast and at universities with more competitive admission standards.⁹ Opioid use is more prevalent at universities that are more academically competitive.¹⁰

Several studies have looked at the diversion of PD among college students (eg,^12-14). Rates of diverting scheduled PD among college students range from 16% to 36%, with the most common method being sharing and selling of one’s own prescription medication.^13,14 These studies indicate that the most common sources of these drugs for nonmedical use are friends and peers (eg,¹²). Few studies have reported on the cost to purchase NMPDs (eg,¹⁵), most likely due to the frequent sharing of these drugs among friends and peers.

Motives for nonmedical use of prescription drugs

A number of studies have assessed university students’ motives for NMUPD using quantitative methods. The focus of the majority of this research has been on motives for stimulant use. Using a large Web-based survey of university students, Teter et al.¹⁶ found that the most commonly reported motives for using prescription stimulants were to “help with concentration,” “increase alertness,” and “provide a high” (p. 253). Additional studies report similar motives, including increased work performance,¹⁷ improved concentration, improved alertness, “getting high,” and experimentation.¹³ In a recent study with university students conducted on Facebook, Lord et al.¹¹ found that the most common motives for NMUP opioids included relaxing, getting high, having fun, and experimenting. Additionally, a limited number of studies have described the NMUP benzodiazepines for recreational purposes, to reduce the effects of other drugs, and for pleasure.^18,19 One study compared motives for the nonmedical use of sedatives among heavy and less heavy users in a community sample and found that heavy users were more likely to use sedatives to get high, modify the effects of other drugs, relieve stress and pain, and “just because.”²⁰ All these studies have been quantitative and have prompted respondents with specific motives to rate as applicable to themselves for NMUPD within a larger survey or interview. Such quantitative methods may therefore limit the responses and consistency, suggesting that qualitative assessment techniques, such as focus groups, may provide an appropriate alternative for further exploration of these ideas (eg,^21,22).

Using five cohorts of high school seniors (2002–2006), from Monitoring the Future a large national survey, McCabe et al.²³ assessed a list of the same 20 motives for the nonmedical use of three different classes of PD: opioids, stimulants, and benzodiazepines. The most frequently endorsed items for all three types of drugs included “To relax or relieve tension,” “To experiment,” and “To feel good or get high.” Several specific motives emerged for the different classes of drugs. A small number of studies have allowed students to provide a qualitative “other” reason for using an NMPD in a text box on a survey (eg,¹⁶), or have collapsed qualitative responses into a small number of categories that include other (eg, five to six categories¹⁵). Quintero used semistructured interviews to assess university students’ recreational motives for using NMPDs and found that they used them to achieve and manage highs, to party, to experiment and to structure free time.⁵

Negative consequences associated with NMUPD

A smaller body of quantitative research has focused on student perceptions of the negative consequences associated with NMUPD. In one longitudinal study of 1,253 first-year university students, NMPD users were more likely to skip class, engage in more socializing, spend less time studying, and had a lower GPA at the end of their first year after controlling for high school GPA compared to nonusers.²⁴ NMPD users report greater alcohol and other drug-related problems (eg, polydrug use),^8,10,25,26 as well as other risk and problematic behaviors compared to nonusers (ie, sexual risk taking, suicide ideation).^27,28 University students who report current NMUP stimulants are also more likely to report decreased sleep quality and increased sleep disturbance compared to nonstimulant users.¹⁷ A growing number of university students indicate sharing and selling their PD to fellow students.^14,29 These findings all suggest that NMUPD and availability on university campuses are a growing public health problem.

Qualitative research on the negative consequences associated with NMUPD is limited. In a qualitative study with university students, Quintero found that despite acknowledging risks associated with NMUPD (eg, physical harm, social and academic concerns, and legal ramifications) a substantial percentage (42%) indicated that they were not concerned about consequences associated with individual episodes of NMUPD.⁵ In another qualitative study, Cutler found that students likened taking prescription stimulants to eating candy or drinking energy drinks and that nothing bad ever happened from taking them.⁴ One of the major limitations inherent in these previous qualitative studies is that negative consequences were not differentiated across drug class (stimulants, benzodiazepines, and opiates). This is an important gap, given that Arria et al.,³⁰ in their quantitative study, found that college students who perceived a low level of harm in NMUPD were at increased risk of using these drugs. Incorporating information on the different negative consequences of each PD class into intervention programs to reduce the misuse of PD could increase awareness of the harms associated with each class of PD, as well as the combined use of PD and alcohol.

