Prescription drug misuse among university staff and ...

Drugs: education, prevention and policy, Early Online: 1–8 Copyright ß 2011 Informa UK Ltd. ISSN: 0968-7637 print/1465-3370 online DOI: 10.3109/09687637.2011.594114

Prescription drug misuse among university staff and students: A survey of motives, nature and extent Katy Holloway & Trevor Bennett

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Centre for Criminology, University of Glamorgan, Pontypridd, CF37 1DL, UK has also risen in recent years (McCarthy, 2007). These increases are of concern because of the health risks associated with prescription drug misuse including, addiction (All-Party Parliamentary Group, 2009), serious side effects (Kroutil et al., 2006), comorbidity with psychiatric disorders and problem behaviours (Spoth, Trudeau, Shin, & Redmond, 2008), as well as poisonings relating to pharmaceuticals used alone or in combination with illicit drugs or alcohol (McCarthy, 2007). There is some indication that prescription drug misuse might also be increasing in the United Kingdom (UK; Sandall, 2008). In response, an All-Party Parliamentary Drugs Misuse Group conducted an investigation into the current state of prescription and over-the-counter drug misuse and the public health risks involved (All-Party Parliamentary Group, 2009). The report identified a range of problems associated with dependence and addiction to benzodiazepines, anti-depressants and other commonly misused medications, as well as the problems associated with buying uncontrolled drugs over the internet. Despite this concern, there is still little known about prescription drug misuse outside of the US. A recent database (Illumina) search of peer-reviewed journals conducted by the authors found over 200 studies that discussed some aspect of prescription drug misuse. However, only 20 of these studies were based on community or national surveys (e.g. Boyd et al., 2006; Hall, Irwin, Bowman, Frankenberger, & Jewett, 2005; Teter, McCabe, Cranford, Boyd, & Guthrie, 2005) and all were conducted in the US. As surveys are the main source of evidence on prevalence and nature of prescription drug misuse, knowledge in this area must be considered limited. The paucity of research on the topic of prescription drug misuse has been noted by others and has been frequently used as a justification for further research. Boyd et al. (2006) suggested that the non-medical use

Aims: To determine the prevalence and nature of prescription drug misuse among university staff and students in the UK. Methods: In 2009, an online questionnaire regarding non-medical use of prescription drugs was completed by 1614 students and 489 staff registered at a large university in Wales. The sample data were weighted to match the population of students and staff and were analysed using SPSS. Findings: The lifetime prevalence of prescription drug misuse (using prescription drugs not prescribed to the person) was 33% among students and 24% among staff. The main medications misused were pain relievers, followed by sedatives and sleeping aids. The main motives for misusing prescription drugs were to gain therapeutic benefit and ‘to get high’. Conclusions: The study shows that a notable proportion of staff and students at the university used prescription drugs in a way that was not intended. The discussion draws attention to a debate about whether all forms of non-medical drug use should be regarded as misuse. The implications of non-medical use include health risks to the user as well as hidden social and economic costs. More research should be done to generate a more in-depth understanding of prescription drug misuse.

INTRODUCTION

There is a growing concern about prescription drug misuse and its implications for public health. Research conducted in the United States (US) has shown that non-medical use of prescription drugs among young people is increasing (Boyd, McCabe, & Teter, 2006; McCabe, Knight, Teter, & Wechsler, 2005; McCarthy, 2007). The number of people visiting emergency departments for pharmaceutical drug-related problems

Correspondence: K. Holloway, University of Glamorgan, Centre for Criminology, Pontypridd, CF37 1DL, UK. Tel: 01443 483586. Fax: 01443 484507. E-mail: [email protected]

