Research Article
Stress, Drugs, and Alcohol Use Among
Health Care Professional Students:
A Focus on Prescription Stimulants
Journal of Pharmacy Practice
2015, Vol. 28(6) 535-542
ª The Author(s) 2014
Reprints and permission:
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DOI: 10.1177/0897190014544824
jpp.sagepub.com
Monica K. Bidwal, PharmD1, Eric J. Ip, PharmD, BCPS, CSCS, CDE1,
Bijal M. Shah, BPharm, PhD1, and Melissa J. Serino, PharmD1
Abstract
Objective: To contrast the characteristics of pharmacy, medicine, and physician assistant (PA) students regarding the prevalence of
drug, alcohol, and tobacco use and to identify risk factors associated with prescription stimulant use. Participants: Five hundred
eighty nine students were recruited to complete a 50-item Web-based survey. Main Outcome Measures: Demographics, nonmedical prescription medication use, illicit drug and alcohol use, Diagnostic and Statistical Manual of Mental Disorders (Fourth
Edition, Text Revision; DSM-IV-TR) psychiatric diagnoses, and perceived stress scale (PSS) scores. Results: Medicine and PA students
reported greater nonmedical prescription stimulant use than pharmacy students (10.4% vs 14.0% vs 6.1%; P < .05). Medicine and
PA students were more likely to report a history of an anxiety disorder (12.1% vs 18.6% vs 5.9%; P < .05), major depressive
disorder (9.4% vs 8.1% vs 3.3%; P < .05), and attention-deficit hyperactivity disorder (ADHD; 4.0% vs 9.3% vs 0.7%; P < .001) than
pharmacy students. PSS scores for all 3 groups (21.9-22.3) were roughly twice as high as the general adult population. Conclusion:
Illicit drug and prescription stimulant use, psychiatric disorders, and elevated stress levels are prevalent among health care
professional students. Health care professional programs may wish to use this information to better understand their student
population which may lead to a reassessment of student resources and awareness/prevention programs.
Keywords
prescription medication misuse, abuse, stimulants, medical professional students
The misuse of prescription medications is not a new phenomenon; during World War II, prescription stimulants were
widely consumed by the armed forces and industrial workers
to enhance alertness.1 A reported 25 million individuals worldwide used amphetamines in 2004, and approximately 1 in 10
Americans between the ages of 18 and 25 reported nonmedical
use of opiate analgesics.1,2 Nonmedical use of prescription
medications is a growing concern among undergraduate college students in the United States and has been reported in multiple national surveys. Monitoring the future stated that misuse
of prescription medications by college students was at the highest level in 2004, and rates have remained steady since 2006.3
According to the National Survey on Drug Use and Health
2012, adults 18 to 25 years old had the highest prevalence of
illicit prescription drug use among all age-groups surveyed.2
Prescription opioid analgesics and stimulants were among the
most widely misused medications among this age-group.2-4
Prescription drug use and diversion represents a significant
problem among undergraduate college students.3-9
There is limited information about these types of behaviors
among health care professional students. Prior studies have primarily analyzed trends at a single institution or a few programs
across 1 state.4,10 As health care professional students will
likely have influence on patient health outcomes in the future,
the presence of such behaviors may potentially affect the quality and type of care they provide to their patients. Of note, prescription opioid analgesics and stimulants are the most
commonly misused medications among pharmacists and
nurses.10 The purpose of this study is to contrast the characteristics of 3 groups of health care professional students in
California: pharmacy (Doctor of Pharmacy), medicine (Doctor
of Medicine/Doctor of Osteopathic Medicine), and physician
assistant (PA) regarding drug, alcohol, and tobacco use and
to identify risk factors associated with prescription stimulant
use. To our knowledge, this study represents the first multischool and multidisciplinary comparison among these groups
of future health care professionals.
1
Department of Pharmacy Practice, Touro University College of Pharmacy,
Vallejo, CA, USA
Corresponding Author:
Monica K. Bidwal, Department of Pharmacy Practice, Touro University College
of Pharmacy, 13010 Club Dr, Vallejo, CA 94592, USA.
Email: [email protected]
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536
Journal of Pharmacy Practice 28(6)
Methods
Health care professional students attending pharmacy school,
medical school, or a PA program in California with Internet
access who received the e-mail announcement were included in
the study. The following subjects were excluded from the study:
health care professional students without Internet access or who
did not receive the e-mail announcement; individuals who opened
and viewed the survey link but decided not to participate; and
individuals who began but did not complete the survey.
