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Current Drug Abuse Reviews, 2008, 1, 255-262 255
1874-4737/08 $55.00+.00 © 2008 Bentham Science Publishers Ltd.
What Constitutes Prescription Drug Misuse? Problems and Pitfalls of
Current Conceptualizations
Sean P. Barrett*,1,2, Jessica R. Meisner1 and Sherry H. Stewart1,2
Departments of 1Psychology and 2Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
Abstract: Many medications with sedative, anxiolytic, analgesic, or stimulant properties have the potential to be inappro-
priately used. However, because these substances have beneficial effects, many issues pertinent to understanding prescrip-
tion drug misuse may differ from those associated with other misused substances. There is currently a lack of consensus
about what constitutes prescription misuse and a wide range of operational criteria have been proposed. Inappropriate
medication use is frequently defined on the basis of user characteristics (i.e. any non-prescribed use), the reason for use
(i.e. use for recreational purposes), the presence of clinically significant symptoms (i.e. meeting diagnostic criteria for
abuse and dependence) or on the presence of any of these factors. In cases where multiple criteria are used to define mis-
use there is often a lack of differentiation among them, while studies that use more specific criteria tend to exclude certain
types of misuse from consideration altogether. In addition, in some cases there are a number of potential ways that a sin-
gle operational criterion can be met and many of these may be associated with substantially different risks, harms, and
predictors. Due to considerable variability in the classification of medication misuse both within and between studies, it is
currently difficult to interpret the clinical significance of existing findings or to determine the true magnitude of problems
associated with any particular form of misuse. In the present review many of the problems and challenges for adequately
defining prescription drug misuse will be overviewed and recommendations will be made on how to better characterize
this phenomenon.
Keywords: Prescription drug misuse, drug dependence, addiction, drug abuse.
INTRODUCTION AND OVERVIEW
The inappropriate use of prescription medications is an
issue of increasing concern [1-4]. Many psychiatric medica-
tions with sedative, anxiolytic, analgesic, or stimulant prop-
erties have the potential to be misused and the inappropriate
use of such medications has been linked to a number of seri-
ous adverse outcomes (e.g. [5-7]). While demand for, and
availability of, such medications have been rising steadily in
recent years, so too have documented cases of their non-
sanctioned use (e.g. [8, 9]). Despite this, prescription medi-
cation misuse remains poorly characterized and understood.
Because these drugs have legitimate therapeutic benefits in
addition to their potential problematic properties, many is-
sues pertinent to defining and characterising their inappro-
priate use may not be adequately addressed by frameworks
that have been developed to describe the use and misuse of
alcohol and illicit substances.
Currently, there is no universally-accepted standard for
what constitutes prescription medication misuse, and a wide
range of operational criteria have been used throughout the
literature. Prescription misuse has been variously defined in
terms prescription status (e.g. any medication uses that occur
without a prescription) [10-22], reasons for use (e.g. any
intentional uses for intoxicating and/or euphoric effects) [8,
12, 16, 19, 23-26], the presence or absence of symptoms of
abuse or dependence [27-31], or some combination of these
factors [8-9, 32-45]. Often in cases where multiple criteria
*Address correspondence to this author at the Department of Psychology,
Dalhousie University, Halifax, Nova Scotia Canada, B3H 4J1; Tel: 902-
494-2956; Fax: 902-494-6585;
E-mail: sean.barrett@dal.ca
are used, there is a lack of differentiation among them (e.g.,
statistics are given for the broad category of prescription
drug misuse while failing to report [or often to even meas-
ure] how many individuals were so categorized according to
each criterion employed). In contrast, studies that use more
specific criteria tend to exclude certain types of misuse from
consideration altogether. Matters are further complicated by
the fact that often a single criterion will encompass several
behaviours and/or patterns of use that may be associated
with substantially different risks and harms and fail to dis-
tinguish among them. For example, there are numerous po-
tential ways that a medication can be used without a pre-
scription (e.g. use for therapeutic benefits vs use for intoxi-
cating properties), for its intoxicating effects (different pat-
terns and routes of administration), or that an individual can
become dependent on a medication (e.g. using medication as
prescribed for extended periods vs substituting medication
for an illicit substance with similar pharmacologic proper-
ties). Due to the heterogeneity in individuals classified as
‘misusers’, both within and between studies, it is often diffi-
cult to interpret the clinical significance of existing findings
or to determine the true magnitude of problems associated
with any particular form of inappropriate medication use.
The primary purpose of this paper is to overview the
problems and challenges for defining prescription drug mis-
use. Emphasis is placed on difficulties posed by various con-
ceptualizations commonly found in the scientific literature
(i.e. any non-prescribed use; recreational use; meeting diag-
nostic criteria for a substance use disorder; and the criteria
used by the American National Survey on Drug Use and
Health [A-NSDUH] [9]; a summary operational definitions
used in the literature is presented in Table 1). Because there
is often a lack of consistency and precision in the terminol-
256 Current Drug Abuse Reviews, 2008, Vol. 1, No. 3 Barrett et al.
ogy used to describe inappropriate medication use, it is not
always possible to coherently compare results from studies
using their original language. In the present paper we will
address past research on the basis of how medication misuse
is operationalized rather than on the original terminology
used. Throughout the paper, the terms “misuse” and “inap-
propriate use” will be used interchangeably to refer to the
various forms of non-sanctioned or illegitimate prescription
medication uses reported irrespective of how the terms are
used in the literature cited. In addition, unless otherwise
specified, the terms ‘abuse’ and ‘dependence’ will be strictly
used in adherence to the Diagnostic and Statistical Manual
of Mental Disorders - Fourth Edition (DSM IV) [45] sub-
stance use disorder categories.
