LM 2 Assignment - Critical Reading

Prescription Opioid Medication Misuse Among University Students

Michael D. Harries, BA, MAT ,1 Katherine Lust, PhD, MPH,2 Gary A. Christenson, MD,2

Sarah A. Redden, BA,1 Jon E. Grant, JD, MPH, MD1 1Department of Psychiatry, Behavioral Neuroscience University of Chicago, Chicago, Illinois 2Boynton Health, University of Minnesota, Minneapolis, Minnesota

Background and Objectives: Prescription opioid misuse is an established problem in the United States. Less information is known regarding the clinical and cognitive characteristics of prescription opioid misusers, specifically in a college age population. This study sought to characterize individuals who misuse prescription opioids and the differences between current, past and non-misusers. Methods: A 156-item survey was administered to over 9,449 university students at a large, public Midwestern university. Survey questions obtained demographic information, self-reported grade point average, sexual behavior, mental health characteristics, and substance use. Participants also completed assessments that asked questions regarding impulsivity, mental health, substance use, and other impulsive behaviors including gambling and sexual activity. 3,522 students completed the survey and were included in the analysis. Results: Of this group, 2.2% reported misusing prescription opioids in the last 12 months and another 5.3% reported misusing prescription opioids previously but not in the past year. This study found prescription opioid misusers to be more likely to live off campus, have a lower GPA, and exhibit increased impulsivity. Prescription opioid misusers were also more likely to report earlier age of sexual activity and were less likely to use barrier protection during sexual activity. Conclusions and Scientific Significance: This study identifies a number of risk factors for thosemisusing prescription opioids that can be used to develop and refine prescription opioid misuse screening tools for university health centers. It also identifies a number of concurring behaviors that can simultaneously be addressed when prescription opioid misusers are identified. (Am J Addict 2018;27:618–624)

INTRODUCTION

The misuse of prescription opioid medication is a growing health issue in the United States. In 2013, approximately 207 million opioid prescriptions were written, an increase from the 76 million opioid prescriptions written in 1991.1 The 2015 National Survey on Drug Use and Health found 91.8 million (37.8%) adults used prescription opioids, with 11.5 million (4.7%) misusing them.2 From 2002 to 2010, the number of admissions to publicly funded substance abuse programs increased from 91,000 to 259,000 for non-heroin opioid abusers, 28% of which were aged 18 to 24.3 The CDC estimates that approximately 115 Americans die every day from opioid overdoses.4

While opioid misuse affects people of all ages, young adults may be particularly vulnerable. The National Survey on Drug Use and Health found approximately 2.5 million (7.3%) young adults aged 18–25 misused pain relievers in 2016.5 The American Society of Addiction Medicine found that four out of every five people who try heroin started with prescription painkillers.6 Another study found that almost 80% of new heroin users reported their initial drug to be a prescribed opioid.7 The lifetime prevalence of college-aged heroin users is estimated to be between 0.3% and 0.8% with over two-thirds of these individuals also misusing prescrip- tion opioids.8,5

Despite the high prevalence of misuse of prescription opioids among young adults, relatively little is known about the associations between opioid misuse, academic perfor- mance, socialization, and impulsivity measures in university settings. Thus, this study sought to examine both the prevalence of the misuse of opioid medications in a university sample, as well as the associated emotional and functional consequences of misuse. Based on the previous literature9–14

we hypothesized that the misuse of opioid medications would be associated with impairments in academic performance; higher rates of other substance problems, depression and anxiety; and elevated questionnaire-measures of impulsivity.

Received March 26, 2018; revised September 17, 2018; accepted September 19, 2018.

Address correspondence to Harries, Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, 5841 S. Maryland Avenue, MC 3077, Chicago, IL 60637. E-mail: [email protected]

The American Journal on Addictions, 27: 618–624, 2018 © 2018 American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/ajad.12807

618

Using this data, university student health centers may be better equipped to address opioid misuse on university campuses.

METHODS

Survey Design The Department of Psychiatry and Behavioral Neuro-

sciences at the University of Chicago and Boynton Health at the University of Minnesota worked in partnership to create and distribute the Health and Addictive Behaviors Survey. The purpose of this survey was to evaluate the mental health and well being of a large sample of university students and included basic demographic questions as well as questions from various validated mental health screening tools. All study procedures were carried out according to the Declaration of Helsinki and were approved by the University of Minnesota Institutional Review Board.