A 50-item Web-based survey, administered through Qualtrics
Labs Inc (Provo, Utah), was used to assess several characteristics
of health care professional students. Specific variables assessed
included the following: demographics; lifestyle/study habits;
prescription stimulant use, motivations for its use, and acquisition history; use of other medications, illicit drugs, tobacco, and
alcohol; Diagnostic and Statistical Manual of Mental Disorders
(Fourth Edition, Text Revision) psychiatric conditions diagnosed by a health care professional; and perceived stress scale
(PSS). The PSS is a validated psychological instrument that measures the degree to which situations in one’s life are appraised as
stressful. There are 10 questions based on a 0- to 4-point scale
that asks about feelings and thoughts during the last month to
measure perceptions of stress.11
as mean + standard deviation. The Pearson’s chi-square test
and analysis of variance were used for comparisons of categorical and continuous data, respectively. The Bonferroni test was
used for comparisons of variables with equal variances, while
the Games-Howell test was used for comparisons of variables
with unequal variances. Logistic regression analysis was used
to identify the risk factors for nonmedical use of prescription
stimulants. A P value of less than .05 was considered a statistically significant difference.
Results
When the survey closed on April 15, 2011, there were 730 survey attempts. Among these, 103 were excluded for filling out
an incomplete survey, 11 did not disclose which health care
professional program they attended, and an additional 27 were
excluded for attending other programs not specified in the
inclusion criteria (3—Pre-Pharmacy, 17—Masters of Public
Health, 1—Education, and 6—other). This resulted in a final
analytical cohort of 589 subjects who fully completed and submitted a valid survey. A total of 309 pharmacy, 173 medicine,
and 107 PA students were included in this analysis.
Demographics
Data Collection and Data Security
Participants were recruited via e-mail between February 15 to
April 15, 2011. The Associate Dean of Student Affairs or program coordinator of each pharmacy, medical, and PA school in
California was contacted to obtain consent for student participation. Of the 27 schools contacted, 5 of the 8 pharmacy (3 private and 2 public) schools, 2 of the 10 medical (1 private and 1
public) schools, and 5 of the 9 PA (4 private and 1 public) programs agreed to allow student participation. Students were contacted via e-mail through their Associate Dean of Student
Affairs or program coordinator with a description of the study
and directions to access the online survey Weblink using Qualtrics. One additional reminder was sent to the students 21 days
after the initial start date of the study.
The survey Weblink directed potential subjects to an
informed consent page providing additional information
regarding the study and assuring confidentiality and anonymity. No individually identifiable data were collected, Internet
provider addresses were not logged, and data transfer was
encrypted. All researchers had previously completed a National
Institutes of Health human subjects training program. The
study received institutional review board approval from Touro
University, California.
Statistical Methods
All statistical analyses were conducted using SPSS for
Windows version 14. Since the survey was primarily descriptive in nature, categorical data were reported as frequency and
percentages of respondents, and continuous data were reported
The demographic data comparing pharmacy, medicine, and PA
students are summarized in Table 1. Pharmacy students were
approximately 1 year younger than medicine and PA students
(26.4 vs 27.2 vs 27.6, P ¼ .016). The majority of pharmacy,
medicine, and PA students were female (71.5% vs 59% vs
78.5%, respectively, P ¼ .001) and never married (84.1% vs
67.4% vs 64.5% respectively, P < .001). Although the largest
proportion of both medicine and PA students were caucasian
(64.7% and 65.4%), the largest proportion of the pharmacy students were Asian or Pacific Islander (53.1%). Most students
were in their didactic portion of their curriculum as opposed
to clinical rotations. Pharmacy students were more likely than
medicine and PA students to be in a fraternity/sorority (29.0%
vs 14.5% vs 2.8%, respectively, P < .001).
Regarding study habits, the majority of pharmacy, medicine, and PA students reported procrastinating in their studies
(79.9% vs 80.3% vs 73.8%, respectively, P ¼ .360). Pharmacy,
medicine, and PA students all averaged less than 7 hours of
sleep (6.6 vs 6.8. vs 6.9 hours, respectively, P ¼ .004). During
examination periods, pharmacy students reported the least
amount of sleep (4.9 hours) compared to medicine or PA (5.8
vs 5.4 hours respectively, P < .001). Medicine students reported
seeing their primary care provider for annual check-ups less
frequently than both pharmacy and PA students (39.5% vs
48.9% vs 58.7%, respectively, P ¼ .008).
There were no significant differences between the 3 groups
regarding reported history of physical abuse. However, medicine and PA students were more than 4 times as likely to report
a history of sexual abuse than the pharmacy students (11.0% vs
11.2%, 2.6%, respectively, P < .001). Similarly, medicine and
PA students were more likely to report having a primary
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Bidwal et al
537
Table 1. Demographics and Background.
