Prescription Stimulant Misuse Among Nursing Students

Authors: Sebastian Magnotti, Avery Beatty, Erek Bickford, Isabella Channell, Lisa Weyandt

Abstract

Nonmedical prescription stimulants are used to reduce symptoms of inattention, impulsivity, and hyperactivity in children and adults with attention-deficit hyperactivity/disorder. They are Schedule II controlled substances because of their high potential for dependence, and individuals who misuse them without a valid prescription are subject to criminal charges. Stimulant medications are also associated with common side effects (e.g., insomnia) as well as more serious but less common side effects (e.g., arrhythmias). Despite the potential health and legal consequences, misuse of prescription stimulants has become a public health crisis on college campuses in the United States. Neurocognitive enhancement is the primary reason that college students report misusing prescription stimulants, despite no enhancement of cognitive functioning when taken by healthy adults. Nursing students may be at risk for misuse because of their high levels of academic and clinical demands and because many start misusing in nursing school. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the databases PubMed, Science Direct, EBSCOhost, and Academic OneFile were systematically searched to investigate the (a) percentage of prescription stimulant misuse studies that have included nursing students, (b) prevalence of prescription stimulant misuse among nursing students, (c) motivations for prescription stimulant misuse among nursing students, and (d) demographic factors associated with increased use among nursing students. Results revealed that of the 197 studies conducted within the past decade (2010–2021), only 1.02% (two) included nursing students. Future studies must investigate the prevalence and nature of prescription stimulant misuse among nursing students.

Prescription stimulants, including methylphenidate (e.g., Ritalin), amphetamine compounds (e.g., dextroamphetamine; Adderall), and lisdexamfetamine dimesylate (e.g., Vyvanse), are commonly used in the treatment of attention-deficit hyperactivity/disorder (ADHD; Barkley, 2004; Mechler et al., 2022). Decades of research support that prescription stimulants are widely regarded as safe and effective at reducing ADHD symptoms of inattention, impulsivity, and hyperactivity in children, adolescents, and adults when taken as prescribed (Adler et al., 2013; Biederman & Spencer, 2008; Castells et al., 2018; Weyandt et al., 2018). Common dose-dependent side effects include decreased appetite, weight loss, headache, insomnia, abdominal pain, dizziness, nervousness, emotional lability, and dry mouth (Solanto, 2001; Weyandt et al., 2014). Serious side effects can also occur when stimulant medications are misused or when they are taken intranasally or intravenously (Greydanus, 2015; Volkow et al., 1995; Westover & Halm, 2012). In rare cases, stimulant medications can result in cardiac arrhythmias and death among individuals with preexisting structural and/or functional cardiac abnormalities (Vetter et al., 2008; Westover & Halm, 2012). Because of their high potential for abuse that can result in dependence, prescription stimulants are classified by the United States Drug Enforcement Administration as Schedule II medications (United States Drug Enforcement Administration, 2021). As a result, prescription stimulants are considered a controlled substance by federal and state laws, and individuals who misuse them without a valid prescription are subject to criminal charges.

Despite the potential health and judicial consequences, misuse of prescription stimulants has become a serious public health problem within the general population but particularly on college campuses across the United States (as well as internationally; Benson et al., 2015; A. DeSantis et al., 2010; Dussault & Weyandt, 2013; Gudmundsdottir et al., 2020; Holt & McCarthy, 2020; Thornton et al., 2020; Verdi et al., 2014; Weyandt et al., 2016). Misuse of prescription stimulant medication refers to taking stimulants without a valid prescription, use of stimulants other than as prescribed, taking prescription stimulants to feel euphoria, or selling/sharing a valid prescription medication (A'see & Cantey, 2019; NIDA, 2020; Weyandt et al., 2016). Several meta-analyses and systematic reviews have substantiated that misuse of prescription stimulants has risen sharply among college students without ADHD compared with a decade ago (Benson et al., 2015; Weyandt et al., 2013, 2016). This rise in misuse corresponds with increasing rates of prescriptions for stimulants and increasing numbers of individuals with ADHD attending college (Weyandt & DuPaul, 2013). For example, Chai et al. (2012) reported that the number of prescriptions for stimulant medications for children and adolescents with ADHD in the United States increased by 46% between 2002 and 2010. Between 2008 and 2012, Muzina (2014) reported that prescription stimulant medications for adults increased by 50%. In 2000, Babcock and Byrne reported a lifetime prevalence rate of prescription stimulant misuse behavior of 16.6% among college students, whereas Messina et al. (2014) reported a lifetime prevalence rate of 25.4% just 4 years later. Others, including more recent studies, have reported a self-reported misuse prevalence rate as high as 80% (e.g., A. D. DeSantis et al., 2008; Faraone et al., 2020; Wilens & Kaminski, 2019). Furthermore, Holt and McCarthy (2020) recently reported that more than 50% of students continue to misuse prescription stimulants after graduating from college.

