Adolescents’ Awareness about Prescription Opioid Misuse and Preferences for Educational Interventions

Abstract

Background

Adolescents are affected by the opioid epidemic, but little is known about their attitudes toward opioids and preferences for opioid safety education.

Objectives

This study explored adolescents’ awareness prescription opioid misuse, sources of medication information, and educational preferences.

Methods

An online survey explored adolescents’ understanding and perceptions of prescription opioids and opioid misuse and safety, medication information sources, and educational preferences. Eligible participants included students from three Wisconsin high schools who could speak and understand English. Participants were recruited through “backpack mail” and completed surveys online at school. Survey responses were compared across demographic information of study participants. Binary response items were compared across demographic strata by Fisher’s exact tests, and Likert responses were analyzed by Kruskal-Wallis tests.

Results

A total of 190 students (53% female, 53% White, 32% Hispanic) were surveyed. Most (83.5%) considered using someone else’s opioid medication to be misuse, 85.2% identified using opioids at a higher dose or frequency than prescribed as misuse, and 67.6% considered using an opioid prescription after its expiration date to be misuse. About 90% of students perceived that opioid misuse causes some, quite a bit, or a great deal of harm to a person’s physical and mental health and school ability. Many students were able to correctly identify examples and consequences of misuse, however 24.7% believed that flushing opioids down the drain was dangerous. The most common source for finding information about opioids was Google or other search engines (67.6%), followed by talking with parents (56.7%), talking with a doctor or nurse (54.9%), and online videos (42.3%).

Conclusion

Adolescents have some opioid safety knowledge, but there is a clear opportunity to increase knowledge and understanding of risks. Adolescents could benefit from opioid safety education, particularly on safe storage and disposal, harms of misuse, and strategies for discouraging peer opioid misuse.

Background

In 2017, 58 opioid prescriptions were written for every 100 Americans, and 17% of Americans filled at least one opioid prescription.¹ Prescription opioid medications provide tremendous benefit to patients when used appropriately but display significant risks when they are misused. Examples of misusing prescription opioids include taking an opioid prescription dispensed for others, taking more than the recommended dose, using an opioid prescription for reasons other than why it was prescribed, or using it after the prescription has expired.² Twenty-one to twenty-nine percent of those who are prescribed opioids for chronic pain misuse them.³ In 2018, an estimated 10.3 million people misused opioids, and two- million people had an opioid use disorder in the United States.⁴ Severe consequences of opioid misuse include overdose and death.⁵ Every day, 130 Americans die due to an opioid overdose, and the number of opioid related overdose deaths in 2017 was six times higher than in 1999.⁵

With the severity of the opioid epidemic, it is important to properly educate patients who are taking opioids about safe storage, handling, and disposal of opioid medications to prevent misuse. According to the National Community Pharmacists Association, about 40% of prescription medications are not completely used, yet remain in the home.⁶ If opioids are left in the home, this poses a major risk for patient or family member misuse, theft, or accidental use and overdose. Approximately 70% of people who report abusing prescription opioids in the US obtain them from friends or relatives.⁷ By educating patients about the importance of safe storage and disposal, this misuse can begin to be prevented.

Nearly one in every four high school seniors in the United States has had exposure to prescription opioids, either medically or nonmedically.⁸ Adolescence is the age group at greatest risk for initiating substance use.⁹ In 2016, 3.6 percent of adolescents ages 12 to17 reported misusing opioids over the past year.¹⁰ Research on the epidemiology and causes of prescription opioid misuse among young people is needed if effective prevention strategies are to be designed and implemented.¹¹ Although current literature suggests that educational interventions may contribute to increasing medication knowledge and safety, little is known about adolescent-specific interventions and preference for education about opioid safety.²

A significant gap exists in knowledge about teens’ perceptions of opioids and their learning preferences about medication safety. This missing information can provide a strong predictor of medication misuse behavior, allowing for the improvement of awareness and the prevention of future misuse behaviors.¹² Preventative education to address teens’ perceptions about opioids is essential to improve medication safety. If educators can increase the perceived risk of opioid misuse, potential for misuse may decrease.