Pharmacy
(n ¼ 309)
Demographics
Current age, Mean + SD, y
Gender, no. (%) of respondents
Female
Male
Race, no. (%) of respondents
Asian or Pacific Islander
American Indian or Alaskan Native
Black, not of Hispanic origin
Hispanic
White, not of Hispanic origin
Other
Marital status, no. (%) of respondents
Never married
Married
Separated/divorced
Institution, no. (%) of respondents
Type of institution
Private
Public
Full time or part time
Full time
Part time
Portion of program, no. (%) of respondents
Didactic
Rotations
Live off or on-campus, no. (%) of respondents
On-campus
Off-campus
Fraternity/sorority, no. (%) of respondents
Yes
No
Year in school, no. (%) of respondents
First year
Second year
Third year
Fourth year
Other
GPA (4.0 scale), no. (%) of respondents
<2.0
2.0-2.49
2.5-2.99
3.0-3.49
3.5-3.99
"4.0
Residency/fellowship, no. (%) of respondents
Yes
No
Procrastinate to study, no. (%) of respondents
Yes
No
Regular doctor or primary care provider, no. (%) of respondents
Yes
No
Physically abused, no. (%) of respondents
Sexually abused, no. (%) of respondents
Primary relative with substance abuse/dependence, no. (%) of respondents
Driven vehicle intoxicated or under influence of drugs, no. (%) of respondents
Sleep—average (h) per night, mean + SD
Sleep—exams (h) per night, mean + SD
Medicine
(n ¼ 173)
P
value
26.4 + 3.6
27.2 + 3.6
27.6 + 4.4
.016
221/309 (71.5)
88/309 (28.5)
102/173 (59.0)
71/173 (41.0)
84/107 (78.5)
23/107 (21.5)
.001
163/307 (53.1)
0
9/307 (2.9)
12/307 (3.9)
86/307 (28.0)
37/307 (12.1)
41/173 (23.7)
0
0
5/173 (2.9)
112/173 (64.7)
15/173 (8.7)
12/107 (12.1)
1/107 (0.9)
3/107 (2.8)
10/107 (9.3)
70/107 (65.4)
11/107 (10.3)
N/A
217/258 (84.1)
38/258 (14.7)
3/258 (1.2)
97/144 (67.4)
47/144 (32.6)
0
60/93 (64.5)
30/93 (32.3)
3/93 (3.2)
.001
200/308 (64.9)
108/308 (35.1)
171/173 (98.8)
2/173 (1.2)
88/107 (82.2)
19/107 (17.8)
N/A
306/308 (99.4)
2/308 (0.6)
171/172 (99.4)
1/172 (0.6)
107/107 (100)
0
.711
208/309 (67.3)
101/309 (32.7)
107/170 (62.9)
63/170 (37.1)
60/106 (56.6)
46/106 (43.4)
.130
28/306 (9.2)
278/306 (90.8)
2/173 (1.2)
171/173 (98.8)
2/107 (1.9)
105/107 (98.1)
N/A
89/307 (29.0)
218/307 (71.0)
25/173 (14.5)
148/173 (85.5)
3/106 (2.8)
103/106 (97.2)
<.001
<.001
92/309 (29.8)
78/309 (25.2)
72/309 (23.3)
67/309 (21.7)
0
66/173 (38.2)
42/173 (24.3)
31/173 (17.9)
33/173 (19.1)
1/173 (0.6)
52/105 (49.5)
36/105 (34.3)
16/105 (15.2)
1/105 (1.0)
0
N/A
1/306 (0.3)
5/306 (1.6)
25/306 (8.2)
148/306 (48.4)
83/306 (27.9)
3/306 (1.0)
1/172 (0.6)
1/172 (0.6)
10/172 (5.8)
82/172 (47.7)
73/172 (42.4)
1/172 (0.6)
0
0
3/107 (2.8)
36/107 (33.6)
63/107 (58.9)
4/107 (3.7)
<.001
204/309 (66.0)
105/309 (34.0)
N/A
246/308 (79.9)
62/308 (20.1)
139/173 (80.3)
34/173 (19.7)
79/107 (73.8)
28/107 (26.2)
.360
150/307 (48.9)
157/307 (51.1)
16/308 (5.2)
8/308 (2.6)
27/208 (8.8)
84/307 (27.4)
6.6 + 1.1
4.9 + 1.5
68/172 (39.5)
104/172 (60.5)
17/173 (9.8)
19/172 (11.0)
40/173 (23.1)
51/173 (29.5)
6.8 + 0.9
5.8 + 1.3
61/104 (58.7)
43/104 (41.3)
9/98 (8.4)
12/107 (11.2)
28/107 (26.2)
33/107 (30.8)
6.9 + 1.1
5.4 + 1.4
.008
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Abbreviations: GPA, grade point average; SD, standard deviation.
