Substance Use & Misuse, Early Online:1–11, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.880485
ORIGINAL ARTICLE
Misperceptions of Peer Pill-Popping: The Prevalence, Correlates, and Effects of Inaccurate Assumptions About Peer Pharmaceutical Misuse Amber Sanders1 , John Stogner1 , Jonathan Seibert2 and Bryan Lee Miller3 1
Department of Criminal Justice and Criminology, University of North Carolina at Charlotte, Charlotte, North Carolina, USA; 2 Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA; 3 Department of Criminal Justice and Criminology, Georgia Southern University, Statesboro, Georgia, USA ture (MTF) study indicates that prescription drugs are currently the second most used category of drugs (after marijuana) by adolescents in the United States (Johnson, O’Malley, Bachman, & Schelenberg, 2013). Misperceptions of safety and legality may be partially responsible for the high rate of pharmaceutical misuse; however, misuse may also be influenced by misperceptions of peer behaviors and social norms.
Peer behaviors may significantly influence personal behavior yet individuals may not accurately estimate their peers’ actions. Overestimations of peer substance use may encourage initiation or exacerbate extant problems. The present study examines misperceptions of peer pharmaceutical misuse and explores the relationship between reported misuse and perceptions of misuse for four categories of prescription drugs. Data collected from 2,349 college students in the Southeastern United States were analyzed and results indicated that overall perceptions of misuse were significantly higher than actual misuse. These findings suggest that intervention efforts may benefit from addressing misperceptions of pharmaceutical misuse. Study limitations and implications are addressed.
Social Norms
Peers are typically highly influential in shaping personal behaviors such as alcohol and substance use. In fact, peers are argued to have a greater impact on an individuals’ behavior than biological, personality, familial, religious, and cultural factors (Berkowitz & Perkins, 1986; Borsari & Carey, 2001; Kandel, 1985). Their influence is especially strong during late adolescence and early adulthood (Kandel, 1980; 1985). However, the majority of peer influence is not direct; peer influences are likely to be based more on what individuals’ think others believe and do (“perceived behaviors” or the “perceived norm”) as opposed to their true beliefs and actions (“actual behaviors” or the “actual norm”). The term misperception is often used to reference a gap between the perceived and actual. Furthermore, misperceptions have been shown to have an effect on substance use behaviors (Berkowitz, 2004), which has yielded cause for numerous “social norms” interventions. Perkins and Berkowitz (1986) were among the first to investigate misperceptions of social norms related to substance use. In their seminal study, they observed that the majority of college students believed a person should never drink alcohol to the point of intoxication or that intoxication was acceptable only in limited circumstances. However, almost two-thirds of the same students thought that other students at the University believed frequent intoxication or intoxication that interfered with academics
Keywords pharmaceutical misuse, prescription drugs, social norms, social norms interventions, social norms campaigns, social marketing campaigns, false consensus effect, stimulants, painkillers, sedatives, antidepressants
INTRODUCTION
Many young adults perceive the recreational use of prescription drugs as a safe and legal alternative to harder, illicit drugs. Though the use of any pharmaceutical substance other than as prescribed or by anyone other than the initial patient is considered illicit use and potentially dangerous, many hold the belief that recreationally using pharmaceuticals is less illegal or hazardous than street drugs simply because they were initially prescribed by a doctor (Schachter, 2012). This false sense of safety has contributed to the rate of prescription drug misuse steadily increasing since the 1990s (Burt, 2002; Compton & Volkow, 2006; Lipman & Jackson, 2006; Blanco et al., 2007). The most recent Monitoring the Fu-
Address correspondence to Dr. John Stogner, Ph.D., Department of Criminal Justice and Criminology, University of North Carolina at Charlotte, 9201 University City Blvd., Charlotte, North Carolina, USA; E-mail:
[email protected].