Studies exploring the motivations for prescription stimulant misuse among college students consistently indicate that neurocognitive and academic enhancement (i.e., increased ability to focus and sustained attention, completion of tasks) are primary reasons that college students misuse prescription stimulants, despite empirical studies that suggest minimal to no enhancement of cognitive functioning when healthy young adults take these medications (Advokat, 2010; Ilieva et al., 2015; Marraccini et al., 2016; Smith & Farah, 2011; Weyandt et al., 2016). Indeed, Weyandt et al. (2018) conducted a double-blind placebo-controlled pilot study and found no evidence of cognitive enhancement in healthy college students taking 30 mg of Adderall compared with placebo and, contrary to expectations, found evidence of short-term memory impairment. Additional reasons reported by college students for misusing prescription stimulants include weight loss, curiosity, getting high, and/or to counteract the effects of alcohol (Blevins et al., 2017; Compton et al., 2018; Marraccini et al., 2017; Thornton et al., 2020). Psychological findings support that students who report higher rates of attention difficulties, internal restlessness, alcohol and illicit substance use, risky behaviors, and problems with time management and executive functions report higher rates of prescription stimulant misuse (e.g., Holt & McCarthy, 2020; Moore et al., 2014; Munro et al., 2017; Novak et al., 2007). Higher rates also have been found among men, Whites, and sorority and fraternity members. Studies also suggest that students seeking professional degrees such as dental hygiene and pharmacy, and particularly nursing students, may be at a particular risk for misusing prescription stimulants (e.g., Dussault & Weyandt, 2013; Holt & McCarthy, 2020; Janusis & Weyandt, 2010; McCabe et al., 2011; McNiel et al., 2011; Rabiner et al., 2009; Verdi et al., 2014).

Nursing programs, unlike many other college student majors, require students to maintain minimum grades in specific courses (e.g., C+ or higher) as well as a relatively high grade point average (e.g., 3.0) to continue in the program. Nursing students are also required to perform well in clinical settings, and studies support these academic expectations in conjunction with clinical experiences can be highly taxing for students (Rafati et al., 2017). Indeed, research substantiates that nursing students report significantly higher levels of stress than other health sciences students (Labrague, 2013). Furthermore, Norman and Ford (2018) found that college students who experienced academic impediments and/or grade strain during the past academic year were significantly more likely to misuse prescription stimulants. Similarly, De Bruyn et al. (2019) reported that medical students who reported higher levels of stress were at a higher risk for misusing prescription stimulants. These findings may have clinical implications for the nursing profession in general, as research has shown that 14%–18% of registered nurses in the United States struggle with substance use or abuse issues, including prescription-type misuse (Monroe & Kenaga, 2010; Monroe et al., 2013; Trinkoff et al., 2022), and many nurses with substance use issues reportedly began using substances while they were in nursing school (Boulton & O’Connell, 2017; Monroe, 2009; Trinkoff et al., 2022). Importantly, Trinkoff et al. (2022) recently found that 9.9% of registered nurses misuse prescription medications. Recently, Starr (2019) emphasized the need for greater information regarding substance dependence and diversion of prescription medications among nursing professionals, including nursing students. These findings raise critical questions pertaining to nursing What is the prevalence and associated factors of prescription stimulant misuse among nursing students, and what factors are associated with prescription stimulant misuse among these students? Given that a substantial number of studies have been conducted during the past two decades concerning prescription stimulant misuse among college students in general, the purpose of this article is to systematically review and summarize the literature within the past decade regarding information concerning prescription stimulant misuse among nursing students. Specifically, the purpose of the present review is to explore the (a) percentage of prescription stimulant misuse studies that have included information regarding nursing students, (b) prevalence of prescription stimulant misuse among nursing students, (c) motivations for prescription stimulant misuse among nursing students, and (d) demographic factors such as age, sex, gender, and ethnicity that may be associated with increased risk of misuse among nursing students.