Physician assistant
(n ¼ 107)
N/A
.140
<.001
<.001
.760
.004
<.001
538
Journal of Pharmacy Practice 28(6)
Table 2. Diagnosed Psychiatric Conditions.
Anxiety disorder, no. (%) of respondentsa
Major depressive disorder, no. (%) of respondentsb
Substance-dependence disorder, no. (%) of respondents
Schizophrenia, no. (%) of respondents
Body dysmorphic disorder, no. (%) of respondents
ADHD, no. (%) of respondents
Anorexia nervosa, no. (%) of respondents
Bulimia nervosa, no. (%) of respondents
Bipolar disorder, no. (%) of respondents
Narcolepsy, no. (%) of respondents
Insomnia, no. (%) of respondents
None, no. (%) of respondents
Perceived stress scale (PSS), mean + SD
Pharmacy (n ¼ 270)
Medicine (n ¼ 149)
Physician assistant (n ¼ 86)
P value
16/270 (5.9)
9/270 (3.3)
0
0
1/270 (0.4)
2/270 (0.7)
0
2/270 (0.7)
1/270 (0.4)
0
6/270 (2.2)
230/270 (85.2)
22.3 + 6.0
18/149 (12.1)
14/149 (9.4)
3/149 (2.0)
0
1/149 (0.7)
6/149 (4.0)
5/149 (3.4)
5/149 (3.4)
2/149 (1.3)
0
6/149 (4.0)
101/149 (67.8)
22.2 + 6.2
16/86 (18.6)
7/86 (8.1)
1/86 (1.2)
0
1/86 (1.2)
8/86 (9.3)
1/86 (1.2)
2/86 (2.3)
2/86 (2.3)
0
6/86 (7.0)
54/86 (62)
21.9 + 6.8
.002
.027
.077
.911
<.001
.010
.140
.245
.110
<.001
.858
Abbreviations: ADHD, attention deficit hyperactivity disorder; GAD, generalized anxiety disorder; MDD, major depressive disorder; OCD, obsessive–
compulsive disorder; PTSD, posttraumatic stress disorder; SD, standard deviation.
a
GAD, panic disorder, PTSD, OCD, and social phobia.
b
Typical MDD, atypical MDD, psychotic MDD, melancholic MDD, and dysthymia.
relative with a history of substance abuse or substance dependence than pharmacy students (23.1% vs 26.2% vs 8.8%,
respectively, P < .001). Over 25% of pharmacy, medicine, and
PA reported driving a motor vehicle while intoxicated or under
the influence of drugs.
Diagnosed Psychiatric Conditions and PSS
As shown in Table 2, both medicine and PA students were
more likely to report a psychiatric diagnosis made by a health
care professional. Significant differences were noticed for selfreported histories of an anxiety disorder, a major depressive
disorder, and attention-deficit hyperactivity disorder (ADHD).
For instance, medicine and PA students were more than twice
as likely to report a history of an anxiety disorder than pharmacy students (12.1% vs 18.6% vs 5.9%, respectively, P ¼
.002). Medicine and PA students were also more than twice
as likely to report a history of a major depressive disorder than
pharmacy students (9.4% vs 8.1% vs 3.3%, respectively, P ¼
.027) and more than 5 times as likely to report a history of
ADHD (4.0% vs 9.3% vs 0.7%, respectively, P < .001).
Regarding stress, there were no significant differences in PSS
scores among the 3 groups (mean scores were 22.2, 21.9, and
22.3, for medicine, PA, and pharmacy students, respectively;
P ¼ .858). As a reference, the average PSS score for the United
States adult population is 12 to 13.11
respondents admitted to use. Among those admitting to prescription stimulant use, only 32.7% reported having a valid prescription in their name. The most commonly used agents were
amphetamine-dextroamphetamine (Adderall, Adderall XR)
and methylphenidate (Ritalin, Ritalin LA/SR). Regarding frequency of prescription stimulant use, 9.6% reported using it 2
to 3 times/month, 13.5% daily, and 11.5% only during examination periods.
The most common route of administration of prescription
stimulants was oral (98.0%). A smaller percentage of users
(6.0%) reported intranasal use (not an indicated route of administration). More than half (58.8%) of the users planned the
duration/dose prior to using their prescription stimulant, and all
of these users adhered to their original plan they had set out.