Objectives

This study explored adolescent attitudes and perceptions of opioids. This includes adolescent perspectives on opioid misuse, the potential harm of misuse, safe storage and handling of opioids, and the likelihood of adolescents to partake in behaviors related to opioid misuse. This study also identified adolescents’ current sources of information and preferences for learning about prescription opioid safety.

Methods

Survey design

The study team developed an online survey consisting of closed-ended questions with “yes or no” or Likert scale response options and multiple-choice and open-ended demographic questions (the survey instrument is in Appendix 1, available on JAPhA.org as supplemental content). Questions were adapted from a statewide survey designed to increase awareness of prescription drug misuse and abuse in the state of Wisconsin.¹³ The University of Wisconsin Population Health Institute (UWPHI) worked with the University of Wisconsin Survey Center to develop this instrument, using community outcome measures and a survey used by the State of Maryland for a similar purpose.^13,14 Questions from the UWPHI survey were adjusted for high-school-aged adolescents and adapted to meet our study objectives. The survey explored adolescents’ perceptions and knowledge of prescription opioids, including misuse, safety, storage, handling, and disposal. Questions also explored adolescents’ information sources and their preferences for receiving opioid safety education. An emphasis was placed on understanding the youth perspective on opioid medicines, as a significant number of adolescents have been prescribed an opioid medication in the past, and most adolescents do not begin to misuse opioids without first receiving a legitimate opioid prescription.^8,15–17 The survey included a section collecting demographic information, including age, grade, gender, race, ethnicity, zip code, and number of people under 18 in the participant’s household. This instrument was pilot tested in two after-school youth programs and revised for clarity and appropriateness for the target audience before use and data collection presented here. The University Survey Center also reviewed the survey and provided expert feedback on content and clarity. The revised study instrument and study protocol were approved by the university’s Institutional Review Board.

Study settings, recruitment, participants

Participants were recruited from three Wisconsin high schools in May 2019 which were in an urban, suburban, and rural location. Eligible students were enrolled in 9^th to12^th grade and could speak and understand English. One school distributed recruitment material to all 112 eligible students enrolled in a required health course, and two schools distributed material to all eligible students (1,100 total). Parents received an invitation letter and consent form sent home via “backpack mail.” All students who consented and were present on the day of data collection participated in the survey. In total, 190 students returned parental consent forms or provided consent (if they were 18 years or older) to participate in the study.

Data collection

The survey was administered during a health class using a REDCap link, provided to students by school administrators or the study team. Students completed the surveys in a private room at school, under supervision of the study team. Study data were collected and managed using REDCap electronic data capture tools hosted at University of Wisconsin-Madison.^18,19. Surveys took an average of 10 minutes to complete, and participants received $15 in cash upon verification of completion.

Measures

Misuse

The survey captured the student’s understanding of opioid misuse through three different questions. To gauge student’s knowledge of opioid misuse, they rated (yes or no) whether six behaviors were examples of someone misusing opioids (e.g. “they are using an opioid they had a prescription for, but after it expired,” “they use someone else’s opioid medication,” or “they share their opioid medications with others”). Next, they indicated the level of harm misuse of opioids can do to a person’s physical health, mental health, ability to do well in school, relationships with their family, and relationships with their peers or friends (from 1= none to 5 = a great deal).

Finally, using a five point Likert scale ranging from “not at all” (1) to “extremely” (5), participants were asked how likely they are to participate in four misuse behaviors: “use an opioid that was prescribed to your friend for your own pain relief,” “offer an opioid that you have a prescription for to a friend for their pain relief,” “use a prescription opioid medication your grandparents have in their house,” and “use someone else’s opioid pain relief medication that you find in your house.” One question focused on safe opioid behavior: “stop your friend from using an opioid medication for non-medical purpose.” All means and frequency distributions for misuse questions are reported in Table 2.

