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College Students’ Perceptions About Prescription Drug Misuse Among Peers

Published online ahead of print, December 2020
March 2021 Vol 14, No 1 - Clinical, Original Research
Chibuzo Iloabuchi, BPharm; Eiman Aboaziza, MD; Xiaohui Zhao, MS, PhD; J. Douglas Thornton, PhD, PharmD, BCPS; Nilanjana Dwibedi, BPharm, MBA, PhD
Mr Iloabuchi is PhD Candidate, Department of Pharmaceutical Systems and Policy, School of Pharmacy, and Dr Aboaziza is PhD Candidate, Department of Clinical & Translational Science, West Virginia University, Morgantown; Dr Zhao is Consultant, IQVIA, Cambridge, MA; Dr Thornton is Assistant Professor, Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, TX; Dr Dwibedi is Associate Professor, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown.
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Abstract

BACKGROUND: Prescription drug misuse is an escalating public health problem that is prevalent among college students. Various factors, such as sex, age, race, mental health conditions, and fraternity and sorority membership, increase the risk for prescription drug misuse. Peer influences may also pose significant risks for starting prescription drug misuse, because peers are the primary source of misused prescription drugs among college students.

OBJECTIVES: To examine college students’ beliefs about prescription drug misuse among their peers and to understand their beliefs about the available and potential intervention efforts to reduce prescription drug misuse.

METHOD: We conducted a cross-sectional survey of 312 college students aged 18 to 30 years who were enrolled in a large midwestern US university. The survey included questions about the responders’ demographic characteristics, beliefs, and perceptions regarding prescription drug misuse among their peers and potential reduction programs for prescription drug misuse.

RESULTS: The respondents’ mean age was 21 years, and most (65%) respondents were women. A majority (90%) of the respondents were enrolled in the university as full-time students. More than 60% of the respondents reported knowing someone with prescription drug misuse in the past 12 months. Fraternity or sorority members were more likely to report peer prescription drug misuse than nonmembers (83% vs 60%, respectively; P = .017). Stimulants were the most misused drug class, accounting for 75% of all reported peer prescription drug misuse. Approximately 60% of the misused prescription drugs were sourced from peers, which included friends, roommates, and classmates. A total of 73% of respondents said that prescription drug misuse was a problem among college students and 67% agreed that interventions were needed to reduce prescription drug misuse. The perceived need for interventions varied by peer prescription drug misuse. A total of 90% of students whose peers did not misuse prescription drugs said that interventions were needed, but only 67% of those with peer prescription drug misuse thought that interventions were needed.

CONCLUSION: Our findings indicate that peer prescription drug misuse is very common among college students, and the most misused drug class is stimulants. Survey respondents perceived that the current interventions used to address prescription drug misuse are not very effective or may not be targeting the right population. Peer prescription drug misuse influences college students’ perceptions about the risks and harms of prescription drug misuse, as well as the need for interventions.

KEY WORDS: college students’ perceptions, interventions for drug misuse, peer influence, prescription drug misuse, stimulants

This article was published online ahead of print in December 2020.

Am Health Drug Benefits.
2021;14(1):29-38

Manuscript received May 27, 2020
Accepted in final form August 5, 2020

Disclosures are at end of text

Prescription drug misuse and abuse are escalating national health crises.1,2 Misuse involves the intentional or unintentional use of medications without a prescription, for purposes for which it was not intended, or in a manner different from how it was prescribed.3 Prescription drugs are the third most misused substances behind marijuana and alcohol, and young adults aged 18 to 25 years have the highest prevalence of prescription drug misuse.3

The 2018 National Survey of Drug Use and Health reported that 16.9 million Americans aged ≥12 years misused a prescription drug in the past year.4 Prescription pain relievers were the most misused drug, and approximately 1.9 million young adults aged 18 to 25 years misused pain relievers in the year before the survey was conducted.4 The other prescription drug classes that were frequently misused included sedatives, tranquilizers, and stimulants.2,4,5

Young adults aged 18 to 25 years misuse prescription drugs more than any other age-group, and prescription drug misuse has become a major concern among college students.4,6 More than 40% of young adults in college report having misused some type of prescription psychotherapeutic drug at least once in their lifetime.5 This rising trend of prescription drug misuse is paralleled by an increase in adverse health consequences, including emergency department visits and hospital admissions.7,8