Participants From a pool of approximately 60,000 students at a public,

Midwestern university, a sub-sample of 10,000 college and graduate students were chosen via a random, computer- generated process. The survey was distributed to this subset of students over a 3-week period during the fall of 2016. Surveys were distributed via email and completed online. Of the 10,000 surveys distributed, 9,449 (94.5%) were successfully received and 3,659 (38.7%) were completed. Before beginning the survey, respondents were required to view the IRB-approved online informed consent page. Once complete, they were allowed to proceed with the survey and were made aware that all information gathered would be both anonymous and confidential. Those who reviewed the survey in full (participants were not required to answer every question due to the sensitive nature of some questions) were entered into a randomly selected drawing for compensation. Four winners received a $250 gift certificate to an online retailer, three winners received tablet computers, two winners received a $500 gift certificate to an online retailer and one winner received a $1000 gift certificate to an online retailer.

Assessments The survey included 156 questions and took approxi-

mately 30 minutes to complete. Individuals were grouped into “current” opioid pain medication misuse if they reported misusing in the last 12 months, those who misused prescription opioid medication previously, but not in last 12 months, were labeled as past prescription opioid medication misusers. Those who never misused prescription opioid medication comprised the third category. Demographic information was obtained in addition to questions pertaining to self-reported grade point average, sexual behavior, mental health character- istics, and substance use. Participants also completed the following assessments:

Barratt Impulsiveness Scale (BIS-11) This 30-item questionnaire assesses impulsivity across

three areas: attentional, motor and non-planning. A higher scores signifies increased impulsivity.15

Minnesota Impulsive Disorders Interview (MIDI) The questions included in this interview assess for a variety

of impulse control disorders, including gambling disorder, and binge eating disorder.16

Alcohol Use Disorders Identification Test (AUDIT) This 10-item questionnaire examines alcohol use behaviors

and related problems. A score of eight or greater indicates harmful alcohol use.17

Patient Health Questionnaire (PHQ-9) This 9-item questionnaire examines depressive systems

based directly on DSM-IV criteria for major depressive disorder.18

Generalized Anxiety Disorder 7 (GAD-7) This seven-item questionnaire screens for generalized

anxiety disorder (GAD). Total scores >10 signify clinically significant anxiety.19

Adult ADHD Self-Report Scale (ASRS-v1.1) This six-item questionnaire screens for attention deficit/

hyperactivity disorder (ADHD).20

Data Analysis This analysis included the individuals who answered

questions regarding prescription opioid medication misuse (3,522%, 96.3% of respondents). Prescription opioid medication misusers were grouped a priori into current, past or non-misusers. Categorical variables were assessed using Pearson’s chi-squared test. Continuous variables were assessed using ANOVA. Effect size was determined using Cramer’s V score. All statistical analyses were obtained using SPSS (version 24). Statistical significance was defined as p < .05.

RESULTS

Of the 3,522 individuals who completed the prescription opioid medication misuse question, 77 (2.2%) endorsed currently misusing prescription opioid medication, 186 (5.3%) endorsed misusing these medications in the past, and 3,259 (92.5%) said they have never misused these medications. Demographic variables for the three groups are presented in Table 1. Those who currently misused prescription opioid medication were more likely to be female (55.8%). Those who misused prescription pain medications in the past were slightly more likely to be male (51.1%). Students who were enrolled part-time, who had a self-reported GPA less than 3.0, or lived off campus were

Harries et al. December 2018 619

more likely to be current or past prescription pain medication misusers (p ¼ .001, p ¼ .001, p < .001 respectively).

Students who currently or previously misused prescription opioid medications were more likely to also currently use or previously have used heroin and other opioids (p < .001), to report problems with alcohol (ie, score 8 or higher on the AUDIT, p < .001) and report gambling (p < .001) (See Table 2).