Table 2.

Student perception of what opioid abuse entails and their likelihood of performing various opioid-centered actions.

Survey Item				n=190
Is someone misusing opioids if:				“Yes” Response n (%)
they use someone else’s prescription to get opioids for themselves				156 (85.7%)
they use opioids at a higher dose, or more often than their prescription calls for				155 (85.2%)
they use someone else’s opioid medication				152 (83.5%)
they share their opioid medications with others				151 (83.4%)
they are using an opioid they had a prescription for, but after it expired				123 (67.6%)
they return their unused opioid medication to the pharmacy when it expires				26 (14.3%)
Survey Item	Not at all	A little	Some	Quite a Bit	A Great Deal	Mean (sd)
Degree of harm opioid misuse does to one’s:
Mental Health	4 (2.2%)	8 (4.4%)	28 (15.5%)	69 (38.1%)	72 (39.8%)	4.09 (0.96)
Relationships with their family	7 (3.8%)	11 (6.0%)	32 (17.6%)	66 (36.3%)	66 (36.3%)	3.95 (1.06)
Relationships with their peers or friends	5 (2.7%)	11 (6.0%)	36 (19.8%)	77 (42.3%)	53 (29.1%)	3.89 (0.99)
Ability to do well in school	4 (2.2%)	14 (7.8%)	43 (23.9%)	65 (36.1%)	54 (30.0%)	3.84 (1.01)
Physical Health	0 (0.0%)	16 (8.8%)	44 (24.2%)	76 (41.8%)	46 (25.3%)	3.84 (0.91)
Survey Item	Not at all	A little	Somewhat	Very	Extremely	Mean (sd)
Likelihood to:
Use a prescription opioid medication that your grandparents have in their house	166 (91.2%)	11 (6.0%)	3 (1.6%)	1 (0.5%)	1 (0.5%)	1.13 (0.50)
Use someone else’s opioid pain relief medication that you find in your house	163 (89.6%)	8 (4.4%)	7 (3.8%)	2 (1.1%)	2 (1.1%)	1.20 (0.66)
Use an opioid that was prescribed to your friend for your own pain relief	149 (82.3%)	19 (10.5%)	7 (3.9%)	5 (2.8%)	1 (0.6%)	1.29 (0.72)
Offer an opioid that you have a prescription for to a friend for their pain relief	143 (78.6%)	19 (10.4%)	11 (6.0%)	8 (4.4%)	1 (0.5%)	1.38 (0.83)
Stop your friend from using an opioid medication for non-medical purpose	12 (6.6%)	13 (7.1%)	28 (15.4%)	56 (30.8%)	73 (40.1%)	3.91 (1.20)

Slight variations in total sample size occurs between items due to non-responders. Likert scales ranged from 1 (not at all) to 5 (extremely).

Safe Management

Participants were asked about safe handling and storage of opioid medications. They rated the level of danger from “not at all” (1) to “extremely” (5) of storing opioids in bathroom cabinet, storing opioids in dining or bedroom open cabinets, throwing opioids away in the trash bin, flushing opioids down the bathroom drain, and returning unused opioid medication to the pharmacy. Means and frequency distributions are reported in Table 3.

Table 3.