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and other responsibilities was acceptable. Further studies consistently demonstrated misperceptions of similar magnitude (Berkowitz & Perkins, 1986; Perkins, 1994; Haines & Spear, 1996; Perkins, Haines, & Rice, 2005). Building off findings from the 1986 study, researchers have hypothesized that the overestimation of peer substance use increases the likelihood that an individual will initiate or continue excessive substance use (Perkins, Meilman, Leichliter, Cashin, & Presley, 1999). Recent studies have suggested that a person’s perceptions of others’ behavior influence their own behaviors significantly more than others’ actual behavior (Perkins et al., 2005; Borsari & Carey, 2001). Thus, in terms of modifying behavior, it may be most beneficial to alter perceptions of peer use. This is a particularly positive programmatic method because doing so replaces inaccurate assessments of the social world with factual information and encourages individuals to make healthy informed decisions. In an attempt to correct misperceptions of peer norms and subsequently reduce the likelihood and extent of substance abuse, numerous intervention measures present young adults with correct information about the norms of their peer groups. These are often referred to as social norms campaigns or social marketing campaigns. The goal of these programs is to correct perceptions of the perceived norm to a more accurate level known as the actual norm (Perkins, 2002). These efforts, also referred to as social norms interventions, have been implemented at many colleges and universities to combat inflated peer norms related to alcohol, tobacco, and marijuana use (Perkins et al., 2005; Borsari & Carey, 2001; Perkins et al., 1999; Arbour-Nicitopoulos, Kwan, Lowe, Taman, & Faulkner, 2010; Martens et al., 2006; Neighbors, Geisner, & Lee, 2008). Social norms campaigns typically address what is referred to as the false consensus effect or the false notion that others behave in a similar way when they actually do not (Berkowitz, 2004). Built on a platform emphasizing public health (Bewick et al., 2013, McAlaney, Bewick, & Hughes, 2010), successful alcohol and tobacco campaigns have presented correct norms for a behavior. Researchers have noted decreased rates of use following implementation of a social norms program (Haines, Barker, & Rice, 2003; Foss, Deikkman, Bartley, & Goodman, 2004,). Social norms campaigns are also common on university campuses with successful efforts relying on taglines such as “whether it’s Thursday, Friday, or Saturday night, 2 out of 3 [university] students return home with a .00 blood alcohol concentration” (Foss et al., 2004, p. 3). Most research on social norms has focused on highfrequency activities such as alcohol use. Martens and colleagues (2006) have extended social norms research beyond the use of alcohol, tobacco, and marijuana and explored misperceptions related to sexual behaviors and a wider variety of illicit drugs including cocaine, amphetamines, and Rohypnol/GHB/Liquid X. They noted significant misperceptions of social norms for all of the studied behaviors and that the vast majority of students overestimated normative behaviors for alcohol use, drug
use, and sexual behavior. While Martens et al. (2006) did not implement or evaluate an intervention effort, their findings suggest that the scope of social norms interventions can be expanded to a wider variety of substances and behaviors. These findings align with the earlier observation by Perkins et al. (1999), which suggests that the tendency to perceive an exaggerated peer norm exists beyond alcohol use. McCabe (2008) evaluated rates of misperceptions of nonmedical pharmaceutical use using data collected from college students in 2005. His work indicated that more than two-thirds of students overestimated the prevalence of opioid (69.9%) and stimulant use (70.2%). Furthermore, McCabe noted that misperceptions of these categories of pharmaceuticals were more common than those of marijuana (50.5%) and larger in magnitude. Overestimation of peer use of each of these drugs was more common among females and users of that substance. DeSantis, Anthony, & Cohen (2013) recently confirmed that United States misusers of pharmaceutical stimulants were more likely to overestimate peer use. Qualitative research suggests that students outside the United States may not consider stimulant misuse to be common, but no statistical analysis was completed to assess overestimation within the Australian population used in the study (Partridge, Bell, Lucke, & Hall, 2013). Looking at elite Australian athletes, Dunn, Thomas, Swift, and Burns (2012) did find that athletes with a history of recreational drug use were more likely to overestimate overall drug use amongst other athletes, but their work did not study use of pharmaceuticals apart from other drugs. Using a small sample of student athletes, Petr´oczi et al. (2008) noted that estimates of performance-enhancing drug (PED) use were higher among athletes that had engaged in “doping” themselves. Their study did not also examine perceptions of other forms of pharmaceutical misuse or traditional drug use. Pharmaceuticals