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K. HOLLOWAY & T. BENNETT


of prescription drugs ‘has received relatively scant attention’ (p. 37) in the US and confirmed that a ‘dearth of published data is also apparent in Europe’ (p. 37). Despite these limitations, there have been some studies that have investigated the prevalence and nature of prescription drug misuse. The United States Research in the US has been based mainly on surveys of university students and school children, but has included some national surveys of young people and adults in the general population. McCabe, Boyd, and Young (2007), for example, conducted a web-based survey of 1086 middle and high school students in Detroit and found that 21% admitted lifetime nonmedical use of prescription drugs. Other surveys have found similar prevalence rates. McCabe, Teter, and Boyd (2006) reported a lifetime prevalence of misuse of four prescription drug types combined (sleeping medications, sedatives, stimulants and pain medications) of 21%. Studies that have investigated specific drug types (e.g. stimulants, pain medication and sedatives) have reported lower life-time prevalence rates. Prudhomme-White, Becker-Blease, and Grace-Bishop (2006) conducted a web survey of prescription stimulant misuse among university students at the University of New Hampshire and found that 16% of students reported non-medical use of these drugs at least once in their lives. Boyd et al. (2006) reported in a study of public school students aged 10–18 currently registered in Detroit that 10% of boys and 22% of girls admitted lifetime non-medical use of prescription pain medications. The main categories of drugs investigated in these studies were pain medication, sleeping medication, sedatives and stimulants. The specific types of drugs identified as being associated with prescription drug misuse included: Vicodin, OxyContin, Tylenol 3 with codeine (pain relief); Ambien, Restoril, Temazepam (sleeping aids); Ativan, Xanax, Valium (sedatives); and Ritalin, Dexedrine and Adderall (stimulants). A survey of the motives given for prescription stimulant misuse among college students in the halls of residence at the University of Wisconsin found that the main reasons for non-medical use of drugs were ‘to feel more energetic’, ‘to stay alert’, ‘so I don’t feel tired’ and ‘to concentrate while studying’ (Hall et al., 2005). Teter et al. (2005) found in a survey of undergraduate college students at the University of Michigan that the most common motives for illicit use of prescription stimulants were ‘to help concentration’, ‘to increase alertness’ and ‘to provide a high’. National surveys of drug use in the US have generated slightly lower prevalence estimates than those found among college and university surveys. McCabe et al. (2007) used data from 2001 to 2002 National Epidemiologic Survey on Alcohol Related Conditions of 43,093 respondents and found that 9% of US adults were life-time non-medical users of a least

one of four prescription drug classes (i.e. sedatives, tranquillizers, opioids or stimulants). Kroutil et al. (2006) reported the results of the 2002 National Survey on Drug Use and Health in the US which showed that 7% of the general population aged 12 or over had used prescription stimulants non-medically at some point in their lives. The United Kingdom The search for peer-reviewed articles on prescription drug misuse mentioned earlier found no surveys conducted in the UK. In order to identify surveys that might have been published in sources other than peerreviewed journals (the ‘grey literature’), we conducted an additional search of four online databases (BBC online, Times online, The Guardian online and The Independent online). This resulted in several hundred items from which we located three surveys that had been conducted on prescription drug misuse in the UK (Campbell, 2010; Royal Pharmaceutical Society, 2008; Varsity, 2009). We obtained the research reports or collected further information on these surveys and extracted the main findings. We found one prescription drug misuse survey based on students. The survey was conducted at the University of Cambridge on behalf of the student magazine Varsity (2009). Questionnaires were emailed to approximately 5000 students of whom 1000 replied (personal communication with Varsity staff). The results revealed that ‘. . .one-in-ten Cambridge students have taken drugs such as Modafinil, Ritalin and Adderall’ (Varsity, 2009). The highest rate of prescription stimulant use was 16% among philosophy students and 18% among students from Christ’s, Corpus Christi, Homerton and Peterhouse colleges (Varsity, 2009). Two surveys focused on the general population. The most widely cited was a survey on non-medical use of prescription drugs conducted on behalf of the Royal Pharmaceutical Society by YouGov. The results of the survey were summarized in a press release prepared by the Society (Royal Pharmaceutical Society, 2008). The publication reported, ‘The research shows that over two million people across Britain now regularly purchase medicines via the web’ (p. 1). The internet survey commissioned by the Society comprised an online questionnaire sent to a random sample of 1950 male and female adults taken from their GB panel. The survey found that 7% of adults at some time in their lives had bought a prescription drug or medicine online. The second less frequently cited survey was commissioned by Lloyds Pharmacy and conducted by ICM survey research company. An email questionnaire was sent to 2043 of Lloyd’s Pharmacy customers. The results showed that 14% of respondents had given their prescription medicines to other people in the last 5 years (Campbell, 2010). Women were more likely to give away prescription drugs (16%) than men (10%). The most common drugs passed on were painkillers