Participants’ views on opioid storage and handling

Survey Item	Not at all	Slightly	Somewhat	Very	Extremely	Mean (sd)
How dangerous would it be to:
Store opioids in dining room or bedroom open cabinets	10 (5.5%)	26 (14.4%)	54 (29.8%)	65 (35.9%)	26 (14.4%)	3.39 (1.07)
Throw opioids away in the trash bin	29 (15.9%)	34 (18.7%)	55 (30.2%)	41 (22.5%)	23 (12.6%)	2.97 (1.25)
Store opioids in bathroom cabinets	21 (11.6%)	65 (35.9%)	61 (33.7%)	21 (11.6%)	13 (7.2%)	2.67 (1.06)
Flush opioids down the bathroom drain	60 (33.0%)	40 (22.0%)	37 (20.3%)	25 (13.7%)	20 (11.0%)	2.48 (1.36)
Return unused opioid medications to the pharmacy	147 (80.8%)	10 (5.5%)	15 (8.2%)	7 (3.8%)	3 (1.6%)	1.40 (0.92)

Likert scales ranged from 1 (not at all) to 5 (extremely).

Education about Opioid Medications

Two questions evaluated the student’s current or potential sources of information about opioid medications to understand how adolescents want to receive opioid educational materials. First, they were asked if they ever used Google or other search engines, newspapers, online videos, educational games, talking with parents, talking to doctors or nurses, or medical journals to find information about opioid medications (yes or no). Next, participants rated five different ways to get educated about opioid medication safety based on helpfulness from “not at all” helpful (1) to “extremely” helpful (5). They rated the helpfulness of instructor led lectures, educational websites, online videos, written information sheets, and educational video games. Means and frequency distributions are reported in Table 4.

Table 4.

Past sources used for information on opioid medications and their perspective on potential sources of opioid education.

Survey Item				n=190
Previous use of sources for information on opioid medications				“Yes” Response n (%)
Google, or other search engines				123 (67.6%)
Talking to your parents				102 (56.7%)
Talking to doctors or nurses				100 (54.9%)
Online videos				77 (42.3%)
Newspapers				35 (19.3%)
Educational games				32 (17.6%)
Medical journals				23 (12.6%)
Survey Item	Not at all	A little	Somewhat	Very	Extremely	Mean (SD)
Potential level of helpfulness for opioid medication education:
Instructor led lectures	15 (8.2%)	44 (24.2%)	50 (27.5%)	59 (32.4%)	14 (7.7%)	3.07 (1.10)
Educational websites	13 (7.1%)	43 (23.6%)	64 (35.2%)	43 (23.6%)	19 (10.4%)	3.07 (1.09)
Online videos	18 (10.1%)	41 (22.9%)	62 (34.6%)	43 (24.0%)	15 (8.4%)	2.98 (1.10)
Written information sheets	27 (15.1%)	65 (36.3%)	52 (29.1%)	29 (16.2%)	13 (7.1%)	2.56 (1.04)
Educational video games	55 (30.2%)	46 (25.3%)	43 (23.6%)	26 (14.3%)	12 (6.6%)	2.42 (1.24)

Slight variations in total sample size occurs between items due to non-responders. Likert scales ranged from 1 (not at all) to 5 (extremely).

Demographics

For the covariates of gender and race, ethnicity, survey participants could select multiple categories. For gender, participants could select from identifying as “male”, “female” or “in another way”. In this paper, “male” is defined as selecting “male” while not selecting other choices, and “female” is defined as selecting “female” while not selecting other choices; “other” was defined as all other combination of choices that occurred. For race, ethnicity, seven different categories were available to select, including “Black or African American,” “Hispanic or Latino,” and “White.” Participants were defined as “Black,” “Hispanic,” or “White,” if they only selected the associated category and no other selection was made; all other combinations were defined as “Other.” Zip codes of the participants’ residencies were used to determine the Rural-Urban Commuting Area (RUCA) 2010 code for their residence. RUCA codes are originally calculated at the census tract level, though a publicly available and government housed aggregation of RUCA codes at the zip code level was used to determine RUCA codes from zip codes.²⁰ Classification is based on population density, urbanization, and commuting flows, ranging from metropolitan and micropolitan to small town and rural areas. Metropolitan areas are described as primary flow to or within an urbanized area, small towns as primary flow to or within an urban cluster of 2,500 to 9,999, and rural areas as primary flow to a tract outside an urbanized area or urban cluster.²⁰