The misuse of stimulants is associated with cardiovascular problems, psychiatric issues, and drug abuse or dependence.9 When stimulants are consumed with alcohol, they increase the risks for alcohol poisoning and alcohol-related injuries.10 There has been a dramatic increase in emergency department visits related to attention-deficit/hyperactivity disorder medications, with an increase from 2131 visits in 2005 to 8148 visits in 2010 among persons aged 18 to 25 years.11

Other negative outcomes that may result from prescription drug misuse include drug overdose, initiating injection drug use, and death.12 The Substance Abuse and Mental Health Services Administration reported that more than 2 million hospital admissions for substance abuse treatment were recorded in 2017 alone.13

Previous studies of prescription drug misuse among college students have examined the risk factors and motivations for prescription drug misuse.2,14,15 Some of these studies reported that being male, being white, living off campus, and being a member of a fraternity or a sorority are risk factors associated with misusing prescription opioids.2,14,15 In addition, many young people perceive prescription drugs to be safer than illegal drugs, because they are prescribed by a physician.5 These attitudes are amplified by the dramatic shift in independence and the influence of peers among college students.16,17

The overarching theme is that peer influence and injunctive and subjective norms pose the most significant risks for starting prescription drug misuse, because peers are the primary source of misused prescription drugs.18-23 Because subjective norms and normative beliefs play a role in the initiation of substance use, we explored the normative beliefs and perceptions of respondents toward their peers’ prescription drug misuse.

Although previous studies have increased our knowledge of the prevalence of, risk factors for, and motives for prescription drug misuse among college students, several issues remain unexamined. First, the pattern of prescription drug misuse varies considerably between individual colleges, and there are only few studies that focus on college students in particular geographic areas,20,21 such as West Virginia, the state with the highest drug abuse in the nation.22

Second, there is scant information regarding how college students perceive prescription drug misuse as a problem among their peers. Such information is essential to evaluate the needs of interventions that reduce prescription drug misuse from the perspective of college students. Furthermore, despite continued efforts by academic institutions and organizations,24,25 there is a lack of sufficient data to demonstrate the effectiveness of specific prevention and intervention efforts. Proposed interventions range from educating students on the dangers and consequences of prescription drug misuse,25 correcting the social norm that “everyone is misusing or abusing” prescription drugs,26 to managing the environment with local law enforcement.27,28

A knowledge gap exists with respect to how college students perceive the availability and effectiveness of such interventions. Such knowledge is valuable to reveal the extent of reach of these interventions. Therefore, this study aimed to examine college students’ beliefs about prescription drug misuse among their peers, and to examine their beliefs about the available and potential intervention efforts to reduce prescription drug misuse.

Method

We conducted a cross-sectional online survey among students aged 18 to 30 years who were enrolled at West Virginia University (WVU), the largest university in West Virginia. All the study instruments and procedures were reviewed and approved by the WVU Institutional Review Board. After that approval, we used a convenience and snowball sampling strategy to recruit participants using listservs, social media, and printed posters.

The survey was developed using Qualtrics XM (2016 Qualtrics; Provo, UT). Responses were collected from March 2017 to February 2018. All survey respondents provided informed consent to participate in the study before starting the survey. Participation in the survey was anonymous and voluntary. No incentives were provided for participating in the study.

The online survey contained questions regarding ­demographic characteristics, beliefs about prescription drug misuse among college students and peers, and beliefs about interventions for reducing prescription drug misuse among college students (see Appendix). The participants were asked to report variables, including date of birth, sex, state of permanent residence, race or ethnicity, level in college, area of study, annual income, housing, membership of a social fraternity or sorority, employment status, and marital status (married, widowed, divorced or separated, never married, member of an unmarried couple).

The perceived prevalence of prescription drug misuse among peers was assessed by asking whether the students knew someone who misused prescription drugs in the past 12 months. The perceived prevalence of prescription drug misuse among peers and college students was measured by 5 percentile ranges (0%-20%, 21%-40%, 41%-60%, 61%-80%, and 81%-100%).

A total of 3 classes of prescription drugs were assessed, including stimulants (eg, methylphenidate, amphetamines), sedatives/tranquilizers (eg, diazepam, alprazo­lam, lorazepam, clonazepam, zolpidem), and opioid analgesics (eg, hydrocodone plus acetaminophen, oxycodone/oxycodone plus acetaminophen, methadone).26 The participants were asked which prescription drug class they believe was the most misused by their peers.