In summary, NMUPD is significantly associated with academic concerns, alcohol problems, and polydrug use among university students.^7,8,26 In addition, a growing number of university students indicate sharing and selling their PD to fellow students.^14,29 These findings all suggest that NMUPD and availability on university campuses are a growing public health problem. Learning more from students who report current NMUPD about similarities and differences in motives and consequences associated with the use of the different classes of PD could provide meaningful information for developing effective intervention programs to reduce the prevalence of NMUPD. To date, however, most of the research on NMUPD has been quantitative and has given limited choices to respondents, a method known to bias responding.^21,22 The present research used a qualitative approach and asked students to describe their perceptions of all motives and negative consequences they associate with the use of PD for nonmedical reasons based on the class of the drug (ie, stimulant, anxiolytic/sedative, opioid analgesic).

Methods

Participants

We conducted eight focus group discussions with 61 students, from one large, research-focused, state university in the northeastern United States, who reported current NMUPD (ie, past 3 months). Students were recruited through advertisements in the University newspaper, fliers, announcements made in classes, and advertisements on campus buses. Interested individuals contacted the research team via telephone and were screened for eligibility. Individuals were eligible to participate if they: (a) were a current student at the university; (b) were over the age of 18 years; and (c) reported the use of one or more PD [ie, stimulants (eg, Ritalin, Adderall, and Vyvanse), benzodiazepines (eg, Ambien, Xanax, and Valium), opioid analgesics (eg, Lortab, Oxycodone, and Fentanyl)] nonmedically within the past 3 months. Eighty-three individuals were screened for eligibility. Seventy (84.3%) were eligible and 67 (95.7%) were available for a scheduled focus group. Of the 67 individuals who were scheduled, 61 (91%) attended a focus group discussion.

The average age of participants was 20 years (SD = 1.6). The majority of participants were men (64%), Caucasian (80%), and not Hispanic (81%). Nearly half (49%) were in their first or second year at the University, and 46% lived on-campus. The sample comprised more male and Caucasian students than the general university population. Approximately half of the undergraduate population lives directly on-campus, or in the surrounding community. Our sample was similar to other samples of college student NMPD users by being predominantly Caucasian and men (eg,^9,10).

Procedure

All procedures for the project were approved by the University’s Institutional Review Board. Participants attended a single (1.5 hours) session in a conference room at the student union. They first completed a brief (10 minutes) anonymous questionnaire and then participated in a confidential focus group with other students about their perceptions about using NMPDs. Prior to participation, students were asked to provide written informed consent, as well as consent to have the discussion digitally (audio) recorded. Each student was remunerated $40 and refreshments were provided.

Focus groups are an ideal method for collecting qualitative data when the desire is to create a comfortable, permissive environment that elicits disclosure.²³ This methodology was particularly well suited for the current study where we wanted students who were current NMUPD to be comfortable talking about their perceptions of an illegal activity that they participate in at their university. This technique has been used successfully in the past by our research group to obtain rich descriptions of aggression women have experienced while drinking in bars,^31,32 as well as men’s descriptions of women bar drinkers.³³ A number of previous studies have used focus groups as a method for exploring substance use (ie, alcohol, tobacco, marijuana, Ecstasy, other illicit drugs) in adolescent and adult populations (eg,^34-38).