NON-PRESCRIBED MEDICATION USE
Prescription drug misuse has often been defined in terms
of ‘any use of a target medication with-out a prescription’
[10-22]. Such definitions have been extensively used in sur-
vey research (e.g. [17]), perhaps in part, because the criterion
is relatively straightforward and amenable to dichotomous
classification. By definition, all non-prescribed uses of
medications that require prescriptions are unsanctioned and
thus constitute forms of inappropriate use. However, such
conceptualizations of misuse exclude from consideration
individuals that inappropriately use their own prescriptions
(e.g. use of higher than recommended doses; recreation use)
as well as those who have prescriptions for illegitimate rea-
sons (e.g. procurement of a prescription to divert or for rec-
reational purposes). Because evidence suggests that pre-
scribed users may represent a significant proportion of cases
of medication misuse [24, 25], the generalizability of find-
ings specific to non-prescribed users might be questioned.
Motives for Non-Prescribed Medication Use
In addition, a growing body of evidence suggests that
‘non-prescribed’ medication use can involve a wide-range of
behaviors and motives that might be associated with very
distinct user characteristics and risks [12, 14, 16, 19, 23, 35,
36, 41, 43]. For example, non-prescribed uses of the same
medication might include very hazardous uses for intoxicat-
ing purposes (e.g. use of high doses intravenously and in
combination with alcohol or other drugs) as well as thera-
peutic use for a bona fide condition outside of a physician’s
supervision (e.g. taking a single therapeutic oral dose of a
friend or relative’s medication to treat symptoms for which
the prescription is normally indicated). While each of these
forms of misuse may be of clinical interest, they likely pose
very different risks and have very different associated fea-
tures. Because most studies that define prescription drug
misuse in terms of ‘non-prescribed use’ only report on over-
all rates of ‘misuse’ without any attempt to separate different
possible motives for use, the results of such studies may give
misleading impressions about the prevalence of the problem.
Although very few studies have attempted to distinguish
among different non-prescribed use motives, the evidence
that does exist suggests that at least among university and
college students, the most commonly endorsed reasons for
the non-prescribed use of stimulants [12, 14] and opiate an-
algesics [19], are related to the medication’s therapeutic
benefits (i.e. to improve concentration for stimulants; to help
relieve pain for analgesics). A recent study using an adoles-
cent sample found that endorsed motives for non-prescribed
use tended to vary by class of medication. For example while
motives for non-prescribed sedative and analgesic use tended
to be associated with the medication’s therapeutic effects
(i.e., to help with sleep; to reduce pain), non-prescribed use
of stimulant medications was more likely to be associated
with recreational motives (i.e., to get high) [35]. It is impor-
tant to note that non-prescribed use with therapeutic inten-
tions may be problematic since it is not medically super-
vised, and often a diagnosis has not been made to support the
particular treatment being administered. However, it likely
does not yield the same level of risk as many forms of inap-
propriate recreational medication uses (discussed in detail in
the ‘recreational use’ section below).
There are numerous potential quasi-legitimate reasons
why an individual might chose to illicitly seek a prescription
medication for its therapeutic benefits. For example, in some
cases the medication may be sought from a friend or relative
with a prescription for an immediate or acute need when it is
not be feasible to seek a formal medical consultation. In
other cases, medications may be illicitly procured due to
socio-economic, geographic, or temporal barriers to access to
the medical system or to a reluctance of physicians to pre-
scribe the most efficacious medications on the grounds that
they have been identified as having the potential to be mis-
used (e.g. [46]).
In cases where the medication has a wide margin of
safety and is used as it would be if it were to be prescribed,
the actual risks and harms associated with non-prescribed
use are often likely no greater than with the legitimate use of
the medication. On the other hand, the non-prescribed thera-
peutic use of a medication in the absence of doctor’s pre-
scription might be extremely risky, especially in circum-
stances where there is a lack of knowledge of appropriate
dosing, potential side-effects and/or interactions, as well as
precautions for use. Ironically, in contrast to medication that
is used for intoxicating purposes, this form of medication
‘misuse’ often may stem from a propensity to under-
medicate certain individuals or conditions with medications
that have identified as having a potential for misuse. Such
misuse would be expected to decrease if there was increased
access to legitimate sources of medication. Because different
non-prescribed medication uses may have opposing implica-
tions for policy, prevention, and treatment, it is important
that investigations using ‘any non-prescribed use’ as a crite-
rion for defining ‘misuse’, begin to systematically identify
how non-prescribed medications are being used as well as
unique characteristics and features associated with different
motives for non-prescribed use.
RECREATIONAL USE
An alternative to defining prescription drug misuse on
the basis of prescription status has been to define it on the
basis of its deliberate use for recreational purposes in order
to achieve intoxicating or euphoric psychoactive effects,
irrespective of prescription status (e.g. [23-26]). This con-
ceptualisation of prescription drug misuse is akin to the use
of illicit substances and is how the issue of prescription mis-
use is often portrayed by the media. Moreover, because
many forms of recreational use have also been associated
with serious adverse outcomes (i.e. overdose, development
What Constitutes Prescription Drug Misuse? Current Drug Abuse Reviews, 2008, Vol. 1, No. 3 257
of symptoms of abuse or dependence), it has also garnered
considerable clinical interest [30, 32]. Unfortunately, how-
ever, there is no single universally-accepted means of assess-
ing the use of prescription medications for recreational pur-
poses developed to date. Instead, there is considerable varia-
tion in the operational criteria used throughout the literature
as well as inconsistencies in the terminology used to describe
the phenomenon (e.g. the term ‘abuse’ is often used to refer
to any recreational use of a medication (e.g. [10, 29]), but is
also sometimes used specifically in reference to DSM diag-
nostic criteria (e.g. [8, 32, 48]). To complicate matters fur-
ther, it is not uncommon for findings to be discussed in terms
of recreational use when they are based on operational defi-
nitions that are not specific to this form of misuse (i.e. infer-
ring recreational use from broad operational definitions of
misuse that encompass various forms of prescribed and non-
prescribed medication use).