When asked about how the prescription stimulant affected their
academic performance, 38.8% noticed an improvement, 61.2%
reported performance staying the same, while no subjects
reported a decline.
Acquisition of Prescription Stimulants
A majority reported obtaining their prescription stimulant from a
friend/classmate (52.0%). Other methods of acquisition included
a community/outpatient pharmacy (32.0%), a family member
(14.0%), a local acquaintance (8.0%), and transportation from
a foreign country (2.0%). A minority of users (8.0%) admitted
to selling or giving out their prescription stimulants to others.
Characteristics of Prescription Stimulant Medication Use
Characteristics of prescription stimulant use are summarized in
Table 3 and shown collectively among the 3 health care professional groups since the numbers in each individual group were
relatively small for comparison. The breakdown among the 3
health care student group is as follows: 6.1% pharmacy,
10.4% medicine, and 14.0% PA students (P ¼ .032). When
asked about lifetime use of prescription stimulants, 8.8% of all
Adverse Effects of Prescription Stimulants
The most common adverse effects reported by prescription
stimulant use were decreased appetite (79.1%), sleep
disturbances/insomnia (69.8%), mood changes (30.2%), palpitations (30.2%), irregular heart rate (25.6%), anxiety
(23.3%), weight loss (14.0%), nausea/vomiting (11.6%), and
high blood pressure (11.6%). Almost half (47.1%) of users
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Bidwal et al
539
were concerned about their long-term health from stimulant
use. Considering these adverse effects and concerns, only
20.0% of prescription stimulant users planned to continue use
after graduation.
Table 3. Prescription Stimulant Utilization.
No. (%) respondents
Background
Lifetime use
Valid prescription in your name
How often stimulant used in past 12 months
Never
#Once a year
Once a month
2-3 times/month
Once a week
2-3 times/wk
Daily
Only during examination periods
Administration
Oral
Intranasal
IV
SQ/IM injection
Who have you informed about stimulant use
No one
Physician/health care provider
Family member/spouse
Friend
Colleague/classmate
Professor/preceptor
Plan duration/dose prior to use
Stick with original plan
Sold/given your prescription
Plan to continue use after graduation
Yes
No
Noticed improvement in academics
Yes
No, grades are the same
No, grades have declined
Adverse effects
Concerned about long-term side effects
Irregular heart rate
High blood pressure
Mood changes
Palpitations
Sleep disturbance (ie, insomnia)
Decreased appetite
Nausea/vomiting
Weight loss
Anxiety
Acquisition
Community/outpatient pharmacy
Family member
Friend/classmate
Internet supplier (not registered pharmacy)
Internet registered pharmacy
Mail order from foreign country
Transported from foreign country
Purchased from local acquaintance
From health care setting (without a rx)
Other
52/589 (8.8)
17/52 (32.7)
25/52
4/52
1/52
5/52
1/52
3/52
7/52
6/52
(48.1)
(7.7)
(1.9)
(9.6)
(1.9)
(5.8)
(13.5)
(11.5)
49/50 (49.0)
3/50 (6.0)
0
0
4/51
17/51
22/51
33/51
20/51
4/51
30/51
30/30
4/50
(7.8)
(33.3)
(43.1)
(64.7)
(39.2)
(7.8)
(58.8)
(100.0)
(8.0)
10/50 (20.0)
40/50 (80.0)
19/49 (38.8)
30/49 (61.2)
0
Disclosure of Prescription Stimulant Use
Most students were not secretive about prescription stimulant
use. Almost two-thirds (64.7%) of users informed a friend,
43.1% informed a family member/spouse, 39.2% informed a
colleague/classmate, 33.3% informed a physician/health care
provider, and 7.8% informed a professor/preceptor. Only
7.8% of users had not informed anyone.
Motivations for Prescription Stimulant Use
‘‘Improve concentration/help focus’’ was ranked as an important reason for using prescription stimulants. The following
were ‘‘somewhat important reasons’’ for use: improve alertness
(pharmacy and medicine) and perform better scholastically
(pharmacy and PA). The following were not highly rated reasons for using prescription stimulants among the 3 groups: perform better on rotations, lose weight, stay up all night, peer
pressure, physical dependence, gain an academic edge over
other students, or economic worries/financial pressure.
Awareness of Prescription Stimulant Use
A majority (87.1%) of all students reported being aware that
prescription stimulants were being used to enhance academic performance at their academic institution. Roughly
two-thirds (67.3%) of the students believed that faculty at
their institution were also aware that prescription stimulant
abuse was occurring.