PRESCRIPTION DRUG MISUSE AMONG UNIVERSITY STAFF AND STUDENTS


(66% of all shared medications) followed by antibiotics (11%) and anti-depressants (4%). The main reason given was that the drugs were no longer needed. It is perhaps surprising that, despite the plethora of publications on the general area of prescription drug misuse, so little survey research has been conducted on the topic, especially in the UK. Most of what we currently know about the prevalence of prescription drug misuse comes from non-peer reviewed studies reported in the media. This study In this article, we report the findings of the first survey of prescription drug misuse in the UK of university staff and students covering a range of prescription drug types. As far as we know, it is also the first paper in any country to report the findings of drug use among university staff. M ET H OD S

The study was based on an email survey of all staff and students currently registered at a large university in South Wales. The population of students (the study sampling frame) was obtained from the Academic Registry and included all 1st and 2nd year undergraduates and all postgraduates (14,839 in total). The population of staff was obtained from email lists generated by Human Resources (2535 in total). The staff survey was emailed to the staff list in July 2009 and the student survey was distributed in November 2009. The questionnaire and measures The questionnaire was designed using the online facilities provided by the research company Survey Monkey. There were several benefits in using this remote source, including preserving anonymity of respondents, monitoring submissions through IP addresses (which were not accessible to the researchers), and offering the ability to prevent or permit duplicate returns from the same source. The questionnaire was designed to cover the main issues relating to prescription drug misuse discussed in the research literature. The responses were recorded by mouse clicking on the categories shown and by entering short sections of text when requested in response boxes. The nine page questionnaire concluded with several questions relating to respondent demographics. The student and staff surveys were essentially the same apart from the introductory page which provided a preamble relevant to staff members and the demographic section which was coded to apply to staff. In order to identify prescription drug misuse, respondents were asked, ‘Have you ever used a prescription drug that was not prescribed to you?’ Those who answered ‘Yes’ were asked, ‘Which of the following prescription drugs have you ever used that were not prescribed to you by a doctor? (tick all