In addition to other potentially addictive problems, current and past misusers were significantly more like to report symptoms of PTSD (p < .001), anxiety (p < .001), ADHD (p < .001) and depression (p ¼ .001) but not binge eating. Current and past users were also more likely to score high on a scale of impulsivity (BIS-11), report earlier age of first sexual behavior, and used a physical barrier during sexual activity less frequently (all p < .001). Results are shown in Table 2.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

A number of novel relationships between opioid misuse and impulsivity were identified in this study. From a public health perspective, we observed a strong association between misuse of prescription opioids, earlier first sexual experience,

greater likelihood of being currently sexually active and decreased likelihood of using a physical barrier during sexual activity. A recent study showed that individuals who engage in sexual activity at a younger age were more likely to engage in poorer decision-making,21 and the current data reflects perhaps a complex relationship between sexual behavior, drug misuse, and decision-making. Similarly, those who misused prescription opioids were more likely to gamble and have a gambling disorder. While the temporality of prescrip- tion opioid misuse and gambling activity is unknown, previous studies have also shown that gambling in a college student population to be associated with impulsive behavior.22 A similar relationship was found to exist between opioid misuse and alcohol as 70.1% of current prescription opioid medica- tion misusers and 58.1% of past misusers scored an eight or higher on the AUDIT, signifying problematic alcohol use, compared to 21.7% of non-misusers. Taken together, these findings suggest a more global impulsive nature in young adults who misuse prescription opioids (evidenced in part by higher BIS-11 scores also observed). The level of impulsivity among prescription pain medication misusers seemed to lie on a continuum: current misusers scored the highest on the BIS (67.79) compared to past misusers (63.41) and non-misusers (59.02). Engagement in gambling followed a similar pattern, 22.9%, 14.8%, and 8.2%, in the same respective order. Whether opioid misuse results in these other unhealthy

TABLE 1. Demographic information of university students who misuse prescription opioid medications

Variable

Students who currently misuse prescription opioid medication (n ¼ 77)

Students who have misused prescription

opioid medication in the past (n ¼ 186)

Students who have never misused

prescription opioid medication (n ¼ 3259)

Likelihood ratio x2

(�Pearson’s x2) p-value

Effect size

Cramer’s V

Sex, female, n (%) 43 (55.8) 91 (48.9) 1900 (58.3) 26.45 df ¼ 6 .000 .074 Year in college, n (%)

• Undergraduate 57 (74.0) 121 (65.1) 2139 (65.6) 3.194 df ¼ 4 .526 .019 • Graduate 20 (26.0) 64 (34.4) 1101 (33.8) • Non-degree 0 (.0) 1 (.5) 19 (.6)

Full time student, n (%)

69 (89.6) 159 (85.5) 3017 (92.6) 13.206�

df ¼ 2 .001 .061

GPA, n (%) • Less than 3.00 13 (16.9) 32 (17.2) 317 (9.9) 13.757�

df ¼ 2 .001 .063

• 3.00 or higher 64 (83.1) 154 (82.8) 2901 (90.1) Involved in a

fraternity or sorority, n (%) YES

9 (12.0) 15 (8.1) 354 (10.9) 1.571� df ¼ 2 .456 .021

Living arrangements, n (%) • Residence hall 11 (14.7) 13 (7.0) 633 (19.4) 26.857 df ¼ 4 .000 .054 • Fraternity or sorority house

0 (0.0) 5 (2.7) 79 (2.4)

• Off campus 64 (85.3) 168 (90.3) 2544 (78.1)

All numbers are n (%) unless otherwise stated.

620 Prescription Opioid Medication Misuse December 2018

TABLE 2. Clinical and cognitive characteristics of university students who misuse prescription opioid pain medications

Variable

Students who currently misuse prescription opioid medication (n ¼ 77)

Students who have misused prescription opioid medication in the past (n ¼ 186)

Students who have never misused

prescription opioid medication (n ¼ 3259)

Likelihood ratio x2 (�Pearson’s

x2) p-value

Effect size

Cramer’s V

Heroin, other opiates • Never 61 (79.2) 160 (86.0) 3246 (99.7) 190.915 df ¼ 8 .000 .266 • In past, not within past 12 months

10 (13.0) 23 (12.4) 4 (.1)

• Rarely 2 (2.6) 2 (1.1) 2 (0.1) • Occasionally 1 (1.3) 1 (0.5) 1 (.0) • Daily 3 (3.9) 0 (.0) 2 (.1) • BIS Total Mean (SD)

67.79 (11.4)a 63.41 (10.3)a 59.02 (10.0)a F (2,3181) ¼ 39.110 .000 .486

Gambles • Yes 16 (22.9) 27 (14.8) 258 (8.2) 26.687� df ¼ 2 .000 .089

Gambling disorder? • Positive screen 4 (5.7) 2 (1.1) 8 (.3) 17.454 df ¼ 2 .000 .124

Binge eating disorder? • Positive screen 3 (4.3) 5 (2.7) 75 (2.4) 0.929 df ¼ 2 .628 .018