A total of 6 frequently reported motivations (which were identified from a review of previously published articles) were assessed, which included improving academic performance, reducing stress, recreational use (eg, to feel good or get high), reducing nervousness in a social scene or to party, enhancing athletic performance, and losing weight.26-30 The participants were asked to report all the motivations underlying prescription drug misuse among their peers.

The participants were asked to report all the sources (ie, peers, family members, the Internet, prescribers, pharmacists/pharmacist assistants, and others) from which their peers obtained the prescription drug for misuse. The ease of obtaining prescription drugs from each source was evaluated by calculating the mean score of a 4-point response set ranging from very difficult (1) to very easy (4).

The perceived relevance of prescription drug misuse as a problem among college students was measured by asking how concerned the participants were about prescription drug misuse among college students and peers, as well as whether the participants perceived prescription drug misuse as a problem (true, false, not sure) for themselves, their peers, and college students in general. The response set for concern ranged from not concerned at all (1) to very concerned (4).

The participants were asked whether interventions were needed to reduce prescription drug misuse among their peers. The responses ranged from strongly disagree (1) to strongly agree (4). The perceived need was represented by the mean score of the responses. The participants were asked about their awareness of any prescription drug misuse intervention and a current program that provides consulting services for prescription drug misuse (Student Assistance Program) at WVU. The perceived availability was measured dichotomously (yes or no), with “yes” being defined as both of the questions having a response of “yes.”

The perceived effectiveness of 4 prescription drug misuse interventions—the Student Assistance Program, education on the dangers and consequences, correcting the social norm, and environment management—were represented by the mean score of a 4-point response set ranging from strongly disagree (1) to strongly agree (4).

The beliefs of effective prescription drug misuse interventions were explored by the following open-ended question: “What would be an effective intervention to reduce prescription drug misuse among peers/college students?”

Statistical Analysis

Frequencies, means, and standard deviations (SDs) were used to describe the study sample. Bivariate association between the students’ characteristics and the misuse of prescription drugs by peers was assessed using chi-square statistics for dichotomous and categorical variables. One-way analyses of variance and post-hoc pairwise comparisons using Tukey’s Honestly Significant Difference tests were conducted for continuous variables.

A P value of <.05 was considered statistically significant. All the quantitative analyses were conducted with SAS version 9.4 (SAS Institute, Inc; Cary, NC). The ATLAS.ti qualitative analysis tool (Scientific Software Development GmbH; Berlin, Germany) was used to analyze the responses to the open-ended questions using word frequencies and word cloud.

Results

A total of 359 participants responded to the survey; after removing the incomplete responses, we had 341 complete responses. After excluding the respondents who did not meet the age and enrollment eligibility criteria, we had 312 eligible responses that were used for statistical analysis.

Table 1 shows select demographic data for the respondents. The mean age of the respondents was 21 years (SD, 2.85). Approximately 68% of the respondents were women, and more than 90% of the respondents were enrolled as full-time students. More than 68% of the students reported that they live off campus, and 55.6% said they were employed either part time or full time.

Table 1

Of the respondents, 38% said they believed that between 21% and 40% of all college students misuse prescription drugs, and 65% of the respondents said they perceived that less than 40% of college students misuse prescription drugs. A total of 62% of the respondents reported knowing someone who had misused prescription drugs in the past 12 months (Table 1).

The respondents who did and did not report having peers who are misusing prescription drugs were similar in most demographic characteristics (Table 2). The percentages of male and female students who reported peer prescription drug misuse were similar. Freshmen, sophomores, and graduate or professional students all reported similar rates of peer prescription drug misuse.

Table 2

Peer prescription drug misuse was highest (70%) in individuals with a family income of ≥$50,000, and although prescription drug misuse did not differ significantly by type of residence, individuals who lived in off-campus housing reported slightly higher peer prescription drug misuse compared with those who lived on campus (65% vs 56%; P = .120). Students who reported having peers who misuse prescription drugs consisted of a significantly higher percentage of fraternity and sorority members than the students who did not report peer prescription drug misuse (83% vs 60%, respectively; P = .017; Table 2).