A total of eight, mixed gender focus groups, comprising four to twelve students (N = 61), were conducted with the first author as facilitator, between April 24 and November 6, 2013. Prior to beginning the focus groups, participants were asked to fill out a brief quantitative questionnaire about their individual alcohol, illicit drug use, as well as their current NMUPD. Thereafter, a semistructured script was used by the facilitator to guide each discussion in order to assure consistency in data collection across groups. For example, at the beginning of each discussion, participants were provided with a definition of NMUPD (see below) and asked to describe PDs that were most commonly used (class/or specific drug) on campus. For each drug category, students were then asked to provide their perceptions of student motives for use and experiences with associated negative consequences. The facilitator probed for additional information as needed, but often the group discussion flowed naturally with minimal prompting. The facilitator routinely queried the group throughout the discussion to make sure that the meaning of their responses and comments were being interpreted correctly (ie, validity check). These procedures have worked successfully in the past and are the standard methods for running focused discussions to generate ideas.^32,39,40

Measures

The brief self-administered questionnaire included basic demographic questions (eg, age, racial makeup, marital status), as well as information about living arrangement (on or off campus) and year in school. It included questions about typical drinking patterns (eg, “On average how many times per month do you drink alcohol?”) and illicit drug use (yes/no) in the past 3 months (marijuana, cocaine, heroin, LSD/psychedelics, Ecstasy/other club drugs, Crystal meth, other). Participants also were asked to report (yes/no) which PD [ie, stimulants, opioid analgesics/pain-killers, benzodiazepines (sedatives/anxiolytics), antidepressants, and erectile dysfunction] they had used nonmedically (ie, without a doctor’s prescription or in a manner different than prescribed by a doctor) and frequency of use (“1,” “2–3,” or “4 or more times”) in the past 3 months. Medical misuse of PD was subsumed within our definition of NMUPD because previous research indicates that motives for misuse are similar to those for nonmedical use (eg,⁴¹). Medical use was not assessed separately as we neither were controlling for previous exposure to these drugs as a function of medical history or prescription, nor was the goal of the current study to assess motives or consequences of medical use of these drugs.

Data analysis

Qualitative data analysis

When analyzing focus group data, the unit of analysis is the group, rather than the individual participants; therefore, when thematic analysis is conducted, data are reported in aggregate form with representative quotes provided to illustrate major themes (see^21,39). During each focus group, key words were written on large pieces of paper by the facilitator (first author) to capture major themes and thoughts being discussed. In addition, the third author took extensive notes during each group discussion. Finally, written transcripts were created for each group based on the digital audio recordings. Thematic analyses³³ of these qualitative data were conducted to determine student perceptions of: (a) the classes of PD most commonly used for nonmedical reasons at their University; (b) why they and other students (ie, motives) use each of the different classes of PD for nonmedical reasons; and (c) the negative consequences they experience associated with nonmedical use of each class of PD described. Thematic analysis has been used successfully by our research group in previous studies and is a rapid and efficient means for extracting the primary ideas and themes that emerge across a majority of focus groups from a series of notes and transcripts (eg,^32,33,40). Lists of specific NMPDs, student perceptions of motives for use, as well as negative consequences experienced associated with use were distilled across focus groups individually by the first three authors. These lists were then discussed and any discrepancy was resolved.

Quantitative analysis

Of the 61 students who participated in the focus groups, 59 (96.7%) provided sufficient data on the questionnaire for inclusion in basic descriptive statistics.

Results

Among the participants who completed the brief questionnaires, 16 (27.6%) reported using only one class of PD for nonmedical reasons (ie, stimulant, benzodiazepine, or opioid analgesics), while 42 (72.4%) reported using two or more classes in the previous 3 months. Participants reported consuming 6.8 (SD = 2.4) drinks per occasion an average of 10.2 (SD = 6.6) times per month, and engaging in heavy episodic drinking [ie, four (female) or five (male) drinks in 2 hours] 3.2 (SD = 2.8) times in the past 2 weeks. Students reported using an average of 2.5 (SD = 1.3) types of illegal drugs, not including PD, in the past 3 months. Nearly all participants (92%) reported using marijuana, 61% reported using Ecstasy or another club drug, 51% reported using LSD, and 44% reported using cocaine in the past 3 months.