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that apply)’. The drug classes listed were: ‘sleeping pills (e.g. Zimovane)’, ‘sedatives/tranquillisers (e.g. Valium)’, ‘stimulants (e.g. Ritalin)’, ‘pain relievers (e.g. Diconal)’ and ‘anti-depressants’ (e.g. Prozac)’. Those who ticked the boxes were then asked in relation to each of them: ‘When you last used prescription drugs not prescribed to you, how often did you use them’ (response categories included ‘just once’, ‘a few times’, ‘monthly’, ‘weekly’ and ‘daily). They were then asked: ‘For each drug type, please type in the name of the drug that you used most often (e.g. ‘Valium’)’, and ‘For what purpose did you use each of the drugs that you listed above? (e.g. reduce anxiety, weight loss, pain relief, aid concentration, stay awake)’. They were also asked about the use of medications prescribed to them in a way that was not intended. This was investigated through the question, ‘Thinking about drugs that have been prescribed to you, have you always followed the instructions about how to use them (tick all that apply)’. The response categories were: ‘Yes, I have always followed the instructions’, ‘No, I have sometimes not followed the instructions on frequency or amount (e.g. took more dosages a day or more drugs per dosage)’, ‘No, I have sometimes kept the prescribed drugs for later use (e.g. kept them for the same or another illness) and ‘No, I have sometimes used the prescribed drugs beyond the illness for different purposes (e.g. because you liked the effect)’. Prescription drug abuse also included selling, trading or giving away prescribed drugs. In order to measure this, respondents were asked, ‘Have you ever sold, traded, or given away drugs that were prescribed to you by a doctor (tick all that apply). The response categories were: ‘sold’, ‘traded’ ‘given away’, ‘none of these’. Response rates and sample characteristics In total, emails were sent to 14,839 students, with 1614 completed questionnaires returned (response rate of 11%) and to 2535 staff, with 489 completed questionnaires returned (response rate of 19%). The characteristics of the two samples selected are shown in Table I. The table shows that there was a greater proportion of females than males in both the student and staff samples. The majority of students were aged under 30 years old whereas the majority of staff were aged 30 years old and over. The vast majority of both students and staff were self-designated as ‘white’. RESULTS Use of prescription drugs not prescribed to the user Overall, one-third of university students and onequarter of university staff reported lifetime use of prescription drugs not prescribed to them. The relationship between prescription drug misuse and demographic variables is shown in Table II. Females were associated with higher rates than males among both

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Table I. Demographic characteristics of the sample.


Students, n ¼ 1517 totala Staff, n ¼ 458 totalb Characteristics % (n) % (n) Sex Males Females Total

38 (514) 62 (843) 100 (1357)

44 (187) 56 (239) 100 (426)

Age 17–20 21–29 30þ Total

39 36 25 100

(509) (468) (325) (1302)

0 14 (59) 86 (362) 100 (421)

Ethnic group White Non-white Total

89 (1206) 11 (151) 100 (1357)

93 (397) 7 (29) 100 (426)

Notes: Unweighted data. a 160 respondents did not complete the sex and ethnicity section of the questionnaire and 215 respondents did not complete the age section of the questionnaire. b 32 respondents did not complete the sex and ethnicity section of the questionnaire and 37 did not complete the age section of the questionnaire.

Table II. Use of prescription drugs not prescribed to the user by demographic characteristics.

Characteristics All

Students, n ¼ 1517 totala % (n)

Staff, n ¼ 458 totalb % (n)

33 (505)

24 (111)

Sex Males Females Age 530 30 or more

26 (176) 30 (204)

21 (43) 23 (50)

27 (261) 31 (99)

17 (10) 23 (82)

Ethnicity White Non-white

29 (326) 23 (54)

22 (90) 18 (3)

Notes: Weighted data. a 152 respondents did not complete the sex and ethnicity section of the questionnaire and 202 respondents did not complete the age section of the questionnaire. b 36 respondents did not complete the sex and ethnicity section of the questionnaire and 38 did not complete the age section of the questionnaire.

students and staff. Older staff and students were associated with higher rates of misuse than their younger counterparts and white staff and students were more likely than non-white to report prescription drug misuse. The main types of drugs misused were pain relievers, reported by approximately 22% of students and 15% of staff. This was followed by sedatives