METHODS

Search and Retrieval

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Liberati et al., 2009; Moher et al., 2009), we conducted a systematic literature review of studies examining the misuse of prescription stimulant medication in undergraduate college nursing students. For data analyses, only undergraduate college nursing students, that is, students enrolled in an accredited undergraduate Associate Degree in Nursing and/or Bachelor of Science in Nursing program, were included in this study. Misuse of nonmedical prescription stimulant medications was defined as the use of stimulants (e.g., Adderall or Vyvanse) without a valid medical prescription or the use for something other than directed by a prescribing health care provider (e.g., using more frequently, larger doses, combining with other drugs, or for other nonmedical purposes).

All researchers were trained in the systematic review study protocol before article and data retrieval. A combination of the following key terms were searched within the bibliographic databases PubMed, Science Direct, EBSCOhost, and Academic OneFile: “college students and psychostimulants and nursing students,” “prescription stimulant misuse and neurocognitive enhancement,” “prescription stimulant misuse,” “undergraduate nursing students,” “prescription stimulant misuse and prevalence and college nursing students,” “prescription stimulant misuse and motivation and college nursing students,” and/or “prescription stimulant misuse and ethnicity and college nursing students.” The search included articles that were published between January 1, 2010, and May 2021. The initial search of the databases yielded 197 studies. After exclusion criteria were applied, a search of the databases yielded two studies.

Eligibility Criteria

Studies Were Included in the Systematic Review if They Met the Following Criteria

In order for a study to be included in the systematic review, each article must have met the following

• The study examined nonmedical prescription stimulants use or misuse (i.e., using prescription stimulants without a prescription or the use outside of the prescribing doctor's recommendations). Studies that did not explicitly identify nonmedical prescription stimulant misuse were excluded.
• The study included an undergraduate college nursing student sample. Studies that did not explicitly identify nonmedical prescription stimulant use or misuse among undergraduate nursing students were excluded.
• The study was published no earlier than 2010.
• The study was published in English.
• The study was conducted in North America.
• The study was relational, experimental, or quasi-experimental.
• The study used an original or secondary data set (i.e., reviews and meta-analyses were excluded).

RESULTS

One hundred ninety-seven titles were initially identified via the bibliographic databases including PsycINFO, PubMed, Science Direct, EBSCOhost, and Academic OneFile. With regard to the first research question concerning the percentage of prescription stimulant misuse studies that included nursing students, findings revealed that 1.02% (two studies) included nursing students. Combined, these studies yielded 4,282 nursing student participants. Boulton and O'Connell (2017) employed a cross-sectional, correlational design to investigate past-year substance use, including amphetamines or other prescription stimulant drugs for academic enhancement, and its relationship to perceived peer use and harmfulness of peer use in a convenience sample of student nurses derived from the National Student Nurses' Association (N = 60,000). Their results showed that approximately 8% of undergraduate nursing students reported using nonprescribed stimulants for academic enhancement and that students reportedly misused prescription medications at greater rates as their stress score increased.

Furthermore, Kirkpatrick and Boyd (2018) utilized a cross-sectional design to investigate nonmedical prescription stimulant use in a convenience sample of undergraduate nursing students (N = 249) attending a large Midwestern university. The study also compared stimulant use with participant scores on the Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) measure, a well-validated substance use screening tool. Results revealed that, in the past year, 10.4% of nursing students reported using prescription stimulants nonmedically and 51% screened positive for alcohol and drug misuse behaviors on the CRAFFT. Regarding the second research question concerning the prevalence of prescription stimulant misuse among nursing students, these two studies collectively revealed that 9.2% of the sample reported using prescription stimulants without a valid prescription (e.g., 10.4% and 8%).