Table 1. Varied Operational Definitions for Prescription Drug Misuse
Operational Definitions Ref.
Non-prescribed use (use without having a doctor’s prescription for the medication) Teter et al. (2005) [12]
Teter et al. (2003) [15]
Low & Gendasezek (2002) [16]
McCabe et al. (2004) [20]
McCabe et al. (2005) [13]
McCabe et al. (2007) [19]
Boyd et al. (2006) [35]
Kaloyanides et al. (2007) [10]
McCabe (2005) [18]
Poulin (2001) [11]
NSDUH criteria: Use of any form of prescription drugs that were not prescribed for the respondent or that the
respondent took only for the experience of feeling they caused (SAMSHA, 2006 [9]). DSM IV criteria for
abuse and dependence are also assessed.
Kroutil et al. (2006) [8]
Sung et al. (2005) [37]
Wu et al. (2007) [38]
Becker et al. (2007) [32]
Smith & Woody (2005) [34]
Arria et al. In press [45]
Meeting DSM-IV criteria for abuse and/or dependence. Simoni-Wastila & Strickler, (2005) [27]
O’Brien (2005) [29]
“How often do you use stimulant medications in ways not prescribed? “ White et al. (2006) [14]
“Individuals were asked whether they had ever used a sedative on their own, without having been prescribed
one or if they had used more than the amount prescribed by the physician.” Goodwin & Hasin (2002) [33]
“…without a prescription, in greater amounts, more often, or longer than prescribed, or for a reason other than
a doctor said you should use them.” Blanco et al. (2007) [30]
“…when you are prescribed a drug by a doctor for a specific condition, but then use the drug in a way that is
not consistent with the doctor's orders, like using too much or too frequently... when you do not have a
prescription, but obtain the drug from someone else…”
Arria et al. (2008) [44]
“…life-time non-medical use of prescription drugs that were not prescribed to them by a doctor or used in a
manner not intended by the prescribing clinician (e.g. more often than prescribed, longer than prescribed or for
a reason other than prescribed, such as to get high).”
McCabe et al. (2007) [42]
“Nonmedical use, prescription drug abuse, and/ or illicit use of prescription medications (drugs) is defined as
‘the use of prescription medication to create an altered state, to ‘get high,’ or for reasons (or by people) other
than those (or for whom) intended by the prescribing clinician.’ Medical misuse and/or non-compliant use is
defined as ‘the use of a prescribed medication by a person (and for the purpose) intended by the prescribing
clinician’; however, in the case of misuse (unlike medical use), the medication is not used in the prescribed
dose and/or is not taken within a prescribed time interval”
Boyd et al. (2006) [35]
“…lifetime use it in a way that was not prescribed…” Darredeau et al. (2007) [24]
“(1) Have you sold your prescribed medication?
(2) Have you used too much of your medication? (3) Have you gotten high on your medication? (4) Have you
misused your medication? (5) Have you skipped your medication to use alcohol or drugs? (6) Have you used
your medication with alcohol or drugs? (7) Have you experienced a reaction with your medication and alcohol
or drugs?”
Wilens et al. (2006) [25]
“use of any personal prescription medication used other than as prescribed by dose, frequency or route or the
use of someone else’s prescribed medication in any way.” Marsh et al. (2000) [39]
Concomitant use of methylphenidate with alcohol. Barrett & Phil (2002) [26]
Any recreational or non-prescribed use. Barrett et al. (2005) [23]
“Have you ever taken Ritalin for fun?” Babcock & Byrne (2000) [52]
Any non-medical use, including prescribed use. Davis & Johnson (2008) [41]
Unspecified or unclear. Lankenau et al. (2007) [43]
Steinmiller & Greenwald (2007) [36]
258 Current Drug Abuse Reviews, 2008, Vol. 1, No. 3 Barrett et al.
Notwithstanding issues related to discrepancies in how
recreational prescription drug use is defined and discussed in
the literature, there appears to be considerable variability in
the ways that various medications are used for their intoxi-
cating or euphoric effects. Although many misused medica-
tions fall into the same pharmacological classes as misused
illicit substances, when they are used as prescribed, their rate
of onset of action and dosages are generally thought to be
insufficient to produce psychoactive effects that are desirable
for recreational use [48], and it is often necessary for users to
alter a substance’s normal rate of delivery and/or availability
to the brain when using it recreationally. Ingestion of a sub-
stance through injection, smoking, or inhalation results in a
much more rapid entry of a drug into the brain than oral ad-
ministration, and there have been numerous reports of medi-
cations with stimulant, analgesic, anxiolytic, or sedative
properties being recreationally used through alternative
routes of administration.
There have also been several reports of recreational oral
use of medications from different classes being co-
administered with alcohol and/or other substances [26, 49-
52]. The simultaneous use of multiple substances can lead to:
pharmacokinetic changes that affect a substance’s metabo-
lism, concentration and/or rate of delivery to the brain;
pharmacodynamic changes that affect its actions in the brain;
and/or the production of new psychoactive metabolites (e.g.
the production of ethylphenidate following alcohol-
methylphenidate co-administration [53]) that might have
different effects than the individual or additive effects of the
parent compounds. Polysubstance users often appear to seek
medications that have particular pharmacologic actions that
will complement the actions of the other substances they are
using, and different combinations of substances might be
deliberately sought to achieve specific purposes. For exam-
ple, medications may be mixed with other substances to
augment desirable psychoactive effects (e.g. the co-
administration of opiates and stimulants has been reported to
produce greater euphoric effects than either drug alone (e.g.