reported by 9% of students and 4% of staff, and sleeping pills reported by slightly fewer students and staff. Stimulants and anti-depressants were misused by 3% or lower of respondents. There was a difference in the reporting rates among staff and students in relation to three of the five drug types. University students were more likely than university staff to report misusing pain relievers (22% compared with 15%), sedative drugs (9% compared with 4%) and sleeping pills (7% compared with 3%). All respondents who reported misusing a prescription drug type were asked to name the most common medication taken during their last period of use. The most common sleeping aids were zopiclone and temazepam, used by 43% of students and almost onethird of staff who reported using sleeping aids not prescribed to them. The most common sedative reported was diazepam, mentioned by over 80% of all misusers of sedative drugs. The most frequently cited stimulants were ephedrine, followed by methylphenidate and amphetamine. The favoured pain relievers were co-codamol and tramadol, although the largest category overall was ‘Other’ drugs which included a mixture of drug types including antibiotics and antihistamines. The most commonly misused antidepressants were fluoxetine and citalopram cited by the majority of users of these drugs. Misusers of prescription drugs were also asked their motives for using the drug types mentioned. Not surprisingly, the most common reason given for using sleeping aids was ‘to sleep’ (Table III). However, a small proportion of respondents said that they took them ‘to get high’ or ‘to relieve anxiety’. Sedatives were used mainly ‘to relieve anxiety’, but they were also used ‘to get high’ and ‘to sleep’. The most common reason given for using prescription stimulants was ‘for pleasure’. However, a fifth of students and more than half of staff who used stimulants for non-medical purposes said that they used them ‘to lose weight’. Perhaps surprisingly, bearing in mind the results of the US research on student use of prescription drugs, using stimulants ‘to stay awake’ or ‘to study’ were the least cited reasons for their use. Less surprisingly, anti-depressants were mainly used ‘to relieve depression’, but some students used them ‘to relieve anxiety’ or ‘for pleasure’. Finally, respondents were asked how they obtained the prescription drugs on the last occasion. Sixty per cent of students and approximately three-quarters of staff said they obtained them from family member or partners. Just over 4% of both staff and students obtained them from the internet and the remainder obtained them from friends, acquaintances or housemates. Misuse of prescription drugs prescribed to the user The survey also investigated two additional forms of prescription drug misuse. The first form of misuse occurs when a drug prescribed to the user is used in

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Table III. Motives for using common drug types among those who used prescription drugs not prescribed to them. Students, n ¼ 505 % (n)a

Staff, n ¼ 111 % (n)a

Sleeping aids To sleep To get high To relieve pain To relieve anxiety Other Total

79 (56) 6 (4) 5 (4) 4 (3) 6 (4) 100 (71)

77 (10) 24 (3) – – – 100 (13)

Sedatives To relieve anxiety To get high To sleep Other Total

32 (35) 27 (30) 20 (22) 21 (23) 100 (110)

44 (6) 20 (3) 29 (4) 7 (1) 100 (14)

Stimulants For pleasure To lose weight To play sport To stay awake To study Total

37 (10) 19 (5) 18 (5) 16 (5) 11 (3) 100 (28)

42 (4) 58 (5) – – – 100 (9)

Pain relievers To relieve pain For pleasure To get high Other Total

93 (223) 3 (7) 2 (4) 2 (5) 100 (240)

95 (55) – 4 (2) 2 (1) 100 (58)

Anti-depressants To relieve depression To relieve anxiety For pleasure Other Total

39 (8) 27 (6) 18 (4) 17 (3) 100 (21)

100 (1) – – – 100 (1)

Other drugs mentioned To treat infection To relieve pain To lose weight Other Total

25 (20) 21 (17) 6 (5) 49 (41) 100 (84)

38 (9) 7 (2) 4 (1) 52 (12) 100 (24)


Motives

Table IV. Misuse of prescription drugs prescribed to the user.

Types of misuse Not followed instructions Different amounts/frequencies Kept for later use Used for a different purpose Other Sold, traded or given away Sold Traded Given away Not followed instructions only Sold, traded or given away only Both of the above Total

Students, Staff, n ¼ 1517 total n ¼ 458 total % (n) % (n) 23 15 12 2 1 11 1 1 10 12 17 11 40

(351) (227) (174) (28) (7) (168) (13) (16) (157) (178) (263) (171) (612)

21 11 11 2 1 10 51 51 10 10 17 10 37

(94) (52) (50) (9) (3) (45) (1) (1) (45) (46) (79) (44) (169)

Note: Weighted data.