Finally, regarding the role of demographic factors such as age, sex, gender, and ethnicity in prescription stimulant misuse among undergraduate nursing students, most of the participants were female (93.9%) compared with 6.1% male Boulton and O'Connell (2017) reported that 79% of their sample identified as White, 8% identified as Asian, and 6% identified as African American, whereas Kirkpatrick and Boyd (2018) did not provide race/ethnicity information other than stating the sample “closely resembled the overall population of the undergraduate nursing students at the university.” In addition, Kirkpatrick and Boyd did not find a significant association between any demographic variables and prescription stimulant misuse, whereas Boulton and O'Connell found that male students were at a higher risk for misuse than female students and that male students “born in this country” were at a significantly higher risk for substance use compared with those born outside the United States. Finally, age was reported as a significant predictor for substance use in one study (with increasing age associated with decreased use); however, the study did not delineate between substances (Boulton & O'Connell, 2017).

DISCUSSION

Prescription stimulant misuse is a public health crisis across college campuses in the United States, with estimates varying widely from less than 10% to 80% (e.g., Faraone et al., 2020; Weyandt et al., 2009). On the basis of research by Norman and Ford (2018) and De Bruyn et al. (2019) concerning the relationship between academic stress and prescription stimulant misuse, nursing students may be particularly at risk. Given the potential harm this behavior confers on oneself and potentially others (e.g., patients), as well as the high rate of substance use disorders among nurses who often begin in college and continue after (Holt & McCarthy, 2020; Monroe, 2009; Starr, 2019; Trinkoff et al., 2022), the purpose of this study was to explore prescription stimulant misuse among college nursing students. Specifically, this study conducted a systematic review of the prescription stimulant misuse literature in college students over the past decade to identify the percentage of prescription stimulant misuse studies that included information regarding nursing students, as well as the prevalence, motivations, and role of demographic factors among these students.

Results revealed that of the 197 studies conducted within the past decade (2010–2021), only 1.02% (two) included nursing students. This finding was unexpected and somewhat startling and speaks to the dire need for more research on nursing students, particularly given the prevalence results derived from the present studies. Specifically, an average of 9.2% of nursing students across the studies reported using prescription stimulants without a valid prescription (10.4% and 8%). Notably, 68% of these students reported that they began misusing prescription stimulants while in college and they did not use them before attending college (Kirkpatrick & Boyd, 2018). Overall, these prevalence findings are similar to those reported by McNiel et al. (2011) among dental hygiene students (12%); however, they are lower than an early study concerning graduate students (Verdi et al., 2014). The present findings support Salman et al.'s (2017) call for all medical schools to “take a bold step and critically examine the issue of nonmedical prescription stimulant use by medical students” (p. 901) and apply to nursing programs as well.

With regard to motivations for misuse, the present review found that Kirkpatrick and Boyd (2018) did not investigate student nurses' motivations for misuse of prescription stimulants. However, Boulton and O'Connell (2017) found that nursing students reported misusing prescription stimulant medications for academic enhancement, which aligns with current research on prescription stimulant misuse among college students (e.g., Antshel et al., 2021; Benson et al., 2015; Gudmundsdottir et al., 2020; Marraccini et al., 2016). These findings harken the need for training programs to conduct additional research to help (a) identify nursing students at risk for misusing prescription stimulants, (b) increase awareness and education about prescription stimulant misuse among nursing students in general, and (c) explore alternative methods to help increase nursing students' attention and ability to focus (e.g., mindfulness practice, improved study habits, time management, stress management). Interventions that follow from this future research may play a critical role in helping to curb the onset of substance use problems that often persist after college and into the nursing profession. These findings may also have clinical implications for the nursing profession in general, as research has shown that 14%–18% of registered nurses in the United States struggle with substance use or abuse issues, including prescription-type misuse (Monroe & Kenaga, 2010; Monroe et al., 2013; Trinkoff et al., 2022). Importantly, Trinkoff et al. (2022) recently found that 9.9% of registered nurses misuse prescription medications, and Trinkoff et al. (1999) found that nurses with easy access to prescription medications were most likely to have misused these drugs. Reportedly, many cases of substance use problems among nurses begin in college nursing programs and continued after graduation, underscoring the urgent need for information regarding prescription stimulant misuse among nursing students.