Table 3 shows the perceptions regarding prescription drug misuse and interventions among respondents who reported peer prescription drug misuse. Stimulants were the most prevalent prescription drug misused. The most common reasons reported for misuse were recreational use (66%) and improving academic performance (51%). Most (85%) respondents said that peers were the most common source of obtaining prescription drugs for misuse. The majority of respondents noted that prescription drug misuse is a problem for college students (73%) and agreed that interventions are needed to reduce prescription drug misuse (67%).

Table 3

Perceptions about the need for interventions differed significantly by peer misuse (P <.001), level of concern about college students’ prescription drug misuse (P <.001), year in school (P = .004), state of residence (P = .03), and sex (P = .04). Approximately 67% of individuals with peer prescription drug misuse agreed or strongly agreed that interventions are needed, whereas 90% of individuals without peer prescription drug misuse agreed or strongly agreed that interventions are needed.

Awareness of the available interventions was lower for individuals who reported peer prescription drug misuse (P = .04), and a significantly higher proportion of individuals who responded “no” to being aware of prescription drug misuse interventions had peers who misused prescription drugs (78%). More than 20% of participants with peer prescription drug misuse did not know about any available interventions compared with 11% of those without peer prescription drug misuse.

The perceived effectiveness of the Student Assistance Program differed significantly between the peer prescription drug misuse groups (P = .04). Approximately 70% of individuals without peer prescription drug misuse agreed or strongly agreed that the Student Assistance Program could be effective at reducing peer prescription drug misuse compared with only 56% of those with peer prescription drug misuse. The perceived effectiveness of prevention education differed significantly between the peer prescription drug misuse groups (P = .03).

Approximately 80% of individuals without prescription drug misuse agreed or strongly agreed that prevention education can be effective compared with 69% of those with peer prescription drug misuse. The perceived effectiveness of social norm correction was lower for students who had peer prescription drug misuse (P = .005), and more than 70% of students without peer prescription drug misuse agreed or strongly agreed that social norm correction would be effective at reducing peer prescription drug misuse compared with 58% of those with peer prescription drug misuse.

The perceived effectiveness of environmental management differed significantly for those who reported peer prescription drug misuse compared with those who did not (P <.001), and approximately 70% of respondents without peer prescription drug misuse agreed or strongly agreed that environmental management would be effective at reducing prescription drug misuse at their college compared with 40% of those with peer prescription drug misuse (Table 3).

The responses to the open-ended questions that asked what type of interventions should work best to reduce peer prescription drug misuse (see Appendix) were multifaceted. A total of 136 responses were collected. The respondents with peer prescription drug misuse were twice as likely to provide a response to the open-ended question than those without peer prescription drug misuse (67% vs 33%, respectively). We identified 12 common features from all the responses and classified them into 3 main themes—primary prevention, harm reduction, and no need for intervention (Table 4).

Table 4

A total of 21 (15.4%) respondents perceived no need for an intervention. For the primary prevention theme, 53 (53.5%) respondents proposed some form of educational intervention, 20 (20.2%) proposed addressing reasons for prescription drug misuse, and 14 (14.1%) proposed policy or law enforcement. For harm reduction, 14 (43.8%) proposed removing barriers to intervention, 10 (31.3%) proposed family or peer support, and 9 (28.1%) proposed professional treatment for drug use disorders (Table 4). Some examples of the interventions suggested by the survey respondents to the open-ended questions are shown in Table 5.

Table 5

Discussion

The current study explores the perceptions and beliefs of college students regarding prescription drug misuse among their peers. The results of this study show that peer prescription drug misuse is prevalent among college students, and that students perceive that the current interventions used to address prescription drug misuse are not very effective or may not be targeting the right population. Peer prescription drug misuse was very common among college students in our study and more than 50% of the respondents knew a peer who had misused prescription drugs in the past 12 months.