Notes: Weighted data. The responses refer to the function of the drugs and might not always correspond with their pharmacological categorization. a Percentages relate to those using the drug type and providing a motive for use of the drug.

a way that was not intended. The main forms of drug misuse of this kind were using different amounts to those recommended, taking the medication at the wrong frequency, keeping back part of the prescription for later use and using the drug for a different purpose than originally intended. The second form of misuse occurs when prescription drugs are sold, traded or given away. The results relating to misuse of drugs prescribed to the users are shown in Table IV. Approximately one-fifth of university students and university staff said

that they had not followed the instructions recommended for a drug prescribed to them. The main ways in which instructions were not followed were using different dosages or changing the frequency of dosages. Over 10% of both groups said that they had kept prescription drugs to be used at a later date. The remainder said that they misused their prescription by using the medication for a different purpose or for other reasons. Approximately one-in-ten students and staff said that they had sold, traded or given away their prescription drugs. The majority of respondents reporting this said that they had given away some or all of their prescribed drugs. Few university staff or students said that they had sold or traded their prescription drugs. Overall misuse of prescription drugs Combining the two main forms of prescription drug misuse discussed in this article (using drugs not prescribed to the user and using prescribed drugs incorrectly) generates even higher prevalence rates of non-medical use of prescription drugs. This survey showed that almost half (48%) of students and staff (46%) had misused prescription drugs in at least one of these two ways. DISCUSSION

The survey found that one-third of university students and one-quarter of university staff had used prescription drugs not prescribed to them. The main types of drugs misused were pain medications, followed by sleeping pills, stimulants and anti-depressants. The most common drugs misused in each of the categories were co-codamol, zopiclone, ephedrine and fluoxetine.


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The motives for misuse were generally to obtain the therapeutic benefits of the drugs, but a proportion of respondents said that they used them ‘to get high’ or to use their properties for non-medical purposes, such as ‘to stay awake’ or ‘to study’. The most common source of illicit prescription drugs were family and friends. Few students or staff obtained them from the internet or drug dealers. Prescription drugs were also misused in the way in which they were consumed by the patient. The most common form of misuse was changing the recommended dosages or frequencies and keeping back part of the prescription for later use. A proportion of staff and students had also sold, traded or given away their prescriptions.

these kinds of uncontrolled and unsupervised use. There are many such harms mentioned in the literature, including dependence and addiction. Users might misdiagnose their problem and use inappropriate drugs which might result in making the underlying problem worse rather than better. Other harms include drug poisoning resulting from overdose or drug mixing and adverse physiological or psychological effects of excessive use. The implications can extend to broader drug-related harms, including social and lifestyle effects in relation to the individual and social and political effects relating to society. The economic costs of over- or inappropriate-prescribing also need to be taken into account.

Implications of the findings In order to assess the implications of the findings it is first necessary to make some moral judgements about acceptable and unacceptable use of prescription drugs. It could be argued that there is nothing wrong with users making adjustments to their prescription drug consumption by borrowing from others or by adjusting their own prescription medication. If this view is taken, then the concept of misuse has little meaning in the context of the current discussion. The strongest arguments that we have heard in questioning the concept of misuse have been applied to users who make adjustments to their own prescribed medication. It could be argued that should patients use less of the drug prescribed because of side effects or the lack of need this hardly constitutes misuse. Conversely, it could be argued that should patients use more of the prescribed drug to gain full therapeutic benefits then this too could be seen as reasonable. It is perhaps harder (but not impossible) to argue the case in relation to people who use prescription drugs not prescribed to them. It might be considered that there is nothing wrong in a member of a family giving their prescribed pain relievers to another member of the family when there is a need to do so. The arguments against these views and in favour of the concept of misuse are equally compelling. Any user who consumes a drug not prescribed to them or in a way that is not recommended is doing so without proper medical supervision and advice, and perhaps without full knowledge of the risks involved. Prescription drugs are controlled through medical practice and statutory regulation precisely to guard against the risks associated with uncontrolled and unsupervised use. While this is a topic area that requires more debate, we will stand by our original position taken in this article that the two forms of non-medical use of drugs described in this article represent forms of drug misuse. If we take this view, then the main implications of prescription drug misuse concern individual and public health and the harms that might be generated from