Data analysis

Descriptive statistics were conducted to analyze survey responses. Continuous survey items were reported as mean and standard deviations. Non-responses were not used in the calculations of percentages, means, or standard deviations. Survey responses were compared across different strata of gender, grade, race, ethnicity, and RUCA code. Fisher’s exact tests were used for comparing binary response items (yes or no), and Kruskal-Wallis tests were used for comparing Likert responses. For the five Likert scale questions in the misuse knowledge, misuse behavior, safe storage, and education helpfulness themes, all pairwise differences in responses were assessed using Wilcoxon Signed Rank tests. All statistical significance was assessed at the 5% level. Due to the large number of comparisons, multiple comparison correction using the Benjamini-Hochberg procedure was used, controlling false discovery rate (FDR) at 5% and reported pairwise p-values were unadjusted. Pairwise comparisons that were statistically significant before adjustment were also significant after both within variable and after overall adjustment. All calculations were performed in R 3.6.1.²¹

Results

Demographics

The participants were majority female (53.7%), White (53.2%), and living in a metropolitan area (71.9%). All high school grade levels participated with 16.7% in 9^th grade, 43.9% in 10^th grade, 18.3% in 11^th grade, and 21.1% in 12^th grade. The average student was 16 years old (SD=1.02) living in a household with 2 children under the age of 18 (SD=1.16). See Table 1 for a summary of demographic characteristics.

Table 1.

Participant Demographics

Characteristic	n (%)
Grade
9th	30 (16.7%)
10th	79 (43.9%)
11th	33 (18.3%)
12th	38 (21.1%)
Gender
Female	102 (53.7%)
Male	74 (38.9%)
Other	14 (7.4%)
Race / Ethnicity
White	101 (53.2%)
Black	2 (1.1%)
Hispanic	60 (31.6%)
Other	27 (14.2%)
Household Location
Metropolitan area	128 (71.9%)
Small town	45 (25.3%)
Rural areas	5 (2.8%)
Age
Mean (SD)	16.21 (1.02)
Number of Household Members under 18
Mean (SD)	2.19 (1.16)

Gender identity choices of “male”, “female” and “in another way” were not mutually exclusive in the survey. As such, “male” is defined as selecting “male” while not selecting other choices; “female” is defined as selecting “female” while not selecting other choices; “other” was defined as all other combination of choices that occurred. Race / ethnicity were not mutually exclusive choices between 7 different options. As such, “white”, “black”, and “Hispanic” were defined as selecting only one of those associated options and selecting none of the other 6; “other” was defined as any other combination of selections.

Misuse

The majority of participants identified the following behaviors as misuse: using someone else’s prescription to get opioids for themselves (85.7%), using opioids at a higher dose, or at a higher frequency than prescribed (85.2%), using someone else’s opioid medication (83.5%), and sharing opioid medications with others (83.4%). Additionally, participants also considered using a prescribed opioid after its expiration date to be misuse (67.6%).

Overall, participants rated the degree of harm to one’s mental health as highest (M=4.09, SD=0.96), with a majority (78%) saying it would cause “quite a bit” or “a great deal” of harm. A majority of responders also believed that opioid misuse causes harm to one’s relationships with their family (73%), relationships with their peers or friends (71%), physical health (67.1%), and to one’s ability to do well in school (66.1%). Wilcoxon Signed Rank tests on pairwise comparison indicate adolescents rated harm to mental health significantly higher than harm to relationship with peers or friends (p<0.003), ability to do well in school (p<0.001), and physical health (p<0.001).

In terms of misuse behaviors, on average, most of the participants reported they would be “not at all” likely to do any of the four misuse behaviors (e.g. use someone’s else prescription, offer their opioid to a friend). However, 70.9% of participants reported they would be “very” or “extremely” likely to stop a friend from using a medication for non-medical purposes. Pairwise comparisons showed adolescents were more likely to say they would offer an opioid to a friend than to use an opioid from their grandparent’s house (p<0.001), one found in their house (p<0.001), or one prescribed for a friend (p<0.009).