Approximately 62% of college students in our study reported having a peer with prescription drug misuse; this prevalence of peer prescription drug misuse was higher than those reported by previous studies.31,32 Using a sample drawn from a large midwestern US university, Hall and colleagues reported that the rate of peer prescription drug misuse was 44%,31 whereas Babcock and Byrne found that the prevalence of peer prescription drug misuse was 53.4% among respondents attending a northeastern US liberal arts college.32

The greater prevalence of peer prescription drug misuse in this study may reflect an overall increase in prescription drug misuse over the past 15 years,33-35 or may be related to the increased opioid and other drug-related problems that West Virginia has faced within the past decade.3,36,37 Furthermore, this may also depict the regional variation in prescription drug misuse previously reported by Cicero and colleagues that showed a greater prevalence in rural, suburban, and small- to medium-sized urban areas.38

This study’s results show that the survey respondents underestimated the prevalence of prescription drug misuse among college students. Nearly 65% of the respondents thought that less than 40% of college students misused prescription drugs, which is lower than the prevalence reported in the literature.31,32 Findings from previous studies show that college students often overestimate the prevalence of drug misuse among their peers.21,39

Consistent with previous studies,9,40 stimulants were the most often misused drug class, accounting for almost 75% of all reported peer prescription drug misuse in our study. These numbers indicate that prescription stimulant misuse is emerging as a significant problem among college students, predominantly for academic purposes to increase alertness, improve concentration, and aid in studying.41

This rising trend in stimulant misuse may be traced to easier access to these medications through peers and family members who receive prescription stimulants from their physicians. Approximately 60% of the college students in our study reported that drugs that their friends misused were sourced from peers, which included friends, roommates, or classmates. This finding is similar to previous studies reporting that the most common sources of prescription drugs misused by college students are peers and family members.6,9,16,33,34

In our study, students who were members of a fraternity or sorority perceived less need for interventions than individuals who were not members of a fraternity or sorority. Individuals who had peers with prescription drug misuse were less likely to be aware of available interventions and to perceive a lower need for prescription drug misuse interventions. Almost 90% of individuals who did not have peers with prescription drug misuse agreed that interventions were needed to address prescription drug misuse at their college, whereas only 66% of students who had peer prescription drug misuse agreed that there was a need for any intervention.

These differences may be explained by normative beliefs within friend groups of students with peer prescription drug misuse versus those without peer prescription drug misuse. Several studies have established the role of injunctive norms, which refers to the perceived approval of the behavior by their peers, in the initiation of drug use behavior.21-23,35,36 Perceiving that their peers would approve of drug misuse behavior may encourage or help maintain this behavior. This peer approval may manifest as complacency toward the need for, and effectiveness of, the available interventions.37

This finding has significant implications for researchers who are designing interventions on college campuses to address prescription drug misuse. Targeting students who misuse prescription drugs, as well as their peers, may yield better results than focusing solely on the students who are misusing. Interventions that are aimed at the peers of students with prescription drug misuse should focus on increasing their perceptions about the need for interventions and the negative consequences of prescription drug misuse.

Among the 3 major themes identified from the participants’ written responses regarding interventions, primary prevention was the most prominent, with 72.8% of respondents recommending that interventions that implement primary prevention approaches, such as education and addressing or removing the triggers for prescription drug misuse among college students, would be effective.

Education should focus on informing students about the possible short- and long-term effects of prescription drug misuse, changing misconceptions regarding stimulant use for academic reasons, and teaching coping techniques to deal with stress. A 19-year-old female student suggested the following education strategy, stating “Students need to be presented with the facts. We, as a whole, need to stop acting like drug misuse isn’t an extremely severe issue in our current country. Students need to hear testimonies from other students, families, recovering addicts, people in general who lose someone to addiction. I personally have lost a significant other to an opioid overdose. I hate seeing young people all through my town, my state, and my country being torn down by addiction. We need to do something, anything.”

The second most prominent theme was harm reduction approaches for students who are already misusing prescription drugs, including removing barriers to intervention (eg, stigma, cost, and access), peer and family support, and getting help from a professional. While proposing a harm reduction strategy, a 24-year-old female student stated, “I think education on the dangers of overdosing. Also, people who need help can get the help they need without being punished. It also needs to be affordable or free.” Previous studies have explored various harm reduction strategies to help young people with drug misuse.42-44

The third prominent theme was that interventions were not needed. The respondents who supported this theme had more positive attitudes toward prescription drug misuse among college students, and this was correlated with having peer prescription drug misuse. This suggests that having friends who misuse prescription drugs shapes the perceptions about the behavior and its acceptability and decreases the level of concern about the harms and negative outcomes of prescription drug misuse.

Limitations

This study has several limitations that need to be considered when interpreting the results of this study. First, the cross-sectional design of the study precludes any causal inferences; therefore, we cannot assume any temporality of events.