Commonly used prescription drugs: cost, source, and diversion

Qualitative analysis of the focus group data indicated that students reported stimulants, benzodiazepines, and opioid analgesics as the three most common classes of PDs being used nonmedically at their university, respectively. Using a combination of data from the questionnaire responses and information obtained in the discussions, we determined that most of the participants had used stimulants (93.1%), and that the majority (83%) did so one or more times per month. Participants from all the focus groups reported diversion of PD. In each focus group, students described diversion of PD through selling or sharing their own PD (stimulants, benzodiazepines, and opioid analgesics), and reported that friends and peers on campus were the primary sources for purchasing stimulants and benzodiazepines. However, in five of the eight groups, participants also indicated that it was easy to get a prescription for a stimulant or benzodiazepine from their own physician or a physician at the campus health center by describing symptoms of attention-deficit/hyperactivity disorder (ADHD) or anxiety and indicating that these were interfering with academics. In three of the eight groups, participants described fluctuations in the cost of stimulants based on the time of the semester, with the cost increasing during midterm and final exam weeks. Benzodiazepines and opioids fluctuated in cost based on the type and dose of the drug. In all eight groups, participants indicated that the sources for opioid analgesics were different than for stimulants and benzodiazepines. They indicated that they were less likely to be able to get a prescription for themselves, unless they had recently had surgery (eg, wisdom teeth removed, athletic injury). In addition, they were less likely to get these drugs on campus, but rather, reported getting them through more opportunistic means (eg, stealing, purchasing from elderly). One student provided the following example of a method he had used for obtaining opiates:

“From relatives keeping them in medicine cabinets, like they have them in their house. Relatives, friends, anyone when you go into their house and you’d have the opportunity to check to see if they [opioid analgesics] are there.”

Motives for nonmedical use of prescription drugs

The motives for NMUPD were specific to the class of drug, with a few notable exceptions. Students reported using all these drugs to get high and to enhance the effect of alcohol.

Stimulants

When participants were asked about PD use on campus, Ritalin and its derivatives (eg, Concerta, Focalin), or Adderall and its derivative, Vyvanse, were identified. The general consensus across focus groups was that Adderall and Vyvanse are most popular. Participants indicated primarily utilitarian motives for using stimulants, including studying, getting more done, staying awake, increasing focus and attention, and improving grades or test scores. Somewhat less frequently they reported stimulant use to lift their mood and to make study materials more interesting. As one participant described:

“If I have an exam, like a midterm or something, and I take an Adderall, because I want to make sure that I get everything at once [that I’m studying], and I usually do even better than I expected [on the test].”

Benzodiazepines

Students reported using a number of different benzodiazepines (eg, Ativan, Klonapin, Librium, Valium, and Xanax). Unlike stimulant use, participants indicated primarily recreational motives for using benzodiazepines, such as to loosen up, relax, and “do crazy stuff, stupid stuff [they] would never do” when sober. These were often referred to as the “party drugs” or “good vibes in a pill.” Students indicated that use of these drugs with alcohol was a guaranteed blackout—and further indicated that this was a desired and positive consequence of combining the two substances. According to one participant:

“Basically every time you take a Xanax and then you drink, you get f**d up very easily …and you do crazy stuff, like stupid stuff that you would never do…and eventually, most often you black out. It’s amazing! (Laughing) Then you hear crazy stories from the night before…when you do, it’s generally amazing, but you don’t remember any [of the] amazing.”

Although less commonly discussed, benzodiazepines also were used for some utilitarian purposes, such as coming down from other drugs (eg, stimulant crash, LSD) and for reducing general, as well as school-related anxiety (during examinations, public speaking, following studying). As one participant explained:

“I always take a Xanax ….coming down from an Acid trip – Xanax is the best.”

Opioid analgesics

Students reported using a number of different opioids (eg, Fentanyl, Lortab, oxycontin/Oxycodone, Opana, Tramadol, and Vicodin). Students only discussed recreational motives for use of this class of PD, with the exception of easing physical pain or withdrawal symptoms. For example, one participant stated (when asked why students use opioids without a prescription):

“I think fun is the big one. I think that’s the reason most people do. I originally started doing them for pain management, but it kind of spirals into fun pretty fast….”

In each focus group, students described using these drugs only for the sensation. Common perception was that the feeling from opioids was like no other drug (eg, it was “warm and cozy,” made you “love the world”). They also described using opiates to enhance the effects of other drugs (eg, alcohol, marijuana) and to experiment.