24/51
11/43
5/43
13/43
13/43
30/43
34/43
5/43
6/43
10/43
(47.1)
(25.6)
(11.6)
(30.2)
(30.2)
(69.8)
(79.1)
(11.6)
(14.0)
(23.3)
Potential risk factors for nonmedical use of prescription stimulants are summarized in Table 5. Hispanic (5.66, P ¼ .017) or
caucasian decent (2.85, P ¼ .014), heavy alcohol use (3.83, P ¼
.015), and smoking (3.88, P ¼ .005) were identified as risk factors or predictors for nonmedical use of prescription stimulants.
16/52
7/52
26/52
0
0
0
1/52
4/52
1/52
2/52
(30.8)
(13.5)
(50.0)
Use of Prescription Medications, Over-the-Counter Products, Illicit Drugs, Tobacco, and Alcohol
Abbreviations: IV, intravenous; IM, intramuscular; SQ, subcutaneous.
(1.9)
(7.7)
(1.9)
(3.9)
Risk Factors for Nonmedical Use of Prescription
Stimulants
Use of prescription medications, over-the-counter products,
illicit drugs, tobacco, and alcohol consumption patterns in the
past 12 months are described in Table 6. Over 40% of all 3
groups consumed caffeinated energy drinks. No differences
were seen regarding tobacco or alcohol use; however, over
30% of all groups reported binge alcohol drinking. Medicine
students were more than twice as likely to report marijuana use
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540
Journal of Pharmacy Practice 28(6)
Table 4. Rating of Motivations for Prescription Stimulant Use.a
Pharmacy
Medicine
Physician
assistant
Improve concentration/help focus 4.2 + 1.3 4.4 + 1.0 4.5 + 1.1
Improve alertness
3.2 + 1.5 3.3 + 1.4 2.9 + 1.4
Perform better scholastically
3.7 + 1.4 2.8 + 1.6 3.3 + 1.8
Perform better on clinical
1.1 + 0.2 1.6 + 1.3 2.2 + 1.8
rotations
Lose weight
1.2 + 0.5 1.3 + 0.6 1.7 + 1.3
Stay up all night
2.4 + 1.6 2.2 + 1.3 2.1 + 1.6
Due to peer pressure
1.00 + 0
1.2 + 0.5 1.3 + 0.7
Due to physical dependence
1.00 + 0 1.00 + 0 1.00 + 0
To gain an academic edge over
1.6 + 1.2 1.00 + 0
1.6 + 1.0
other students
Economic worries or financial
1.00 + 0 1.00 + 0 1.00 + 0
pressure
Abbreviation: SD, standard deviation.
a
Data are mean + SD.
Table 5. Risk Factors for Nonmedical Use of Prescription Stimulants.
Odds ratio, confidence interval
Age
Gender (male vs female)
Hispanic vs non-Hispanic
Caucasian vs noncaucasian
GPA
Fraternity vs nonfraternity
Binge alcohol
Heavy alcohol
Smoking
Procrastination
Major depressive disorder
Anxiety
8.91,
0.49,
5.66,
2.85,
1.40,
0.77,
1.55,
3.83,
3.88,
1.16,
1.97,
1.29,
0.77-1.03
0.20-1.22
1.37-23.34
1.24-6.54
0.97-2.00
0.32-1.85
0.66-3.64
1.30-11.32
1.49-10.10
0.45-2.98
0.50-7.50
0.42-3.95
P value
.127
.125
.017
.014
.071
.559
.319
.015
.005
.754
.332
.652
Abbreviation: GPA, grade point average.
compared to pharmacy and PA students (20.8% vs 7.4% vs
8.4% respectively, P < .001).
Discussion
The current study confirms the presence of nonmedical use of
prescription medications (in particular stimulants) as well as
illicit drugs, tobacco, and alcohol use among health care professional students in the state of California. These findings are
similar to 2 Northeastern-based studies involving pharmacy
and/or nursing students by Lord and colleagues and Kenna and
Wood.4,10 Both prior studies revealed that marijuana (21%66.7%), hallucinogens (13.8%-19.7%), prescription opiates
(7.9%-39.2%) and stimulants (6.7%-11.8%), and ecstasy
(7.8%-11.5%) were the most commonly used illicit agents.
Although marijuana and stimulants were the most commonly
used agents in the current study, the percentage of users of marijuana, hallucinogens, prescription opiates, stimulants, and
ecstasy were all considerably lower than the 2 abovementioned studies.4,10 Possible differences seen by the subjects
in our study may be a result of different trends in illicit drug use
patterns or perhaps regional differences.