[50]), counteract or diminish certain undesirable effects (e.g.
sedatives have been reported to be mixed with stimulants to
reduce insomnia [49]) or to facilitate continuous consump-
tion (e.g. methylphenidate has been reported to be used to
prolong alcohol drinking sessions [26, 52]). While there are
often different motives for co-administering prescription
drugs and other substances for recreational purposes, differ-
ent combinations of substances are likely to be associated
with very different levels of risk. For example, a normally
therapeutic dose of a sedative or anxiolytic medication might
have lethal consequences when used in combination with
some other substances (e.g. increased risk of overdose with
heroin or alcohol (e.g. [5, 6]), while it might help mitigate an
adverse reaction to another substance (e.g. decreased am-
phetamine- or cocaine-induced agitation (e.g. [29, 32]).
Despite the variability in behaviours considered to be
recreational prescription drug use as well as in their associ-
ated risks, most studies that address recreational use fail to
distinguish among them. To date, most information about the
different ways prescription medications are recreationally
used comes from studies that have used targeted sampling
methods [23-25] or that have relied exclusively on anecdotal
reports [26, 49, 52, 54]. Although such investigations have
been very valuable for documenting various possible forms
of misuse, they are typically not able to provide reliable es-
timates of their relative rates of occurrence or relative risks.
In addition, it is also possible that different forms of recrea-
tional medication use require different targets for prevention.
For example, the use of tamper-proof formulations may be
effective in preventing use of medications through different
routes of administration (e.g. [55]) but may be less effective
in preventing polysubstance users from inappropriately using
medications to alter or enhance certain other substance-
related effects.
DSM CRITERIA
A third method for defining prescription drug misuse that
has been employed in the extant literature has been to make
use of established criteria for diagnosing a disorder of clini-
cal significance associated with use of these medications [8,
32, 34]. Most often, such definitions make use of the diag-
nostic criteria for substance use disorders available in the
DSM. The most recent version of this manual is the DSM
Fourth edition, text revision (DSM-IV-TR; American Psychi-
atric Association, 2000). Most mental health professionals
and psychopathology researchers use the classification sys-
tem contained in the DSM-IV-TR [47]. It is the official sys-
tem for classification of mental health and addictive disor-
ders in North America and it is a system used widely around
the world. While the International Classification of Disease
[56] has a comparable system of classification of problem-
atic substance use, to date, the bulk of the research that has
defined problematic prescription drug use in terms of diag-
nostic criteria has utilized the DSM criteria. Use of the diag-
nostic criteria within a system like the DSM allows for con-
sistency in assessment, facilitates communication between
scientists/practitioners, and assists with the advancement of
knowledge [57]. The DSM-IV-TR recognizes two forms of
substance use disorders – abuse and dependence – which
vary in severity. Dependence is the more severe of the two
types of disorder.
Abuse
The DSM defines substance abuse as a pattern of mal-
adaptive substance use that is associated with recurrent and
significant adverse consequences. A diagnosis of substance
abuse requires meeting at least one of the following four
criteria due to recurrent substance use: 1) failure to fulfill
obligations at home/school/work; 2) use in situations that are
physically hazardous; 3) legal problems; and/or 4) social or
interpersonal problems [47]. Although numerous studies
purport to discuss prescription medication abuse (e.g. [7, 10,
14, 28, 34, 49-50, 54]), few actually assess it. And those that
have assessed it according to DSM criteria suggest that it is
actually a relatively rare occurrence. For example, fewer
than 4% of individuals reporting past year misuse of stimu-
lant medications (using the A-NSDUH criteria discussed
below) met the diagnostic criteria for abuse [8], and less than
10% of past year sedative and anxiolytic misusers met the
criteria for either abuse or dependence [32]. Unfortunately
data was not separately reported for each diagnosis or for
each class of drug so it is impossible to know the exact rates
of abuse vs dependence (see next section for discussion of
prescription drug dependence). It is important to note how-
ever that because a user must perceive their behaviour as
dangerous or problematic to receive a diagnosis of abuse,
What Constitutes Prescription Drug Misuse? Current Drug Abuse Reviews, 2008, Vol. 1, No. 3 259
many potentially hazardous medication uses (e.g. infrequent
mediation use in a polysubstance context) may not be ade-
quately assessed with these criteria.
Dependence
According to the DSM-IV [47], substance dependence is
defined as a compulsive pattern of substance use character-
ized by a loss of control over substance use and continued
use despite the significant substance-related problems. The
diagnostic criteria for dependence require the presence of
three or more of the following symptoms: tolerance (i.e., the
need to use increased amounts of substance for effect or a
diminished effect with use of same amount), withdrawal,
taking the substance in greater amounts or over a longer pe-
riod of time than intended, unsuccessful attempts to cut back
use, spending excessive time procuring, using, or recovering
from the effects of the substance, giving up important activi-
ties in order to use the substance, and continued use of the
substance despite evidence that it is causing serious physical
and/or psychological problems. When the diagnostic criteria
for dependence are met and symptoms of either withdrawal
or tolerance are present, the dependence diagnosis can be
further specified as involving ‘physical dependence’ on the
substance.