Despite the pharmaceutical industry being more highly regulated than ever before, pharmaceutical abuse and misuse has grown into a burgeoning problem. Misuse increased at a remarkable rate during the 1990s with the number of illicit opioid misusers quadrupling in just 10 years (SAMHSA, 2004) and has remained at a worrisome level ever since (SAMHSA, 2012a). Among both young adults and teenagers, pharmaceuticals are the second most commonly abused illicit substance following marijuana (SAMHSA, 2012a; Johnston, O’Malley, Bachman, & Schulenberg, 2013). Monitoring the Future indicates that 7.9% of high school seniors have misused prescription pain medications in the last year (Johnston et al., 2013) and the National Survey on Drug Use and Health (NSDUH) reports a similar number (9.8%) for young adults between 18 and 25 years old (SAMHSA, 2012a). Monitoring the Future also reports that perceived harmfulness remains relatively low for most prescription drugs. In most cases, fewer than 40% report that there is “great risk” associated with recreational use of pharmaceuticals.
MISPERCEPTIONS OF PEER PILL-POPPING
These misperceptions, which are believed to have contributed to rather high rates of use, have been relatively stable in recent years1 (Johnson, O’Malley, Bachman, & Schelenberg, 2011). Reported rates of disapproval of pharmaceutical misuse have also remained stable but are much higher (over 80% disapprove of experimentation and over 90% disapprove habitual use). It seems that though most individuals disapprove of the act, that the majority view it as having far fewer negative repercussions than of illicit drug use. This clearly appears to be a false sense of safely as over 1.3 million emergency room visits were attributed to negative reactions from abused or misused pharmaceuticals in 2010 (SAMHSA, 2012b). This represents twice the number reported just 5 years earlier. Older adults are disproportionately responsible for this growth, but medical consequences to young adults are also increasing (SAMHSA, 2012c). While the focus of this analysis is misperceptions of peer use, it is important to also note that health care providers can help reduce pharmaceutical misuse by stressing the dangers associated with using medications other than those prescribed and using prescribed medications only as explicitly directed. To clarify the terminology utilized within the current study, prescription drug misuse is used to describe any use of a prescription medication other than as explicitly directed and prescribed by a physician. This can include recreational users, those who take too much medication, and those who take medication to treat a medical condition but do not have an appropriate prescription (Compton & Volkow, 2006). While all of these forms of abuse and misuse are potentially problematic, our analysis focuses solely on recreational use (and perceptions of recreational use) and not self-medication, illicit treatment, or any other subtypes. Recreational use of pharmaceuticals presents issues not unlike those of illicit drug use; users run the risks of overdose, dependence, or other adverse reactions. Critser (2005) posits that prescription drug misuse is becoming more common in populations that have not typically been associated with recreational drug use due to misperceptions of safety and community norms as well as overprescribing and overuse of pain relievers. McCabe, Boyd, & Teter (2009) describe four categories of pharmaceuticals that are commonly misused recreationally, analgesic, antianxiety, and sleeping medications. The present study collapses two of these (antianxiety and sleeping medications) into one sedative category and adds a fourth (athletic performance-enhancing drugs; PEDs). Prescription stimulants are misused for a number of reasons including to increase concentration, remain alert, stay awake, increase energy, and to obtain a euphoric high (Teter, McCabe, LaGrange, Cran-
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The authors of the MTF report attribute the small but significant deviation in the perception of the harmfulness of prescription stimulants to the changing of the question’s wording and not an underlying change in the population’s beliefs. As such, we describe these perceptions as stable along with those that remained statistically stable.