Medicine and PA students in the current study were more
likely to report nonmedical use of prescription stimulants, dextromethorphan, marijuana, tobacco (smokeless and cigarettes)
as well as binge alcohol and heavy alcohol compared to pharmacy students. Possible risk factors and associations may contribute to these findings. For instance, this finding may be
influenced by cultural differences. A majority of medicine and
PA students were caucasian when compared to a majority of
pharmacy students were Asian or Pacific Islander. In 2012, the
national rates of illicit drug, alcohol, and tobacco use among caucasians (9.2%, 57.4%, and 29.2%, respectively) were higher than
Asians (3.7%, 36.9%, and 10.8%, respectively).2 Furthermore,
medicine and PA students were 5 times more likely to report sexual abuse, 3 times more likely to report a primary relative with
substance abuse or substance dependence disorder, twice as
likely to report a history of an anxiety disorder or major depressive disorder, and 5 times as likely to report a diagnosis of
ADHD compared to pharmacy students. Whether these factors
were the direct cause or result of the above-mentioned drug and
alcohol use behaviors cannot be determined from this study and
would be of interest to explore in the future.
Compared to the undergraduate population, health care professional students appear less aggressive in nonmedical use of
prescription medications, illicit drugs, tobacco, and alcohol.
Collectively, the health care professional students reported lower
nonmedical use of opioid analgesics or anxiolytics compared to
the undergraduate population. Only 2% to 4% of health care professional students in the current study reported past-year use of
either opioids or benzodiazepines as opposed to 7% past-year
use among college-aged students.5 Similarly, the health care professional students in the current and prior studies reported less
tobacco, binge alcohol drinking, cocaine, and marijuana use than
the undergraduate population.4,10 Despite this, the health care
professional students in our survey still reported higher marijuana use than the 4.8% national rate in adults 26 year or older.2
Perhaps marijuana is not perceived as harmful or addictive to the
body as other types of illicit drugs.
For prescription stimulants, roughly 9% of all students in
our study reported using a prescription stimulant in their lifetime, with 4.6% using it in the past year. In comparison, college students reported a lifetime prescription stimulant use of
approximately 8% and past-year use of 5% to 6%.3,12 The
majority of health care professional students obtained their
prescription stimulant illegally, as more than half of the individuals who reported its use did not have a valid prescription
in their name. Most subjects reported obtaining their prescription stimulant supply from a friend or classmate to improve
concentration or perform better scholastically. Prescription
stimulants are considered scheduled II controlled medications
in the United States and have strict dispensing rules due to the
high potential of abuse and physical dependence. The act of
possessing a controlled substance without a valid prescription
is a violation of the law.13 Interestingly, a majority (80.0%) of
users stated they did not plan to continue stimulant use after
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Bidwal et al
541
Table 6. Past-Year Nonmedical Use of Medications and Illicit Drugs.
Pharmacy
(n ¼ 309)
Medicine
(n ¼ 173)
Prescription stimulants, no. (%) respondents
19/309 (6.1)
18/173 (10.4)
Caffeine pills, no. (%) respondents
32/309 (10.4) 11/173 (6.4)
Caffeinated energy drinks, no. (%) respondents
141/309 (45.6) 77/173 (44.5)
Ephedrine, no. (%) respondents
2/309 (0.6)
2/173 (1.2)
OTC pseudoephedrine for nonmedical purposes, no. (%) respondents
12/309 (3.9)
6/173 (3.5)
Dextromethorphan (ie, Robitussin) for nonmedical purposes, no. (%) respondents
4/309 (1.3)
4/173 (2.3)
Promethazine/Phenergen þ codeine for nonmedical purposes, no. (%) respondents
0
1/173 (0.6)
Beta-blockers for nonmedical purposes, no. (%) respondents
11/309 (3.6)
4/311 (2.3)
Opioids/narcotic analgesics for nonmedical purposes, no. (%) respondents
7/309 (2.3)
7/173 (4.0)
Anxiolytics/benzodiazepines for nonmedical purposes, no. (%) respondents
9/309 (2.9)
3/173 (1.7)
Cigarettes, no. (%) respondents
25/209 (8.1)
26/173 (15.0)
Smokeless tobacco, no. (%) respondents
23/309 (7.4)
22/173 (12.7)
Any alcohol use, no. (%) respondents
198/309 (64.1) 125/173 (72.3)
Binge alcohol use (5 or more drinks on the same occasion)
96/309 (31.1) 58/173 (33.5)
Heavy alcohol use (5 or more drinks on the same occasion on 5 or more days within a 28/309 (9.1)
19/173 (11.0)
30-day period), no. (%) respondents
Marijuana (ie, pot, weed)
23/309 (7.4)
36/173 (20.8)
Methamphetamine (ie, meth, crystal, ice), no. (%) respondents
0
1/173 (0.6)
Cocaine, no. (%) respondents
1/309 (0.3)
2/173 (1.2)
Crack, no. (%) respondents
1/309 (0.3)
1/173 (0.6)
Hallucinogens (ie, LSD, PCP, mushrooms), no. (%) respondents
2/309 (0.6)