Has been treated for drug/alcohol abuse • Yes 5 (6.8) 21 (11.5) 35 (1.1) 60.667 df ¼ 2 .000 .185

AUDIT Total • Score <8 23 (29.9) 78 (41.9) 2546 (78.3) 212.437� df ¼ 2 .000 .246 • Score 8 or higher

54 (70.1) 108 (58.1) 706 (21.7)

Has been treated for psychological/emotional problems • Yes 47 (65.3) 89 (48.6) 888 (27.9) 80.007� df ¼ 2 .000 .153

Currently taking prescribed mental health medication(s) • Yes 34 (47.2) 47 (25.7) 391 (12.3) 96.050� df ¼ 2 .000 .167

Has used drugs in order to lose weight • Yes 17 (35.4) 23 (21.3) 95 (6.5) 51.775 df ¼ 2 .000 .217

PHQ-9 Total • Score of less than 10

58 (84.1) 169 (93.9) 2989 (95.8) 14.510 df ¼ 2 .001 .081

• Score of 10 or more

11 (15.9) 11 (6.1) 132 (4.2)

PTSD • Positive screen 31 (44.9) 36 (19.7) 423 (13.4) 58.730� df ¼ 2 .000 .131

Anxiety total Grouped • No Anxiety (score 0–4)

15 (21.4) 81 (44.5) 1851 (59.8) 61.983 df ¼ 6 .000 .100

• Mild (score 5– 9)

25 (35.7) 58 (31.9) 725 (23.4)

• Moderate (score 10–14)

15 (21.4) 26 (14.3) 330 (10.7)

• Severe (score 15–21)

15 (21.4) 17 (9.3) 191 (6.2)

(Continued)

Harries et al. December 2018 621

behaviors (eg, opioid misuse makes a person gamble more), is itself a result of one or more of these other behaviors (ie, alcohol use disinhibits and leads top misuse of opioid), or is driven by a deeper underlying cognitive/physiological mechanism (eg, impulsivity as seen on the BIS-11) cannot be determined given the cross-sectional nature of these data. One study found that the administration of oxycodone to a group of healthy volunteers did not affect impulsivity.23

Another identified that individuals who react impulsively to negative mood states and craving may be more likely to develop misuse when taking prescription opioids.24 Cognitive, personality, and imaging research is needed to better understand these associations.

Differences between groups also existed prominently when examining the mental health of respondents. Previous studies have identified a number of relationships between mental health disorders and prescription opioid use including bipolar disorder, post-traumatic stress disorder (PTSD), panic and depressive symptoms.11,25–27

In addition to supporting these existing data, this study provides a more nuanced look at this relationship: current prescription opioid medication misusers were more likely than past misusers, who were more likely than

non-misusers, to report more depressive symptoms (as measured by the PHQ-9), to screen positive for PTSD, to endorse more symptoms of anxiety, to screen positive for ADHD, and to be either currently taking prescribed mental health medications or to have been treated for psycholog- ical/emotional problems in the past. This relationship between groups is similar to the one established previously with impulsivity, suggesting again that there may be intrinsic differences in the individuals that comprise each of the three groups. These data carry implications for providers: known current prescription opioid misusers should be screened for comorbid mental health illness.

There are limitations to this study. First, temporality is unknown; the survey administration method did not gather data on when current or past prescription opioid medication misuse began relative to the other questions asked. For example, it cannot be concluded whether prescription opioid medication misuse drove anxious symptomology, or if the reverse relationship is true. Second, this study did not analyze differences between those who use daily, occasionally or rarely. There may be differences in these subgroups that this study is unable to illuminate. Third, while the study population

TABLE 2. Continued

Variable

Students who currently misuse prescription opioid medication (n ¼ 77)

Students who have misused prescription opioid medication in the past (n ¼ 186)

Students who have never misused

prescription opioid medication (n ¼ 3259)

Likelihood ratio x2 (�Pearson’s

x2) p-value

Effect size

Cramer’s V

ADHD • Positive screen 30 (44.1) 45 (24.7) 515 (16.5) 41.836� df ¼ 2 .000 .112

Has been sexually active • Yes 72 (94.7) 179 (96.8) 2295 (71.1) 77.074� df ¼ 2 .000 .149 • No 4 (5.3) 6 (3.2) 933 (28.9)