In addition, the participants were asked about their peers prescription drug misuse, and this approach may overestimate the prevalence of prescription drug misuse on the campus; different individuals might have had common friends, and 2 respondents might have been referring to the same person when reporting peer prescription drug misuse.

Finally, we used a convenience sampling approach to recruit participants for this study; hence, the results may not be generalizable to the entire student population in the United States.

Conclusion

This is the first study to explore the perceived needs for interventions among peers of college students who misuse prescription drugs and the perceived effectiveness of available interventions. The insights generated from this study may help to explain why many interventions do not produce the expected outcomes on college campuses. The inclusion of open-ended questions provides valuable insights from friends of students with prescription drug misuse about how to design interventions that may work for their peers. This insight is valuable for researchers and university officials to use when designing future interventions. Further research is needed to understand why students with peer prescription drug misuse perceive very little need for interventions and have fewer positive perceptions about the effectiveness of available interventions. Future studies could focus on understanding the perceptions of harm and consequences of peer prescription drug misuse among individuals with peer prescription drug misuse compared with those without peer prescription drug misuse.

Author Disclosure Statement

The authors have no conflicts of interest to report.

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  44. Marshall BDL, Green TC, Yedinak JL, Hadland SE. Harm reduction for young people who use prescription opioids extra-medically: obstacles and opportunities. Int J Drug Policy. 2016;31:25-31.
Stakeholder Perspective
Helping College Students Avoid Prescription Drug Misuse and Peer Pressure
Quang Nguyen, DO, FACP, FACE, FTOS
Medical Director, Las Vegas Endocrinology, Clinical Associate Professor, Clinical Education, AZCOM, and Adjunct Associate Professor of Endocrinology, Touro University Nevada

PAYERS: The early use of drugs increases a person’s chance of becoming addicted. The risk for drug use increases significantly during times of transition from one social setting to another. The article by Iloabuchi and colleagues illustrates the high prevalence of prescription drug misuse among college students aged 18 to 30 years.1 Overall, 62% of college students in the study reported knowing a peer with prescription drug misuse. Approximately 60% of misused prescription drugs were obtained from peers and were more prevalent in fraternity and sorority members than in nonmembers.1

This study shows that individuals who know someone with prescription drug misuse are less likely to admit that intervention is needed than those who do not know someone with prescription drug misuse. The former group is also less likely to know of available intervention programs or to believe in those programs’ effectiveness than individuals without peer prescription misuse.1 “Injunctive norms,” the perceived approval of the behavior by peers in the initiation of drug use, is one culprit for the maintenance of such behavior.2

The federal budget for drug control in 2020 is $34.6 billion.3 Fair use of this federal budget should focus on prevention programs or initiatives directed at the actual user, as well as the user’s peers. Education on the detrimental effects of drug misuse and removing users’ barriers to seeking help are also essential strategies for addressing the drug misuse crisis.

PATIENTS: Marijuana, alcohol, and prescription drugs are the 3 most misused substances in the rising national abuse and misuse health crises.1 In general, prescription pain relievers are the most misused drug, but in young adults aged 18 to 25 years, stimulants were the most prevalent prescription drug misused in this study, accounting for 75% of the reported prescription drug misuse.1 Peer perception and approval played significant roles in the initiation and maintenance of drug misuse.

According to Iloabuchi and colleagues, “Having friends who misuse drugs shapes the perceptions about the behavior and its acceptability and decreases the level of concern about the harms and negative outcomes of prescription drug misuse.”1 Although a certain amount of risk-taking and experimentation is routine during these transition years, young adults need education on the short- and long-term consequences of drug misuse, and they should be made aware of peer pressure’s powerful influence.

  1. Iloabuchi C, Aboaziza E, Zhao X, et al. College students’ perceptions about prescription drug misuse among peers. Am Health Drug Benefits. 2021;14(1):29-38.
  2. Silvestri MM, Correia CJ. Normative influences on the nonmedical use of prescription stimulants among college students. Psychol Addict Behav. 2016;30:516-521.
  3. US Government Publishing Office. Federal drug control funding. www.govinfo.gov/content/pkg/BUDGET-2020-PER/pdf/BUDGET-2020-PER-5-9.pdf. Accessed December 8, 2020.
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