Development of dependence typically requires prolonged
and sustained exposure to a substance. In many cases this
can occur when the medication is taken exactly as prescribed
and in the absence of intentional misuse (e.g., opioid pain
management during hospital care [58]; use of benzodiazepi-
nes for the management of anxiety disorders [31]). Alterna-
tively, many individuals who develop tolerance to the same
psychotherapeutic medications do so completely outside of a
legitimate context. For example, illicit drug users may ha-
bitually use a prescribed opiate medication as a substitute for
an illicit drug that is more expensive or difficult to obtain,
such as heroin. Individuals who become dependent on a
medication during the course of treatment for a bona-fide
medical or psychiatric condition might be expected to differ
from those developing dependence through varied forms of
illicit use in terms of their risk factors, and symptom expres-
sions. Evidence suggests that individuals who develop symp-
toms of dependence during the course of a legitimate treat-
ment appear to be particularly prone to the development of
some symptoms (e.g. use for longer periods than intended;
withdrawal upon cessation) but not others (e.g. dose escala-
tion due to tolerance), while this different susceptibility to
symptoms does not appear to occur in recreational users [29,
59]. Moreover, although past research has linked dependence
on analgesic and anxiolytic medications to distinct diagnos-
tic [31, 32], personality [59], and demographic features [27],
due to the existence of distinct pathways to dependence, it is
not clear to what extent these factors are associated with the
pathologies the medications are intended to treat or with the
propensity to deliberately misuse the medications. Because
different pathways to dependence may be associated with
distinct risk factors and symptom expressions as well as hav-
ing different optimal targets for treatment, information about
the pathogenesis of symptom development is of considerable
clinical importance. Unfortunately, to date, the vast majority
of studies of prescription drug dependence fail to distinguish
among different possible trajectories to symptom onset.
A-NSDUH CRITERIA
Perhaps the most widely cited source of datum used to
define and describe inappropriate medication misuse in the
Americas is the National Survey on Drug Use and Health
(A-NSDUH). The A-NSDUH is an annual epidemiological
study that, in part, documents the non-medical use of pre-
scription stimulant, analgesic, anxiolytic, and sedative medi-
cations in a civilian, non-institutionalized American popula-
tion aged 12 years or older [9]. It is important to note that the
A-NSDUH was formerly known as the National Household
Survey of Drug Abuse (NHSDA); however they represent
two different surveys and thus cannot be directly compared].
The data collected through this survey is publicly available
for research purposes and it has been used extensively in
recent years to describe the prevalence and patterns of pre-
scription drug misuse in the United States [8, 27-28, 30, 32,
34, 45]. For A-NSDUH purposes, prescription drug misuse
is defined as “use of the target medication (or class of medi-
cations) without a prescription or that was taken only for the
experience or feeling the medication causes”, while DSM IV
criteria for substance abuse and substance dependence are
used to infer problematic use. Thus, the A-NSDUH criteria
encompasses each of the more specific criteria discussed in
detail above.
Unfortunately, however, although broader in its overall
coverage, the A-NSDUH retains perhaps the most serious
limitation of more specific conceptualisations of prescription
medication use in that it does not adequately distinguish be-
tween inappropriate medication uses for therapeutic vs rec-
reational purposes, or among most forms of recreational use
(the A-NSDUH currently collects limited data about the in-
travenous use of some substances but no information is col-
lected about other routes of administration or about simulta-
neous polysubstance use). In addition, because A-NSDUH
prevalence data is typically reported in terms of ‘any use’
during a particular timeframe, vastly different behaviors and
patterns of use can be given the same weight for determining
overall rates of misuse (e.g. a solitary non-prescribed thera-
peutic oral dose of codeine is treated in the same way as
chronic intravenous administration of OxyContin when de-
termining the rates of analgesic misuse) making it difficult to
interpret the clinical significance of the findings. Interpreta-
tion of A-NSDUH data may also be limited by a degree of
ambiguity in exactly what constitutes “use of the medication
for the experience or feeling it causes” as the A-NSDUH
does not specify what it includes [36]. Does it include using
a prescribed medication at a higher than recommended dose,
or using a medication to counteract the effects of another
substance? What about using a medication appropriately to
“experience” relief from a condition for which it is pre-
scribed or to “feel” better? The A-NSDUH leaves it for re-
spondents to decide.
Despite its limitations, the A-NSDUH provides perhaps
the most comprehensive definition for inappropriate medica-
tion use currently found in the literature, and it enables esti-
mates of both the overall prevalence of any form of misuse
medication, as well as of the prevalence of medication abuse
and dependence. In addition, recent versions of this survey
have begun to collect more details about certain forms of
hazardous use (e.g. intravenous administration) for at least
some substances (e.g. methamphetamine). Although such
260 Current Drug Abuse Reviews, 2008, Vol. 1, No. 3 Barrett et al.
efforts have not been exhaustive, and information regarding
motives for misuse is currently entirely lacking, the A-
NSDUH appears to have the potential to provide both vast
coverage as well as some insight into more specific forms of
prescription medication misuse. Because it would likely not
be feasible for the A-NSDUH to systematically examine
every possible form of inappropriate medication use, it is
important that the most prevalent, pervasive, and/or harmful
forms of misuse are identified through examining targeted
populations so that their inclusion in larger scale studies can
be justified.
CONCLUSIONS
Given the wide range of behaviors and characteristics
that can be considered inappropriate medication uses, as well
as the ever-growing array of psychoactive medications that
may be liable for misuse, it may prove difficult to achieve
both complete coverage and specificity for all potentially
clinically relevant forms of misuse within the same assess-
ment instrument. There are innumerable potential ways a
medication can be misused in a polysubstance context by an
individual. And for each combination of substances there
may be variations in the routes of administration as well as
in the user characteristics (e.g. prescribed users vs non-
prescribed users) and in the motives for use (e.g. to increase
intoxication vs medication of unpleasant side-effects). Thus
it may not always be feasible to systematically examine all
possible combinations of medications, administration pat-
terns, user characteristics, and motives for use in the same
investigation. Moreover since certain methods of data collec-
tion do not easily lend themselves to delineating such details
(e.g. self-report questionnaires) and other approaches may be
time and/or cost prohibitive (e.g. in-depth semi-structured
interviews), it may not be reasonable to expect that all inves-
tigations will be able to provide the same degree of coverage
or specificity. However, it is important, irrespective of the
approach used, that all operational definitions are clearly
stated, that the precise meaning of the terms used in the
study are specified, and that the limits to the generalizability
and specificity of findings be clearly and directly acknowl-
edged.