Age at first sexual activity with another • <11 years 1 (1.4) 4 (2.2) 16 (.7) 103.607 df ¼ 8 .000 .154 • 12–14 years 16 (22.2) 30 (16.8) 109 (4.8) • 15–17 years 38 (52.8) 96 (53.6) 928 (40.5) • 18–20 years 15 (20.8) 40 (22.3) 929 (40.6) • 21 years or older

2 (2.8) 9 (5.0) 308 (13.4)

Frequency of physical barrier use • <50% of the time

31 (43.1) 85 (47.5) 865 (37.8) 24.283� df ¼ 6 .000 .069

• 50–75% of the time

10 (13.9) 20 (11.2) 203 (8.9)

• 76–95% of the time

18 (25.0) 30 (16.8) 370 (16.2)

• 96–100% of the time

13 (18.1) 44 (24.6) 850 (37.2)

a b: Post Hoc Bonferroni Test for Significance: The mean difference is significant at the .05 level.

622 Prescription Opioid Medication Misuse December 2018

comes from a large, public, mid-western university, there always exists some degree of selection bias based off the relative homogeneity of the geographical area and the type of student such a university draws. As shown in previous studies, a sample drawn from a private, religiously affiliated school may present differently.28 Finally, apart from the clinical scales used in this study, the demographic and substance use variables are all self-reported values.

Despite these limitations, this study provides a wealth of data that both supports the existing literature and provides additional insight into potential interventions that university student health systems can undertake to better prevent, identify and treat prescription pain medication misusers. This study identified those who live off-camps and have low GPAs to be risk factors. This was supported by previous studies.29,30 Additionally, individuals identified as prescription opioid medication misusers should be screened for comorbid substance use, specifically alcohol as over 70% of current users were found to use alcohol in a concerning manner. They should also be screened for mental health disorders, specifically including PTSD, anxiety, depression and ADHD as the prevalence of these disorders was increased in individuals misusing prescription opioids. The reverse should also occur: those with a current or past medical history of psychiatric disorders should be screened for prescription pain medication misuse. Other studies found similar connections.9,10,14 While success rates vary for its specific use, cognitive behavioral therapy has shown to be efficacious as a treatment modality for substance use disorders as well as mental health disorders.31 Therefore, while specific medical therapy may be needed in severe cases of prescription opioid misuse, university student health centers may be able to provide therapy that addresses not only anxious or depressive symptoms, but also comorbid prescription opioid misuse. Additional studies have suggested that primary care providers receive increased training on addiction and pain management and that combined therapy including both medication (metha- done, buprenorphine, naltrexone) and psychosocial ther- apy can be efficacious for opioid addiction.32,33 Finally, the finding that prescription opioid misusers are not only more likely to engage in sexual activity with another at a younger age, but also are less likely to use barrier protection carries additional opportunities for provider intervention. Individuals screening positive for opioid misuse should be given additional education regarding the habits of safe-sex practices and should be provided with contraception when available.

While this study seeks to better identify the characteristics of individuals engaging in prescription opioid medication misuse, additional research is needed to better understand this behavior. Future studies should seek to continue illuminating the causative factors driving individuals to engage in prescription opioid medication misuse.

Funding for this study came from internal sources. No funding source had any involvement in the conduct of the research and/or preparation of the manuscript.

Declaration of Interest Mr. Michael Harries has no disclosures to report. Dr. Lust

has no disclosures to report. Dr. Christenson has no disclosures to report. Ms. Sarah Redden has no disclosures to report. Grant has received research grants from NIAAA, National Center for Responsible Gaming, Brainsway, AFSP, TLC Foundation, and Takeda Pharmaceuticals Dr. Grant receives yearly compensation from Springer Publishing for acting as Editor-in-Chief of the Journal of Gambling Studies and has received royalties from Oxford University Press, American Psychiatric Publishing, Inc., Norton Press, and McGraw Hill.

AUTHORS’ CONTRIBUTION

MH was the primary composer of the manuscript. KL assisted in data collection and analysis and provided edits to the manuscript. GC assisted in data collection and provided important edits to the manuscript. SR assisted in drafting the manuscript and provided edits. JG assisted in the initial draft of the manuscript and provided edits as well.

REFERENCES

1. Volkow ND. “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.” Witness appearing before the Senate Caucus on International Narcotics Control. 14 May 2014.

2. Han B, Compton WM, Blanco C, et al. Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. 2017;167:293–301.

3. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of national findings. NSDUH Series H-44. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2012.

4. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2017.

5. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17–5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2017.

6. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. 2013;132:95–100.

7. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2016;372:241–248.

8. Schulenberg JE, Johnston LD, O’Malley PM, et al. Monitoring the Future national survey results on drug use, 1975–2016: Volume II, college students and adults ages 19–55. Ann Arbor: Institute for Social Research, The University of Michigan, 445. 2017.

9. Brady JE, Giglio R, Keyes KM, et al. Risk markers for fatal and non-fatal prescription drug overdose: A meta-analysis. Inj Epidemiol. 2017;4:24.

Harries et al. December 2018 623

10. Elzey MJ, Barden SM, Edwards ES. Patient characteristics and outcomes in unintentional, non-fatal prescription opioid overdoses: A systematic review. Pain Physician. 2016;19:215–228.

11. Zullig KJ, Divin AL. The association between non-medical prescription drug use, depressive symptoms, and suicidality among college students. Addict Behav. 2012;37:890–899.

12. Becker WC, Sullivan LE, Tetrault JM, et al. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: Psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2008;94: 38–47.

13. Baldacchino A, Balfour DJ, Matthew K. Impulsivity and opioid drugs: Differential effects of heroin, methadone and prescribed analgesic medication. Psychol Med. 2015;45:1167–1179.

14. Michna E, Ross EL, Hynes WL, et al. Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. J Pain Symptom Manage. 2004;28:250–258.

15. Stanford MS, Mathias CW, Dougherty DM, et al. Fifty years of the Barratt impulsiveness scale: An update and review. Personal Individ Differ. 2009;47:385–395.

16. Grant JE. Impulse control disorders: A Clinician’s guide to understanding and treating behavioral addictions. New York: WW Norton and Company; 2008.

17. Saunders JB, Aasland OG, Babor TF, et al. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol Consumption–II. Addict Abingdon Engl 1993;88:791–804.

18. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613.

19. Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006;166:1092–1097.

20. Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): A short screening scale for use in the general population. Psychol Med. 2005;35:245–256.

21. Harries MD, Paglia H, Redden SA, et al. Clinical and cognitive differences in those who voluntarily engage in sexual activity at younger ages. Annals of Clinical Psychiatry 2018;30:102–112.

22. Grant JE, Lust K, Christenson GA, et al. Gambling and its clinical correlates in university students. Int J psychiatry Clin Pract. 2018;9: 1–7.

23. Zacny JP, de Wit H. The prescription opioid, oxycodone, does not alter behavioral measures of impulsivity in healthy volunteers. Pharmacol Biochem Behav. 2009;94:108–113.

24. Vest N, Reynolds CJ, Tragesser SL. Impulsivity and risk for prescription opioid misuse in a chronic pain patient sample. Addict Behav. 2016;60:184–190.

25. Tragesser SL, Jones RE, Robinson RJ, et al. Borderline personality disorder features and risk for prescription opioid use disorders. J Pers Disord. 2013;27:427–441.

26. Mackesy-Amiti ME, Donenberg GR, Ouellet LJ. Prescription opioid misuse and mental health among young injection drug users. Am J Drug Alcohol Abuse. 2015;41:100–106.

27. Tetrault JM, Desai RA, Becker WC, et al. Gender and non-medical use of prescription opioids: Results from a national US survey. Addiction. 2008;103:258–268.

28. McCabe SE, West BT, Teter CJ, et al. Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 20013-2013: Connecting the dots. Addict Behav. 2014;39: 1176–1182.

29. Gallucci AR, Wynveen C, Hackman C, et al. An examination of the situational factors associated with the misuse of prescription analgesics among college students. J Drug Educ. 2014;44:116–136.

30. Garnier LM, Arria AM, Calderia KM, et al. Nonmedical prescription analgesic use and concurrent alcohol consumption among college students. Am J Drug Alcohol Abuse 2009;35:334–338.

31. Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognit Ther Res. 2012;36: 427–440.

32. Kennedy-Hendricks A, Busch SH, McGinty EE, et al. Primary care physicians’ perspectives on the prescription opioid epidemic. Drug Alcohol Depend. 2016;165:61–70.

33. Dugosh K, Abraham A, Seymour B, et al. Systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. J Addict Med 2016;10:93–103.

624 Prescription Opioid Medication Misuse December 2018

Copyright of American Journal on Addictions is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.