Evidence-Based Reviews

How to prevent misuse of psychotropics among college students

Current Psychiatry. 2015 August;14(8):29-31, 43-46

References

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Benzodiazepines are prescribed for their anxiolytic and hypnotic properties and students could use these drugs with other agents to augment the euphoric effects or diminish withdrawal symptoms.³⁰ Patients taking benzodiazepines for anxiety might self-medicate with alcohol, which increases sedation and depression, and can contribute to the risk for respiratory depression.¹⁰ Misuse of benzodiazepines can result in cognitive and psychomotor impairment and increase the risk of accidents and overdose.^29,31

Although overdose with monotherapy is rare, the risk increases when a benzodiazepine is used with alcohol¹⁰ or another respiratory depressants, such as opioids, because combination use can produce additive effects.²⁸ You should therefore avoid prescribing benzodiazepines to patients who have a history of significant substance abuse and consider using alternative, non-addictive agents, such as selective serotonin reuptake inhibitors, or non-pharmaceutical treatment when such patients present with an anxiety disorder. The risk of adverse effects of benzodiazepines can be reduced by limiting the dosing and the duration of the treatment, and by using longer-acting rather than the more addictive, shorter-acting, agents.

Antidepressants
Health care providers should be aware that, despite the relative absence of physically addictive properties, antidepressants from most classes are abusable agents sought by young people for non-medical use. In particular, the literature highlights monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and bupropion as the antidepressants most likely to be misused for their amphetamine-like euphoric effects or serotonin-induced dissociative effects.³² However, compared with other drug classes discussed in this article, the rate of antidepressant misuse is relatively low among college students.

Regardless of the antidepressant selected, clinicians should be concerned about alcohol use among college-age patients. Persons with depression are at increased risk of alcoholism compared with the general population.³³ This combination can increase depressive symptoms and sedation, and decrease coordination, judgment, and reaction time.³³

Excessive alcohol use can increase the risk of seizures in patients taking antidepressants such as buproprion.³⁴ Employ caution when prescribing bupropion to patients who have a predisposing clinical factor that increases seizure risk, such as excessive alcohol use and abrupt cessation, use of other medications that may lower seizure threshold (eg, theophylline, amphetamines, phenothiazines), and a history of head trauma.³⁴

To minimize the risk of seizures with bupropion, titrate up the dosage slowly. Furthermore, using a low dosage during dual therapy for antidepressant augmentation further decreases the risk of seizure.³⁵ For these reasons, we recommend that you avoid bupropion in patients who are at risk of binge drinking, and give careful consideration to providing alternative therapies for them.

Prescribers and patients should also keep in mind that hypertensive crisis could occur if MAOIs are combined with certain types of alcoholic beverages containing tyramine, including some wines and draft beer.³³

How you can identify and prevent misuse
Careful communication between health care provider and patient that is necessary to minimize the risk of adverse drug events with psychotropic medications often is lacking. For example, 24% of study college-age participants did not remember if their physician provided a diagnosis and 28.8% could not recall being informed about side effects and, perhaps as a result, many students did not take their medications as prescribed.⁹

Further, prescribers should ask college-age patients who are undergoing stimulant treatment if they believe that they are being adequately treated. They should inquire about how they are taking their medications.¹¹ These questions can lead to discussion of the need for these medications and reevaluation of their perceived indication.¹¹

Remind patients to take their medication only as directed.³⁶ Highlight the need to:
• store medications in a discreet location
• properly dispose of unused medications
• keep tabs on the quantity of pills
• know how to resist requests for diversion from peers.

The Substance Abuse and Mental Health Services Administration offers additional useful strategies,³⁷ and pharmacists also can be partners in substance use education and prevention.³⁸ These are examples of how health care providers can take an active role in providing patients with a thorough and detailed understanding of (1) their conditions and (2) their prescribed medications to improve efficacy and safety while preventing misuse.⁸

A study found that the most common method of obtaining these medications without a prescription is acquiring them from peers; 54% of undergraduate patients with stimulant prescriptions have been approached by peers to give, trade, or sell their drugs.²⁵ Other methods include purchasing medications online or faking prescriptions.³⁹ Health care providers should remind patients of the legal ramifications of sharing or selling their prescribed medications. Finally, providers must be vigilant for students who may feign symptoms to obtain a prescription:
• be wary if symptom presentation sounds too “textbook”
• seek collateral history from family. Adults with ADHD should have shown symptoms during childhood
• use external verification such as neuropsychological testing for ADHD. A neuropsychologist can detect deception by analyzing the pattern of responses to questions.

How to prevent misuse of psychotropics among college students

References

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