3/173 (1.7)
Anabolic steroids, no. (%) respondents
0
0
Heroin, no. (%) respondents
1/309 (0.3)
0
Inhalants (ie, glue, solvents, gas), no. (%) respondents
1/309 (0.3)
0
Physician assistant
P
(n ¼ 107)
value
15/107 (14.0)
7/107 (6.5)
52/107 (48.6)
0
2/107 (1.9)
3/107 (2.8)
0
1/107 (0.9)
0
4/107 (3.7)
17/107 (15.9)
11/107 (9.5)
72/107 (67.3)
38/107 (35.5)
7/107 (6.5)
.032
.232
.800
.520
.610
.540
.300
.330
.100
.580
.160
.300
.190
.670
.460
9/107 (8.4)
0
2/107 (1.9)
0
1/107 (0.9)
2/107 (1.9)
0
1/107 (0.9)
<.001
.300
.280
.720
.520
.011
.640
.430
Abbreviations: OTC, over-the-counter; LSD, lysergic acid diethylamide; PCP, phencyclidine.
graduating from their professional program. Unlike other illicit drugs that are typically used to obtain a high, prescription
stimulants are presumably being misused primarily for academic purposes.
Various lifestyle habits may contribute to nonmedical use of
prescription medications as well as illicit drugs, tobacco, and
binge/heavy alcohol use among health care professional students. As noted earlier, health care professional students seem
to be under greater amounts of stress (almost twice as much
based on the PSS score) than the general adult population. Perhaps the rigors of a graduate school curriculum, poor study
habits (as indicated by the high frequency of reported procrastination), pressures of obtaining postgraduate residency positions, or decreased sleep (especially during examination
time) may increase the amount of stress experienced by these
students. Of note, more than 60% of the general adult population obtain more than 7 hours of sleep per night, whereas the
majority of health professional students averaged less than 7
hours on an average night.14
Based on our study’s results, health care professional programs may wish to invest more resources to address the stress
levels and increase awareness of illicit drug use among students.
Programs may consider the need to promote and provide additional resources such as counselors, support groups, or relaxation
training. A relatively large amount of students reported various
psychiatric diagnoses, conditions which often benefit from emotional and psychological support. Possible methods to promote
awareness are to incorporate topics on substance abuse into the
curriculum earlier on and to increase understanding of the potential negative legal and medical consequences of illicit drug use.
Support groups and stress coping strategies to counter stress levels have been shown to be beneficial in the undergraduate population and nursing programs and thus may be beneficial for
health care professional students.15-17
Limitations
Several limitations should be considered before assessing the
implications of our study. First, surveys by nature lend to
recall bias since subjects must remember their past experiences. Second, although responses were completely confidential, students may have chosen not to take part in the survey or
answer questions to the fullest extent in fear of potential
repercussions (ie, jeopardizing their intern license or career).
This may have resulted in an underrepresentation of actual
drug, tobacco, and alcohol use. Third, although surveys are
a useful and an efficient tool in obtaining general information
about a target population, it is difficult to assess causality.
Finally, e-mails and the Internet were the primary source for
recruitment and survey administration. This may have introduced selection bias, since individuals who do not look at
their e-mail or Internet regularly would by definition be
excluded. However, consistencies of information with this
study and prior health care student surveys support the current
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542
Journal of Pharmacy Practice 28(6)
results. Various sources have also demonstrated the validity
and reliability of online data collection for research when
compared to traditional methods.18-20
7.
Conclusion
Similar to the undergraduate student population, nonmedical
use of prescription medications, binge drinking, heavy alcohol
use, cigarette smoking, and marijuana were prevalent in the
health care professional student population. Medicine and PA
students reported a higher incidence of a diagnosed anxiety disorder, major depressive disorder, or ADHD compared to pharmacy students. Correspondingly, medicine and PA students
were more likely to report recent use of prescription stimulants
and marijuana than pharmacy students. All 3 health care professional students had approximately double the PSS stress score
than the general adult population. The information presented
in this study may help health care programs better understand
their student population, which may lead to a reassessment of
student resources and awareness/prevention programs.
8.
9.
10.
11.
12.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
13.
Funding
14.
The author(s) received no financial support for the research, authorship,
and/or publication of this article.
15.
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