Because many inappropriate medication uses may in-
clude non-sanctioned therapeutic usage as well as use for
recreational/intoxicating purposes, it is also important that,
whenever possible, efforts be made to distinguish between
these potentially distinct clinical populations. Knowledge of
why an individual is misusing a specific type of prescription
medication can be critical for targeting prevention efforts as
well as for designing the most effective interventions. An
individual who developed dependence on a prescription anx-
iolytic in the context of treatment for an anxiety disorder
presumably has a very different trajectory to dependence as
well as very different treatment needs for discontinuing this
medication [60] than does an individual who developed de-
pendence on a prescription anxiolytic in the context of poly-
substance abuse (e.g., use of the anxiolytic to manage un-
pleasant side effects of stimulant drugs). In fact, recent re-
search suggests that matching treatments to the underlying
motivations for substance misuse improves treatment out-
comes for those with substance use disorders, including for
those with prescription drug abuse/dependence [61, 62].
Another issue, which is beyond the scope of this review,
although pertinent to note, is the health care system’s contri-
bution to prescription drug misuse. Misuse of psychoactive
medications, particularly in the case of prescribed users, may
not only stem from individual factors, but from a lack of
quality health care service. According to the Agency for
Health Care Research and Quality, quality health care
means, “doing the right thing at the right time, in the right
way, for the right person-and having the best possible re-
sults” [63]. Health care providers may play a role in prescrip-
tion drug misuse behaviors through disregard for this quality
of care (e.g., failing to recognize a patients’ potential for
developing a substance abuse/dependence disorder, misdiag-
nosing the patient, over-prescribing the medication; see a
journal article by Chasin and colleagues [64] for a broad
description of the problems surrounding provision of quality
health care). In acknowledging the health care system as an
additional contributing factor to prescription drug misuse, in
addition to the extensive conceptualization problems in-
volved in defining individuals’ prescription drug misuse ad-
dressed in this review, prescription drug misuse clearly
emerges as a complex phenonemenon that requires much
additional research attention.
Key Learning Objectives:
1. To become familiar with different commonly used operational
definitions for prescription medication misuse.
2. To gain knowledge about the different user characteristics, and
medication-related behaviors and problems that are sometimes
used to define prescription drug misuse.
3. To identify strengths and limitations of different conceptualizations
of inappropriate prescription drug use.
4. To understand the clinical importance of assessing different poten-
tial motives for non-sanctioned medication use.
Future Research Questions:
1. In what ways can one achieve both breadth and depth of coverage
when attempting to define and characterize prescription drug mis-
use?
2. What are the clinical implications of different forms of misuse?
3. To what extent would systematically identifying the reasons for
misuse improve prognosis and treatment planning?
REFERENCES
[1] Haydon E, Monga N, Rehm J, Adlaf E, Fischer B. Prescription
drug abuse in Canada and the diversion of prescription drugs into
the illicit drug market. Can J Public Health 2005; 96: 459-61.
[2] Hertz JA, Knight JR. Prescription drug misuse: A growing national
problem. Adolesc Med 2006; 17: 751-69.
[3] 2002 National Report: Drug Trends and the CCENDU Network.
Ottawa, ON: Canadian Community Epidemiology Network on
Drug Use (CCENDU). [Online]. 2003 [cited 2007 July 7]. Avail-
able from: URL: www.ccsa.ca/ccendu.
[4] Report of the International Narcotics Control Board for 2005. New
York, NY: International Narcotics Control Board (INCB). [Online].
2006 [cited 2007 June 20]. Available from: URL:
http://www.incb.org/incb/annual_report_2005.html.
[5] Gutiérrez-Cebollada J, de la Torre R, Ortuño J, Garcés, JM, Camí,
J. Psychotropic drug consumption and other factors associated with
heroin overdose. Drug Alcohol Depend 1994; 35: 169-74.
[6]
Mueller M, Shah N, Landen M. Unintentional prescription drug
overdose deaths in New Mexico, 1994-2003. Am J Prev Med 2006;
30: 423-29.
What Constitutes Prescription Drug Misuse? Current Drug Abuse Reviews, 2008, Vol. 1, No. 3 261
[7] Manchikanti L. National drug control policy and prescription drug
abuse: Facts and fallacies. Pain Physician 2007; 10: 399-424.
[8] Kroutil LA, Van Brunt DL, Herman-Stahl MA, Heller DC, Bray
RM, Penne MA. Nonmedical use of prescription stimulants in the
United States. Drug Alcohol Depend 2006; 84: 135-43.
[9] Results from the 2006 National Survey on Drug Use and Health:
National Findings. Rockville (MD): Substance Abuse and Mental
Health Services Administration (Office of Applied Studies,
NSDUH Series H-30, DHHS Publication No. SMA 06-4194). [On-
line]. 2006 [cited 2007 June]. Available from: URL:
http://oas.samhsa.gov/nsduh/2k6nsduh/2k6Results.pdf.
[10] Kaloyanides KB, McCabe SE, Cranford JA, Teter CJ. Prevalence
of illicit use and abuse of prescription stimulants, alcohol, and other
drugs among college students: Relationship with age at initiation of
prescription stimulants. Pharmacotherapy 2007; 27: 666-74.