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ford, & Boyd, 2006). Prescription stimulants may be the most frequently misused among college students. Opioid painkillers represent the second group of misused pharmaceuticals. Misuse is typically driven by a desire for euphoric effects, maintenance of dependence, or distraction (Lord, Brevard, & Budman, 2011). Sedatives may be used recreationally to manage effects of other substances or in combination with other substances to achieve euphoria. Misuse may involve routes of administration other than those for which the substance was initially designed and can be problematic when paired with alcohol (McLarnon, Monaghan, Stewart, & Barrett, 2011). Anabolic steroids, HGH, and other PEDs are typically abused for the purpose of developing skeletal muscle and androgenic traits (van Amesterdam, Opperhuizen, & Hartgens, 2010), but also may lead to euphoria and hyperactivity (Pope, Kouri, & Hudson, 2000). Regardless of motivation, any use of prescription medications without a legitimate prescription is both illegal and risky. This study seeks to extend McCabe’s (2008) study and provides a more detailed examination of misperceptions of pharmaceutical misuse among a collegiate population. More specifically, we seek to explore whether misperceptions about recreational peer prescription drug use exist, whether they are greater than those associated with alcohol and marijuana use, what traits are linked to inaccurate perceptions, and whether recreational users are more likely to hold inaccurate beliefs about others’ behaviors. We build on McCabe’s work in several ways. First, we also incorporate misperceptions of tobacco and alcohol use for comparison purposes. Second, rather than focusing only on stimulants and opioids, we consider four categories of prescription drugs: stimulants, painkillers, sedatives/antidepressants, and athletic performance-enhancing drugs such as anabolic steroids or HGH. Third, we explore misperceptions of both prevalence and frequency of use. Rather than focusing solely on students incorrectly estimating how many of their friends use a pharmaceutical, the present study also explores their misperceptions about how often their friends misuse pharmaceuticals. Finally and perhaps most importantly, we describe levels of overall misperceptions, but also clearly detail rates of very large overestimations of peer use. This study may highlight the need for schools and universities to incorporate pharmaceutical social norms intervention measures and offer insight into which misperceptions may be most common. We offer the following hypotheses: H1 : Students perceive that recreational prescription drug use is more common among their peers than it is in reality. H2 : Misperceptions of recreational prescription drug use are more common than misperceptions related to more frequently occurring behaviors such as alcohol, tobacco, and marijuana use. H3 : Recreational users of prescription drugs will overestimate use among their peer group to a greater degree than nonusers.
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METHODOLOGY Data
During the 2011–2012 academic year, 40 undergraduate classes at a large university in the Southeastern United States were randomly selected from two strata for participation in a study exploring substance use and high-risk behaviors. Fifteen classes were randomly selected from a list of courses with more than 100 students enrolled and the other 25 classes were selected from those with 30 to 99 students enrolled.2 Laboratory, online, physical education, and low-enrollment classes were excluded from the sampling frame. The courses of instructors unwilling to participate in the study were replaced by another randomly selected course from the same strata. A single research assistant administered a six-page survey to students in each selected course. Over 80% of the students enrolled in the selected courses were in attendance and participated at the time of the survey.3 Students in multiple selected courses were only allowed to participate once. In total, 2,349 unique students completed the survey. Three of these were eliminated due to improbable responses and chronic missing data. The sample was largely representative of the university’s undergraduate population. The sample was 48.4% male, 68.9% White, 24.4% Black, and 2.8% Hispanic (Asian/Indian, Native American, and “Other” were selected by a total of 4.0%). The undergraduate population at the University is 48.5% male, 65.5% White, 25.0% Black, and 3.8% Hispanic. The median family income category of those in the sample was $75,000 to $99,999 and the participants had a mean age of 20.06. Within the sample, 15.7% reported participation in Greek organizations, 5.3% were student athletes, and 2.8% self-identified as lesbian, gay, bisexual, or transgender. Measurement
Perceptions of Peer Pharmaceutical Misuse. We assessed perceptions of normative behavior using a series of items 2
As the present study is an extension of McCabe’s (2008) work, it should be pointed out that he utilized a simple random sample of students with a 68% response rate, whereas this study uses the random stratified cluster sampling process described in the text with a response rate of over 80%. We cannot be certain that our cluster sampling method did not lead to oversampling of some types of individuals, but it appears that our data are representative of the university at least in measurable demographics. We expect that in-class surveys like ours are less likely to be affected by response bias than out of class surveys like McCabe’s since class absences are likely the only thing separating participants from non-participants. 3 This estimate represents the number of completed surveys divided by the total number of students enrolled in the courses at the end of the enrollment period adjusted for students enrolled in multiple selected courses. This 80.4% response rate is viewed as a conservative estimate since a more accurate denominator would be the number of students enrolled in the courses on the day of administration. However, we did not have access to lists of students removed from courses due to nonpayment, on medical or military leave, that were expelled mid-semester, or withdrawing from the course or university. The majority of missing cases are due to absences from class. Students were instructed to simply return the blank survey if they were unwilling to participate. Less than 50 students chose this option.