Comparing responses across strata for the “misuse of opioids” survey items, only race, ethnicity displayed significant differences, and only for the item around if using someone else’s opioid medication is misuse (p=0.002). White and Other students reported considering such behavior as misuse in greater proportion than Hispanic students (91.1% for White, 89.5% for Other, 70.0% for Hispanic).

Safe Management

Regarding safe handling and storage of opioid medications, on average, participants reported it is “somewhat” dangerous to store opioids in dining room or bedroom open cabinet, with 65.7% saying somewhat or very dangerous. Throwing opioids away in the trash bin was reported as “slightly or somewhat” dangerous (48.9%). Participants reported it is “slightly” dangerous to store opioids in bathroom cabinet (35.9%) or flush them down the bathroom drain (22%), and “not at all” dangerous to return unused opioid medications to the pharmacy (80.8%). Pairwise comparisons showed adolescents reported storing opioids in dining room or bedroom open cabinets as more dangerous than throwing them in the trash (p<0.001), storing in bathroom cabinet (p<0.001), or flushing down the drain (p<0.001).

Comparing responses across strata revealed several significant differences. For the item of returning unused opioids to the pharmacy, White students assessed this as less dangerous compared to Hispanic and Other students (p<0.001), though the average responses of all three groups were on the lower end of the Likert scale, with all three means between “not at all” dangerous and “slightly” dangerous. For this same survey item, it appears that students consider returning opioids to the pharmacy as progressively less dangerous as the grade level increases (p=0.023). Similar to the race, ethnicity strata, all the grade level averages were in the “not at all” to “slightly” dangerous Likert scale range. For the “storage and handling” item of throwing opioids away in the trash, Female and Other gender identities considered this behavior more dangerous than Male gender (p=0.001), with the Female and Other averages between “somewhat” and “very” dangerous, while the Male average is between “slightly” and “somewhat” dangerous.

Education about Opioid Medications

The most common source used for finding information about opioids was Google or other search engines (67.6%). Talking with parents was the second most popular source with 56.7% having done so, followed by 54.9% talking with a doctor or nurse and 42.3% using online videos. Participants perceived educational websites, instructor led lectures, and online videos as most helpful for opioid medication education, with 34%, 40.1%, and 32.4% of respective responses indicating these to be either “very” or “extremely” helpful.

Comparing responses across strata for the “sources used” revealed several significant differences. Significant differences between both grade and RUCA strata were observed for Google or other search engine usage for opioid information, where 9^th graders appear to use such search engines less than other grades (43.3% for 9^th grade; 75.9% for 10^th grade, 66.7% for 11^th grade, 71.1% for 12^th grade; p=0.015). Metro RUCA codes used search engines more frequently than rural or small-town codes (75.8% for metro, 60% for rural, 48.9% for small town; p=0.003). For use of medical journals, 12^th graders appear more likely to have used this source than underclassmen (13.3% for 9^th grade, 8.9% for 10^th grade, 6.1% for 11^th grade, 26.3% for 12^th grade; p=0.050). For educational games, Hispanic students had used this source more than White or Other students (30.0% for Hispanic, 10.9% for White, 15.8% for Other; p=0.009). Doctors or nurses as sources were used more by Hispanic and Other students compared to White students (71.7% for Hispanic, 63.2% for Other, 43.6% for White; p=0.002).

Comparing responses across strata for how helpful different forms of opioid education might be, only responses for “instructor led lectures” had significant differences, and only across RUCA strata. Rural students answered less positively towards instructor led lectures than small town or metro students (p=0.017), with the rural mean response between “not at all” and “a little” helpful, while the small town and metro mean responses were just over “somewhat” helpful on the Likert scale.