[11] Poulin C. Medical and nonmedical stimulant use among adoles-
cents: From sanctioned to unsanctioned use. Can Med Assoc J
2001; 165: 1039-44.
[12] Teter CJ, McCabe SE, Cranford JA, Boyd CJ, Guthrie SK. Preva-
lence and motives for illicit use of prescription stimulants in an un-
dergraduate student sample. J Am Coll Health 2005; 53: 253-62.
[13] McCabe SE, Knight JR, Teter CJ, Wechsler H. Non-medical use of
prescription stimulants among US college students: prevalence and
correlates from a national survey. Addiction 2005; 99: 96-106.
[14] White BP, Becker-Blease KA, Grace-Bishop K. Stimulant medica-
tion use, misuse, and abuse in an undergraduate and graduate stu-
dent sample. J Am Coll Health 2006; 54: 261-68.
[15] Teter CJ, McCabe SE, Boyd CJ, Guthrie SK. Illicit Methylpheni-
date use in an undergraduate student sample: Prevalence and risk
factors. Pharmacotherapy 2003; 23: 609-617.
[16] Low KG, Gendaszek AE. Illicit use of psychostimulants among
college students: A preliminary study. Psychol Health Med 2002;
7: 283-87.
[17] Poulin C. Nova Scotia student drug use 2002: Technical report.
Halifax, NS: Addiction Services, Nova Scotia Department of
Health and Dalhousie University. [Online]. 2002 [cited 2007 May].
Available from: URL: http://www.gov.ns.ca/health/downloads/
2002_NSDrugTechnical.pdf.
[18] McCabe SE. Correlates of nonmedical use of prescription benzodi-
azepine anxiolytics: Results from a national survey of U. S. college
students. Drug Alcohol Depend 2005; 79: 53-62.
[19] McCabe SE, Cranford JA, Boyd CJ, Teter CJ. Motives, diversion
and routes of administration associated with nonmedical use of pre-
scription opioids. Addict Behav 2007; 32: 562-575.
[20] McCabe SE, Teter CJ, Boyd CJ. The use, misuse and diversion of
prescription stimulants among middle and high school students.
Subst Use Misuse 2004; 39: 1095-116.
[21] McCabe SE, Teter CJ. Drug use related problems among nonmedi-
cal users of prescription stimulants: A web-based survey of college
students from a Midwestern university. Drug Alcohol Depend
2007; 91: 69-76.
[22] Boyd CJ, McCabe SE, Teter CJ. Medical and nonmedical use of
prescription pain medication by youth in a Detroit-area public
school. Drug Alcohol Depend 2006; 81: 37-45.
[23] Barrett SP, Darredeau C, Bordy LE, Pihl RO. Characteristics of
methylphenidate misuse in a university student sample. Can J Psy-
chiatry 2005; 50: 457- 61.
[24] Darredeau C, Barrett SP, Jardin B, Pihl RO. Patterns and predictors
of medication compliance, diversion and misuse in adult prescribed
methylphenidate users. Hum Psychopharmacol 2007; 22: 529-536.
[25] Wilens TE, Gignac M, Swezey A, Monuteaux MC, Biederman J.
Characteristics of adolescents and young adults with ADHD who
divert or misuse their prescribed medications. J Am Acad Child
Adolsec Psychiatry 2007; 45: 408-14.
[26] Barrett SP, Pihl RO. Oral methylphenidate-alcohol co-abuse. J Clin
Psychopharmacol 2002; 22: 633-34.
[27] Simoni-Wastila L, Stirckler G. Risk factors associated with prob-
lem use of prescription drugs. Am J Public Health 2004; 94: 266-
268.
[28] Simoni-Wastila L, Yang HK. Psychoactive drug abuse in older
adults. Am J Geriat Pharmacother 2006; 4: 380-94.
[29] O’Brien CP. Benzodiazepine use, abuse, and dependence. J Clin
Psychiatry 2005; 66: 28-33.
[30]
Blanco C, Alderson D, Ogburn E, et al. Changes in the prevalence
of non-medical prescription drug use and drug use disorders in the
United States: 1991–1992 and 2001–2002. Drug Alcohol Depend
2007; 90: 128-134.
[31] Griffiths RR, Johnson MW. Relative abuse liability of hypnotic
drugs: A conceptual framework and algorithm for differentiating
among compounds. J Clin Psychiatry 2005; 66: 31-41.
[32] Becker WC, Fiellin DA, Desai RA. Non-medical use, abuse and
dependence on sedatives and tranquilizers among U.S. adults: Psy-
chiatric and socio-demographic correlates. Drug Alcohol Depend
2007; 90: 280-7.
[33] Goodwin RD, Hasin DS. Sedative use and misuse in the United
States. Addiction 2002; 97: 555-62.
[34] Smith MY, Woody G. Nonmedical use and abuse of scheduled
medications prescribed for pain, pain-related symptoms, and psy-
chiatric disorders: Patterns, user characteristics, and management
options. Curr Psychiatry Rep 2005; 7: 337-43.
[35] Boyd CJ, McCabe SE, Cranford JA, Young A. Adolescents’ moti-
vation to abuse prescription medications. Pediatrics 2006; 118:
2472-80.
[36] Steinmiller CL, Greenwald M. Factors associated with nonmedical
use of prescription opioids among heroin abusing research volun-
teers. Exp Clin Psychopharmacol 2007; 15: 492-500.
[37] Sung H, Ritcher L, Vaughan R, Johnson PB, Thom B. Nonmedical
use of prescription opioids among teenagers in the United States:
Trends and correlates. J Adolescent Health 2005; 37: 44-51.
[38] Wu L, Pilowsky DJ, Schlenger WE, Galvin DM. Misuse of meth-
amphetamine and prescription stimulants among youths and young
adults in the community. Drug Alcohol Depend 2007; 89: 195 -
205.