that included the prompt: “How often do you think the average [university name] student has recreationally used the following in the last 30 days?” (emphasis in original; university name redacted). Students were asked about several categories of substances and behaviors including tobacco, alcohol, binge drinking, marijuana, prescription stimulants, prescription painkillers, prescription sedatives, and anabolic steroids or HGH. Earlier items in the survey had clarified binge drinking as five or more drinks and offered Adderall and Ritalin as examples of prescription stimulants, Oxycontin, Vicodin, and Percocet as examples of prescription painkillers, and Valium, Xanax, and antidepressants as examples of prescription sedatives. For each item, participants were offered six options (none, 1 to 2 days, 3 to 5 days, 6 to 9 days, 10 to 19 days, or 20 or more days). Readers should note that the present study is focused on last month use (and perceptions of last month use), rather than use in the last year was done in the McCabe (2008) study. Actual Pharmaceutical Misuse. The actual substance use behavior of the population was estimated using responses to items that instructed respondents to “Please check the appropriate box for the number of days that you have used each of the following substances recreationally in the last 30 days” (emphasis in original). The same substances and the same possible responses as the perceptual items were used in this section. The responses of those in the sample were then aggregated for each substance to create estimates of normative behaviors in the population. Given that the sample of 2,349 respondents represents over 13% of the undergraduate population, these approximations can be considered viable estimates of actual university norms and substance use behavior. As the order of survey items may affect responses, it bears mentioning that respondents were asked about their own substance use prior to the items assessing perceptions of use at the University. We attempted to reduce the likelihood that responses to the perceptual measures were affected by their self-reports by placing 15 unrelated items between the two sections. Additionally, we note that the items assess only recreational use and as such are likely an underestimate of both overall pharmaceutical misuse and perceptions of pharmaceutical misuse. However, this is appropriate as our focus is recreational misuse of pharmaceuticals and the present study is not intended to evaluate self-medication or use of prescription stimulants for instrumental or “cognitive enhancement” purposes. Accuracy of Individual Perceptions of University Norms. For each category of substance, respondents were classified as underestimating, accurate or nearly accurately estimating, overestimating, and extremely overestimating use among their peers. Those respondents who selected the option for the perceptual item which matched or was one value above or below the median value for the self-reported use item of that same substance category were classified as “accurate/ near accurate” estimators. Participants reporting perceptions that were two or three options above the self-report median were classified as overestimating use and those reporting perceptions two
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or three options below the median were labeled as underestimating use. Perceptions four or more options above the self-report median were considered “extreme overestimations.” Following initial analyses, these items were collapsed into dichotomous variables representing whether the respondent reported an overestimation (either overestimation or extreme overestimation) or did not (accurate/ near-accurate estimation or underestimation). Analytic Strategy