Negative consequences associated with nonmedical use of prescription drugs

As with responses to the question of “Why use PD without a doctor’s prescription?”, when asked to describe the negative consequences associated with NMUPD, these were often specific to the class of PD. However, several negative physical and psychological symptoms were reported for all three classes of PD (ie, headache, nausea, dehydration, weight loss, fatigue, nervousness, anxiety, panic attacks). In addition, students mentioned the addictive properties of all three classes of drugs. They indicated that both benzodiazepines and opiates were physically and psychologically addictive and several groups indicated that stimulants were psychologically addictive for academic enhancement. As several participants described:

“People become dependent on it…need it for like every day activities.” (Stimulants)

“I have friends, who because of Xanax [addiction]…completely messed up their life.”

“It’s so addictive.” (Opioids)

Stimulants

Students reported crashing or extreme fatigue following stimulant use as the primary negative consequence. They also reported insomnia, feeling jittery, decreased appetite, and increased smoking as additional, negative side effects of stimulant use. For example, two participants shared the following statements:

“Come down is horrible. It’s the worst!”

“Like for example, you forget to eat and you can go for days without eating …”

Benzodiazepines

Students reported blacking out when combining benzodiazepines with alcohol as the most common negative consequence; yet, they described blacking out as a specific positive motive for using this drug in combination with alcohol. Additional negative consequences included having poor judgment and slowed cognitive abilities, as well as doing things one would not normally do (ie, driving under the influence, “doing crazy stuff”). Students also mentioned “retripping” the following day and passing out or waking up in inappropriate places following a black out. As shared by one female student:

“I took it and drank in a place where I wasn’t really comfortable, and I was like nervous the next morning, I woke up and I was like, ‘wow, six hours, I have no idea what happened in those six hours’.”

This comment led the facilitator to query whether vulnerability in this situation was different for women than for men. A male student was quick to respond:

“No, I get just as nervous. I think if I woke up off a Xanax in a strange house I would feel like I just got molested….”

Opioid analgesics

Students reported the physical difficulty of recovering from using these drugs. They described being extremely tired (ie, sleeping all day), being emotionally drained, and finding it harder to regain energy (ie, “bounce back”). Students indicated that these drugs were highly addictive and expensive. Several told stories of friends or acquaintances that had become addicted and their lives had been ruined. Most participants indicated that they only used these drugs occasionally, when someone had a few available, and were “careful” not to use them regularly (ie, “once every couple months”, “far and few between”). The following comment from one student provides an example of those heard in most of the group discussions:

“… my very good friend started getting into it …they just got really messed up, making really stupid decisions, they were getting to, like, addicted to it.”

Dangers of polydrug use

In all but one of the group discussions, the dangers of combining NMPDs with alcohol and other drugs were discussed. It became clear that students were aware of these dangers, but felt that they were not personally at risk. When asked how they protected themselves from potential adverse outcomes, they indicated that they always let a friend know when they used a PD and drank alcohol—so that the friend could watch out for them. When asked how the “friend” would know that they should stop them from drinking more, they often responded with explanations such as …. “When I’m [vomiting]” or passed out.

Comment

This study provides a qualitative context in which to place previous quantitative research findings on university student NMUPD. Furthermore, it provides support for much of the quantitative research findings on NMUPD on university campuses throughout the United States. As these quantitative studies have found, our focus group participants reported stimulants as the most commonly used NMPD on campus.^8,24 In addition, results indicate that the most frequent sources of NMP stimulants were friends and peers.^11,41-43 We found that students reported diversion of NMPDs as a common occurrence. These results further support previous findings in the literature.^{14,23,25,29,43}

Consistent with other studies, our sample consumed heavy amounts of alcohol per occasion and monthly, and were polydrug users.^8,25,26,44 In addition, they reported combining NMPDs with alcohol to potentiate the effect of the NMPD or the alcohol. In a study of sedative users, Nattala et al.²⁰ found that a majority (61%) reported using sedatives and alcohol at the same time. Indeed, in several of our focus groups, students described the combined use of anxiolytics/sedatives and alcohol with the specific intention of blacking out in order to engage in what appears to be a “time out” from their daily lives, a period of time in which they could engage in crazy behavior and not be responsible for it. One student described an entire day of activity on Xanax and alcohol in the following way:

“I didn’t remember a single thing about it, still, it’s kind of cool, because it happened, but “I” wasn’t there, someone else was, (laugh).”