[39] Marsh LD, Key JD, Payne TP. Methylphenidate misuse in sub-
stance abusing adolescents. J Child Adoles Subst 2000; 9: 1-14.
[40] Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of
stimulants prescribed for ADHD: A systematic review of the litera-
ture. J Am Acad Child Adolesc Psychiatry 2008; 47: 21-31.
[41] Davis RW, Johnson BD. Prescription opioid use, misuse, and di-
version among street drug users in New York City. Drug Alcohol
Depend 2008; 92: 267-276.
[42] McCabe SE, West BT, Morales M, Cranford JA, Boyd CJ. Does
early onset of non-medical use of prescription drugs predict subse-
quent prescription drug abuse and dependence? Results from a na-
tional study. Addiction 2007; 102: 1920-1930.
[43] Lankenau SE, Sanders B, Bloom JJ, et al. Prevalence and patterns
of prescription drug misuse among young ketamine injectors. J
Drug Issues 2007; 22: 717-736.
[44] Arria AM, Caldeira KM, O’Grady KE, et al. Nonmedical use of
prescription stimulants among college students: Associations with
attention-deficit-hyperactivity disorder and polydrug use. Pharam-
cotherapy 2008; 156-169.
[45] Arria AM, O’Grady KE, Caldeira KM, Vincent KB, Wish ED.
Nonmedical use of prescription stimulants and analgesics: Associa-
tions with social and academic behaviors among college students. J
Drug Issues: In press 2008.
[46] Ger LP, Ho ST, Wang JJ. Physicians' knowledge and attitudes
toward the use of analgesics for cancer pain management: a survey
of two medical centers in Taiwan. J Pain Symptom Manage 2000;
20: 335-44.
[47] American Psychiatric Association. Diagnostic and Statistical Man-
ual of Mental Disorders, 4th ed. American Psychiatric Press, 1994
Washington DC.
[48] Compton WM, Volkow, ND. Abuse of prescription drugs and the
risk of addiction. Drug Alcohol Depend 2006; 83: 4-7.
[49] Kurtz SP, Inciardi JA, Surratt HL, Cottler L. Prescription drug
abuse among ecstasy users in Miami. J Addict Dis 2005; 24: 1-16.
[50] Barrett SP, Darredeau C, Pihl RO. Patterns of simultaneous poly-
substance use in drug using university students. Hum Psychophar-
macol 2006; 21: 255-63.
[51] Dasgupta N, Kramer D, Zalman M, et al. Association between non-
medical and prescriptive usage of opioids. Drug Alcohol Depend
2006; 82: 135-42.
[52] Babcock Q, Byrne T. Student perceptions of methylphenidate
abuse at a public liberal arts college. J Am Coll Health 2000; 49:
143-45.
[53] Markowitz JS, DeVane CL, Boulton DW, et al. Ethylphenidate
formation in human subjects after the administration of a single
dose of methlyphenidate and ethanol. Drug Metab Dispos 2000; 28:
620-4.
262 Current Drug Abuse Reviews, 2008, Vol. 1, No. 3 Barrett et al.
[54] Parran TV, Jasinski DR. Intravenous methylphenidate abuse: proto-
type for prescription drug abuse. Arch Intern Med 1991; 15: 781-3.
[55] Fudala PJ, Johnson RE. Development of opioid formulations with
limited diversion and abuse potential. Drug Alcohol Depend 2006;
83:S40-S47.
[56] Hasin D, Hatzenbuehler ML, Keyes K, Ogburn E. Substance use
disorders: Diagnostic and Statistical Manual of Mental Disorders,
fourth edition (DSM-IV) and International Classification of Dis-
eases, tenth edition (ICD-10). Addiction 2006; 101:59-75.
[57] Durand M, Barlow DH, Stewart SH. Essentials of abnormal psy-
chology. 1st Canadian Edition. Toronto, ON: Thomson-Nelson;
2008.
[58] Ballantyne JC, LaForge KS. Opioid dependence and addiction
during opioid treatment of chronic pain. Pain 2007; 129: 235-55.
[59] Conrod PJ, Pihl RO, Stewart SH, Dongier M. Validation of a sys-
tem of classifying female substance abusers on the basis of person-
ality and motivational risk factors for substance abuse. Psychol
Addict Behav 2000; 14: 243-56.
[60] Otto MW, Pollack MH, Sachs GS, O'Neil CA, Rosenbaum JF.
Alcohol dependence in panic disorder patients. J Psychiatr Res
1992; 26: 29-38.
[61] Conrod PJ, Stewart SH, Pihl RO, Côté S, Fontaine V, Dongier M.
Efficacy of brief coping skills interventions that match different
personality profiles of female substance abusers. Psychol Addict
Behav 2000; 14: 231-242.
[62] Watt MC, Stewart SH, Conrod PJ, Schmidt NB. Personality-based
approaches to treatment of co-morbid anxiety and substance use
disorder. In: Stewart SH, Conrod PJ, Eds, The Vicious Cycle:
Theoretical and Treatment Issues in Co-Morbid Anxiety and Sub-
stance Use Disorders. New York, NY: Springer; in press.
[63] Agency for Healthcare and Research Quality. Your guide to choos-
ing quality health care: Summary. [Online]. 2002 Sept [cited 2008
Feb 18]; Available from: URL: http://www.ahrq.gov/consumer/qnt/
qntqlook.htm.
[64] Chassin MR, Glavin R. The urgent need to improve health care
quality: Institute of Medicine National Roundtable on Health Care
Quality. JAMA 1999; 280: 1000-1006.
Received: November 30, 2007 Revised: January 25, 2008 Accepted: March 3, 2008