Importantly, most of the participants in this systematic review were White women (93.9% vs. 6.1% male); however, men were at an increased risk of misusing in one of the two studies. The extant literature is mixed regarding gender, as some studies reported that men were more likely to misuse prescription stimulants, whereas other studies report no differences. It is important to note that whereas one of the studies reported ethnicity/race as 79% White, 8% Asian, and 6% African American (Boulton & O'Connell, 2017), the other study did not provide race/ethnicity information (Kirkpatrick & Boyd, 2018). Future studies would benefit from including ethnicity/race information as well as research concerning nonbinary nursing students and other students from minoritized backgrounds, as preliminary studies suggest that these students may be at an even greater risk for misusing substances such as prescription stimulants (Li & Mustanski, 2018).

Interestingly, this review found that age was a significant predictor of substance use in general, with increasing age associated with decreased use, although information specific to prescription stimulants and age effects were not provided (Boulton & O'Connell, 2017; Kirkpatrick & Boyd, 2018). Given preliminary findings with college students that suggest that prescription stimulant misuse rates are highest among first- and second-year students and rates tend to decline with year in college (Arria & DuPont, 2010), future studies are needed to explore whether this trend applies to nursing students as well or whether these students follow a different trajectory of misuse. Although empirical studies are needed to explore this pattern, it may behoove training programs to consider whether first- and second-year nursing students would benefit from additional academic supports and education about prescription stimulant misuse. Although not the focus of this review, Kirkpatrick and Boyd found that prescription stimulant misuse was highly associated with use of alcohol and other drugs based on the results of the CRAFFT. Tejedor-Cabrera and Cauli (2019) also reported high CRAFFT scores among nursing students in the University of Valencia (Valencia, Spain) with over 50% reporting high alcohol intake. These findings raise additional questions regarding potential polysubstance use among nursing students and the role prescription stimulants might play in this behavior.

It is important to note the methodological limitations of the studies included in the present review. Most importantly, there is a dearth of studies available that focus on prescription stimulant misuse among nursing students, and this review was only able to identify two of 197 studies conducted in the past decade. Both studies were based on convenience samples with varying response rates, limiting the generalizability of the studies. For example, Boulton and O'Connell (2017) reported an 8% response rate of approximately 60,000 nursing students, whereas Kirkpatrick and Boyd (2018) reported a 37.6% response rate; however, the total sample size was small (N = 249). It is unknown, for example, whether nursing students who did not participate in the studies would have reported higher or lower rates of prescription stimulant misuse. Given that the studies were based on self-report, it is also unknown whether those student nurses who did participate provided accurate information. In addition, both studies were cross-sectional in design; consequently, information regarding prevalence rates over time were not available, and neither study reported effect sizes or statistical power. Future studies would benefit from larger, representative samples that ideally are longitudinal in design and seek to better understand the prevalence and nature of prescription stimulant misuse among nursing students. Another limitation included the different ways prescription stimulant misuse was operationalized and measured in each study. For example, Boulton and O'Connell investigated if students used amphetamines or other prescription stimulant drugs (e.g., Adderall) to help them study and/or enhance their academic performance. However, this question does not account for any other commonly endorsed motives for prescription stimulant use, including recreationally (i.e., to get high) or to lose weight. Furthermore, Kirkpatrick and Boyd (2018) examined if student nurses ever used prescription stimulants nonmedically, and thus, the motivations for misuse in this sample of student nurses remain unknown. To properly understand the prevalence and motivations behind nonmedical prescription stimulant misuse among nursing students, future studies should employ a more descriptive definition and measure of stimulant misuse.

In conclusion, the present systematic review revealed that, during the past decade, only 1% of studies that investigated prescription stimulant misuse among college students included nursing students. Collectively, the studies revealed that 9.2% of the sample reported using prescription stimulants without a valid prescription (e.g., 10.4% and 8%). Consistent with the extant literature, neurocognitive enhancement was the primary motivation for prescription stimulant misuse among nursing students sampled. These findings underscore the need for future studies to further investigate the prevalence and nature of prescription stimulant misuse among nursing students.