In addition to corroborating previous quantitative research on university student NMUPD, our qualitative findings move beyond forced choice survey questions by providing new information on student perceptions of additional motives and negative consequences by drug class. These clearly show that one size (ie, a single list of motives or consequences) does not fit all NMPD classes, suggesting that when measures are developed to assess motives and consequences for drug use, care should be given to class of drug. For example, as a result of these focus groups, we included items about sexual victimization and regretted sex associated with the different classes of NMPD in a large Web-based survey with college students.⁴⁵ We found that the odds of sexual victimization of women and regretted sex among men and women were associated with increased nonmedical use of anxiolytic/sedatives.⁴⁵ We gained information on student perceptions of the consequences of using the individual drug classes, as well as the combined use of these drugs with alcohol or other drugs. Students readily acknowledged the potential danger of combining alcohol with NMPDs; however, they also indicated feeling immune to these dangers and reported engaging in minimal practices (eg, protective behavioral strategies) to avoid them. For example, they described relying on friends to know when they might be in danger, yet paradoxically; they appeared to be unaware that this strategy was ineffective since their friends failed to stop them from drinking or using drugs until they vomited or passed out. This suggests that some form of intervention that provides effective harm reduction strategies or greater awareness of signs of overdose and lethality is needed. For example, education on the warning signs of alcohol poisoning and drug overdose could be part of new student orientation programs at colleges. In addition, prevention programs might focus on the dangers of polysubstance use (ie, the synergistic and additive effects of combined drug use), as well as protective behavioral strategies, such as having designated sober individuals to watch out for others. Students appeared to be most concerned about the physical addiction potential of benzodiazepines and opioids and in every group (eight of eight), one or more participants recounted a story of someone they knew who had “messed up their life” because of one of these drugs. While “scaring” them straight is unlikely to be the answer, these personal experiences certainly had made deep impressions on their lives. Arria et al.³⁰ found that students who perceived low harmfulness of using prescription stimulants and analgesics nonmedically were 10.3 and 9.6 times more likely, respectively, to use these drugs compared to students who perceived high harmfulness of using these drugs. This suggests that some form of storytelling or experiential learning (ie, videos, video games, apps) designed to raise awareness of the harms associated with NMUPD may have an impact on reducing or deterring PD use for some individuals if incorporated into preventive intervention programs, particularly if implemented with peer facilitators.

Limitations

The findings from our study should be interpreted keeping in mind limitations inherent to the design and method. First, qualitative research is never generalizable; however, the similarity of our sample composition to larger national samples of PD users (ie, more men, Caucasian^9,10) and the overlap between our findings and those from other studies across the United States suggest the usefulness, and relevance of our qualitative findings. It should be noted that we did not include a measure of social desirability, or assess for this construct when asking students about their motives for using stimulants. This may be an important construct to assess in future work in this area. In addition, we neither assessed legitimate medical use of PD or diagnosis of ADHD, nor differentiated medical users from medical misusers and nonmedical users of PD. We do acknowledge that this could be a limitation to our study; however, the purpose of our study was not to differentiate motives or consequences of use based on medical misuse or nonmedical use. We intend to do so in future studies.

Conclusions

Our findings suggest that the following are needed: (a) more research to fully understand university students’ motives for combining NMPDs together and with alcohol; (b) development of better measures to assess protective behavioral strategies being used to ameliorate consequences associated with simultaneous use of PD with alcohol and other polydrug use; and (c) creative thinking on potential interventions to reduce the increasing trend in NMUPD and polydrug use on university campuses. The current qualitative findings provide critical insight necessary for work currently underway by our research team to develop improved quantitative measures that differentiate among unique motives and consequences associated with use of the three different classes of scheduled PDs most commonly used for nonmedical reasons by university students. These measures will inform future efforts to further determine the differences in motives and consequences that exist based on class of NMPD and type of use (eg, misuse and nonmedical use) among university students. Students clearly articulated negative consequences associated with each class of drug, but less so with stimulants. In addition, they viewed NMUPD as widespread among other students. Stimulant use was viewed as commonly accepted or “the norm.” The recent qualitative work by Cutler supports this perception of stimulant use as normative among university students.⁴ Dispelling this myth will be important for any intervention moving forward.