We first examine whether, as a whole, the student sample overestimates recreational use of pharmaceuticals. That is, we explore whether the perceptions of the sample about the normative substance use behaviors are different from the reported behaviors. To contrast the proportion of students that perceive that the normative behavior is any recreational use of each category of pharmaceutical with the proportion that actually report any use, we utilize ttests. We also explore differences between the ordinal self-reported frequencies of recreational use measures and the perceptions of frequency of recreational use measures with Wilcoxon signed-rank tests. Similar analyses were repeated and presented for tobacco, alcohol, marijuana, and binge drinking for comparison purposes. We next examine the portion of students that underestimate, accurately estimate, overestimate, and severely overestimate the frequency of recreational use for each type of pharmaceutical and compare those findings to more frequently used substances. Specifically, we attempt to determine whether extreme overestimation of normative behaviors is more common with pharmaceuticals than tobacco, alcohol, and marijuana. We then utilize χ 2 tests to determine if there is a bivariate relationship between the recreational use of each substance and misperceptions about normative use of that substance as well as the other substance categories. We also explore misperceptions of peer recreational pharmaceutical use across different demographics to determine if any group would benefit from targeted programmatic interventions. RESULTS
The percentage of students that reported recreational use of each type of pharmaceutical is contrasted with the percentage that perceive that the average student has used
in the last month in Table 1. The subjects of most social norms studies and interventions (tobacco, alcohol, and marijuana) are included for comparison purposes. Last month use of tobacco (37.2%), alcohol (74.7%), binge drinking (57.3%), and marijuana (33.3%) was common within the sample. However, the perception that the average student uses these substances was near ubiquitous for all four: tobacco (97.3%), alcohol (98.4%), binge drinking (97.6%), and marijuana (95.7%). Last month recreational use of pharmaceuticals was comparatively rare. Only prescription stimulants (9.7%) were used recreationally by more than 5% of the sample in the last month, yet the perception that the typical university student recreationally used was held by over half for each of the four pharmaceutical categories. Three-quarters believed that the typical student had used prescription stimulants (76.5%) and prescription painkillers (75.9%) recreationally, whereas a smaller portion believed recreational use of sedatives (65.7%) and steroids (55.7%) was normative. The proportion that perceived normative use was significantly higher than the proportion that reported use for each substance. Table 1 also displays the median values for the actual and perceived frequency of recreational use for each category of pharmaceuticals with commonly used substances included to allow for comparisons. The median category for perceived use of tobacco, alcohol, binge drinking, and marijuana was “6 to 9 days,” whereas the median category for each category of pharmaceuticals was “1 to 2 days.” In each case, the distributions for perceived and actual use were significantly different from one another. The average perceptions of use are displayed in Figure 1 with average self-reported use also indicated. This figure clearly depicts that students perceive use to be more frequent than it is reported to be by their peers. Most concerning, and supportive of Hypothesis 1, students perceive recreational pharmaceutical use to be quite common and frequent despite actual use being rare. As seen in Table 2, more than half of students fell into the “accurate or near accurate” classification for each of the four pharmaceutical groups. This was in stark contrast to tobacco, binge drinking, and marijuana for which less than 40% were categorized as “accurate or near accurate.” Thus, inconsistent with Hypothesis 2, fewer students misperceive normative behaviors related to recreational pharmaceutical use than misperceive use of more
TABLE 1. Actual and perceived incidences and frequencies of drug use
Substance Tobacco Alcohol use Binge drinking Marijuana Prescription stimulants Prescription pain medications Prescription sedatives Anabolic steroids or HGH
Percent reporting last month use
Percent perceiving normative last month use
Proportions t-test p-value
Reported last month frequency (median)
Perceived last month frequency (median)
Wilcoxon Signed-Rank p-value
37.1% 74.7% 57.3% 33.3% 9.6% 4.9% 2.6% 0.6%
97.3% 98.4% 97.5% 95.7% 76.4% 75.8% 65.7% 55.6%