Discussion

This study is among the first to focus exclusively on adolescent perceptions of opioid medication safety. To the research team’s knowledge, there is no other literature assessing adolescents’ understanding of prescription opioid misuse. Findings demonstrate the need for thorough adolescent opioid education to improve medication safety and decrease opioid misuse rates among teens in the United States. Many adolescents understand what actions and behaviors are regarded as opioid misuse, but there are still several who have an unclear impression of what opioid misuse entails. Adolescents cannot be expected to understand the implications of opioid misuse if they do not have clear foundational knowledge of what constitutes inappropriate use of prescription opioids.

Most adolescents understand that opioid misuse can affect health, relationships, and school performance; however, most perceive the effect on mental health to be highest. This outcome suggests more education is necessary to explain how harmful opioid misuse affects a person’s physical and relational health. In addition, 10% of participants indicated that opioid misuse would only affect their school performance a little or not at all. This could potentially be due to students’ own or friend’s misuse that has not yet affected school ability. Some participants indicated that opioid misuse has no effect on relationships with friends and family, school performance, or mental health. Prior research shows that individuals who are concerned about the dangers of prescription drugs are at a lower risk of misusing them.¹⁰ In order to prevent opioid misuse among adolescents, there is a need to increase the perceived harm of opioid misuse.

The results show that participants predominantly indicated they were not at all likely to engage in behaviors that exhibit opioid misuse. Adolescents are more likely to offer opioids to a friend to relieve pain than to take an opioid offered by a friend to relieve their own pain. Some adolescents may perceive that it is important to “help” their friends by giving them opioids if they are in pain. Most adolescents who misuse opioids get the medication from a friend or relative.¹⁰ It is essential to educate adolescents that by sharing opioids with friends, they could be unintentionally harm their friends rather than helping them relieve their pain. Some participants were not likely to intervene when a friend was misusing an opioid (29% did not respond as being “very” or “extremely” likely to intervene). Adolescents must be taught how to react to these scenarios by exposing them to realistic situations in an educational setting where they have to say no, help a friend, or resist offering a friend opioid medications if they are in pain. In this study, a large majority of adolescents would be not at all likely to use an opioid they find in their own home or their grandparents’ home. This is an important finding because the likelihood of adolescents participating in opioid misuse behaviors depends on their surroundings. Youth who begin substance use at a young age are often pressured by peer culture and have family members affected by substance abuse..²²

More ambivalent survey results came from questions regarding safe handling and storage of opioids. With unsafe storage being more common in households with older children and minimal adult supervision among the majority of high school students who are prescribed medications, it is important to evaluate how adolescents handle these medications.^23–25 Adolescents may perceive that it is less dangerous to store prescription opioids in bathroom cabinets than in dining room or open bedroom cabinets. This could be due to the popularity of storing medications in a bathroom medicine cabinet. Adolescents may also assume it is less dangerous to flush opioids down the bathroom drain than to throw them in the trash bin. Nearly 20% of adolescents perceived danger in returning unused opioids to the pharmacy. Responses to questions about storage and disposal of opioid medications were mostly neutral, indicating that there may be confusion and lack of clarity regarding safe handling and disposal of opioids. These findings align with the literature which states that a majority of post-operative patients do not store or dispose of their opioids properly.²⁶ One potential reason for this lack of clarity is that adolescents are usually not in charge of where their family stores their medications or responsible for disposing unused medications. Adolescents need to be educated on safe handling and disposal of opioids to eliminate the confusion about this topic. Reliable information about safe disposal is difficult to access.²⁷ The variance in adolescents’ perceptions toward opioid medicine disposal could be due to conflicting recommendations on what can be flushed from the Food and Drug Administration and studies regarding environmental impact, adults being unsure of how to dispose of opioids, and minimal educational interventions.^7,27–31 This study’s findings also reflect this result and explain why adolescents might not know how to dispose of their opioids. Access and awareness about safe disposal and handling of opioids must be increased to improve medication safety and reduce harm associated with unused prescription opioids.