Limitations The first limitation to mention is that the response rates are quite low. However, response rates of these kinds are not unusual for recent returns from web-based surveys. There is some evidence that on-line survey response rates have gradually decreased over time (Sheehan, 2001). The main problem with low response rates is that the respondents might be different to the non-respondents. We corrected for this in part by weighting the data to ensure that the population and the sample were matched on the key demographic variables sex, age and race. However, there might still remain unmeasured differences between the sample and the population. This problem could be alleviated by determining whether there is a correlation between response rates and the dependent variable. Unfortunately, this requires multiple sub-samples and this study did not include sub-samples from which correlations could be calculated. However, such comparisons have been made in the literature. A study by McCabe et al. (2005) of non-medical use of prescription stimulants using data from a survey of 119 American colleges and universities found no association between non-medical use of prescription drugs and response rates at the college level after weighting on gender, age and ethnicity. A second limitation is that the sample sizes reduce quite quickly as a result of variable breakdowns through crosstabulation or through missing responses resulting from selection criteria (e.g. only those who have misused a certain drug can answer questions about it) or from non-response. This means that the statistical power of significance tests is often quite low. As a result of these problems, we decided not to use statistical tests in the analysis, especially in relation to the small sample sizes of the staff survey. In this respect, we view this study as an exploratory survey which provides an early insight into prescription drug misuse in the UK. It is hoped that future studies will be able to obtain larger samples sizes. Third, the study is exposed to the limitations of all self-reported surveys. Respondents might wish to



conceal prescription drug misuse or exaggerate it. They might also not fully understand or misinterpret the questions. We aimed to minimize the effect of these kinds of limitation. The tendency to conceal or exaggerate was addressed by ensuring that the responses were anonymous and confidential, such that responses could not be attributed to any respondent, even by the research team. We explained to respondents that the collected data would be held by a remote survey company acting on our behalf. In this study, the data were held in secure servers located in another country (in this case the US). The problem of misunderstanding or misinterpreting the questions was tackled by piloting the questionnaires among staff and students and their families and friends. Where possible, we spoke directly to the respondents and asked them to comment on how easy or difficult the questionnaire was to complete and adjusted the questionnaire accordingly. We also used questions used in other surveys when these were available. There have been several studies that have investigated the validity of responses from drug users. These have tended to show a strong correlation between responses and independent measures (Fendrich & Yanchun, 1994). Future research There are many avenues of further research that could be developed to enhance the knowledge base on prescription drug misuse in the UK. This research should be repeated across UK universities to establish the range of outcomes. The main advantage in investigating university students is that they include the age groups most likely to experiment with new drug types. Students also have a strong motive to experiment with performance enhancing drugs. However, it would also be useful to conduct nationally representative surveys of prescription drug misuse across a wide range of respondents. These could be enhanced through targeted surveys of specific groups (such as young people and adults as well as vulnerable and high-risk populations) and through surveys targeted at specific drug types (such as stimulants, anti-depressants, sedatives or pain relievers). Research might also be designed to provide a more in-depth understanding of the phenomenon through qualitative research based on case histories, case studies and semi-structured interviewing. This might involve investigating the development of prescription drug misuse, the meaning that non-medical use has for the person, their perceptions of their own misuse and the conditions that might lead to cessation of misuse. Research might also be conducted on the links between prescription drug misuse and problem behaviours, such as problematic and dependent drug misuse and the commission of drug offences.

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ACKNOWLEDGEMENTS We are grateful to the university for hosting the study and for providing access to email lists and agreeing to mass emailing. We would also like to thank Richard Bromley for his help in advising us on the procedures for conducting web surveys and working through online survey companies. Finally, we would like to thank all of the university staff and students who gave up their time to complete the questionnaires. Declaration of interest: The authors report no conflicts of interest.

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