Online search engines and talking with parents or medical professionals were the most common sources of information about opioid medications. Adolescents noted that educational websites, online videos, and instructor led lectures may be helpful sources for more information. Validated educational resources are currently available through sources such as National Institute on Drug Abuse and Overdose Prevention and provide lesson plans that teachers can use to educate adolescents on various topics surrounding opioid use and misuse.^2,32,33 Teens are increasingly receptive to medication safety education provided by pharmacists and student pharmacists in school settings.^34,35 One study reported perceived benefits of student-led programs to educate fifth and sixth grade children about safe and responsible use of over-the-counter medications. The program provided experiential opportunities for student pharmacists to practice counseling skills with children regarding safe and appropriate use of medicines.³⁵ Pharmacists and student pharmacists can partner with schools to serve as educators in health classes to provide accurate information about prevention of opioid prescription misuse. These discussions can also focus on the use of naloxone, targeted overdose education, and bystander assistance in overdose situations as solely focusing on misuse prevention is not comprehensive.³⁶ Another access point to educating adolescents is collaborating with school nurses, as many state that students would benefit from additional opioid education.³⁷ Nurses would appreciate more opioid training for themselves, and a strong majority of nurses are interested in pharmacist collaboration to address medication management challenges in school settings.^37,38

Limitations

Several important student demographics were underrepresented in this dataset, including African American and rural students. There were only two African American study participants; hence, statistical comparisons across race and ethnicity strata did not include these two subjects and comparisons across race and ethnicity strata were for “White,” “Hispanic,” and “Other.” Additionally, limited information was collected about the socioeconomic environment of the students’ homes, though collecting such information from the students directly might be unreliable and would potentially require input from the students’ parents or guardians. This was a sample size of 190 students from the same geographical region, which therefore is not representative of the entire nation.

Another limitation of this study is interpretation of how grade or age may or may not be related to the topics addressed by this survey. Since data was collected at a single time point for each individual, we cannot know if any grade or age relations might be the result of actual changes in attitudes, behaviors, and education around opioids as students’ progress through high school. Furthermore, there could be real relationships that are obscured by differential dropout or transfer as well. Thus, future directions include use of the survey instrument in a longitudinal study of student opioid attitudes and behaviors. An additional limitation of the survey is that personal risk-taking behaviors and previous substance misuse were not asked because this was out of the scope of this study.

Conclusion

Adolescents are one of the most at-risk populations for opioid misuse, yet they continue to be overlooked when it comes to opioid medication safety research. Youth perspectives on medication safety are crucial to develop targeted and tailored interventions to promote opioid safety and prevent opioid misuse. Particular attention should be focused on increasing adolescents’ perceived harm of opioid misuse, helping youth empower themselves and their friends to not partake in misuse, and promote safe handling and disposal of opioids. Family, healthcare professionals, teachers, and other community members can play a role in educating adolescents on prescription opioid safety. It is critical to assess and address knowledge gaps of adolescents regarding prescription opioids and consider their preferences for receiving education about medication safety.

Key points.

What was already known:

• Opioid misuse presents a major public health issue in the United States.

• Many adolescents are exposed to prescription opioids and are at an increased risk for initiating substance misuse.

• Adolescents’ perceptions of prescription opioid misuse and preferences for opioid safety education tend to be overlooked in research.

What this study adds:

• Most adolescents perceived actions such as using opioids too frequently or in higher amounts than prescribed to be misuse, though opioid safety knowledge varied across gender, race, ethnicity, grade level, and place of residence.

• Many adolescents did not believe that flushing opioids down the drain was dangerous and were unaware of the dangers of not practicing safe opioid storage and handling practices.

• Adolescents frequently used search engines, parents, doctors and nurses, and online videos as information sources and indicated that instructor-led lectures and online videos would be helpful for learning about prescription opioids.