Substance Use & Misuse

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Nonmedical Use of Prescription Medications

Among Medical Students in Greece: Prevalence of
and Motivation for Use

Georgios Papazisis , Ioannis Tsakiridis, Chryssa Pourzitaki, Eirini

Apostolidou, Dimitrios Spachos & Dimitrios Kouvelas

To cite this article: Georgios Papazisis , Ioannis Tsakiridis, Chryssa Pourzitaki, Eirini Apostolidou,
Dimitrios Spachos & Dimitrios Kouvelas (2017): Nonmedical Use of Prescription Medications
Among Medical Students in Greece: Prevalence of and Motivation for Use, Substance Use &
Misuse, DOI: 10.1080/10826084.2017.1325373

To link to this article: http://dx.doi.org/10.1080/10826084.2017.1325373

Published online: 04 Aug 2017.

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 SUBSTANCE USE & MISUSE
, VOL. , NO. , –
https://doi.org/./..

ORIGINAL ARTICLE

Nonmedical Use of Prescription Medications Among Medical Students in Greece:

Prevalence of and Motivation for Use
Georgios Papazisis a , Ioannis Tsakiridisb , Chryssa Pourzitakia , Eirini Apostolidoua , Dimitrios Spachosc ,
and Dimitrios Kouvelasa
a
Department of Pharmacology/Clinical Pharmacology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece; b rd Department of
Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece; c Laboratory of Medical Physics, Faculty of
Medicine, Aristotle University of Thessaloniki, Greece

ABSTRACT KEYWORDS
Background: Non-medical use of prescription medications has risen to unprecedented levels over Non-medical use of
the past decade worldwide; however, studies assessing misuse across medical students are sparse. prescription medications;
Objectives: The purpose of this study was to1) estimate the lifetime and the past-year prevalence of opioids; tranquillizers;
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stimulants; medical students;

non-medical use of prescription medications among medical students in Greece 2) identify the moti-
Greece
vation for use. Methods: 591 medical students completed an anonymous, self-administered, web-based
survey assessing lifetime and past-year prevalence of non-medical use of four classes of prescription
drugs (opioid painkillers, tranquillizers, sleeping and stimulant medications). According to the motiva-
tion to use the responders were classified into three subtypes (selftreatment, recreational, and mixed).
Results: The prevalence of lifetime use was 10.7% for at least one of the four prescription drug classes
and 9% of the respondents reported lifetime misuse of multiple categories of prescription drugs. The
past-year prevalence was approximately 7.7% for at least one of the four prescription drug classes,
while the majority misused the drugs “1-2 times per year”. Senior students used tranquilizers more
than junior students. Self-treatment and mixed subtypes of tranquillizers misuse was more prevalent
among women than men while the self-treatment subtype was the most prevalent subtype in all the
four drug classes. Conclusions: This is the first study investigating non-medical use of prescription med-
ications among Greek medical students and indicates a high prevalence of misuse of some categories
of prescription drugs, mostly for self-treatment purposes.

Introduction
particular, epidemiologic studies show that emergency
Nonmedical use of prescription medications (NUPM) department visits due to the misuse of prescription opi-
is a growing global public health issue because of its oids increased 153% between 2004 and 2011 in the United
increasing prevalence and associated negative conse- States, and the rates of death nearly quadrupled between
quences. NUPM is defined as the use of prescription 2000 and 2014 (DAWN, 2013). Furthermore, available
drugs, whether obtained by prescription or otherwise, data indicates that the nonmedical use of prescription opi-
other than in the manner, for the reasons, or time period oids is a strong risk factor for heroin use (Compton et al.,
prescribed or by a person for whom the drug was not 2016).
prescribed (UNODC, 2011). NUPM is not a new prob- A key risk period for the development of abusive
lem, but it is one that deserves renewed attention. Sev- behaviors is late adolescence into early adulthood, which
eral studies have shown that NUPM has increased signif- encompasses the typical ages of college students, a pop-
icantly over the past two decades and is most prevalent ulation for whom increasing prevalence of NUPM has
among adolescents and young adults (Compton, Jones, been reported. Based on data from more than 100,000
& Baldwin, 2016; McCabe & Cranford, 2012). Accord- European students, the European School Survey Project
ing to the United Nations office of drugs and crime, on Alcohol and Other Drugs (ESPAD) reported a life-
“the misuse of prescription drugs, including opioids, ben- time use of tranquillizers without a prescription at 6% of
zodiazepines, and synthetic prescription stimulants, is a the students on average (ESPAD, 2012). The prevalence
growing health problem in a number of developed and of nonmedical use of prescription stimulants is also con-
developing countries” (UNODC, 2011). NUPM is asso- siderably high among college students with past-year use
ciated with increased risk of morbidity and mortality; in rates ranging from 5% to 35% reported in various studies
CONTACT Georgios Papazisis MD, PhD [email protected] Psychiatrist, Assistant Professor of Pharmacology/Clinical Pharmacology, Department of
Pharmacology/Clinical Pharmacology, Faculty of Medicine, Aristotle University of Thessaloniki.
©  Taylor & Francis Group, LLC
 2 G. PAPAZISIS ET AL.

among college-age individuals (Wilens et al., 2008). Med- University of Thessaloniki, the second largest Medical
ical students may also be at a high risk for licit and illicit School in Greece. A random sample of 1000 students
substance misuse. Several contributing factors to this was selected from the total undergraduate student pop-
behavior include increased depression and anxiety lev- ulation. The entire sample was mailed a pre-notification
els, stressful academic curricula, and familiarity and eas- e-mail describing the study and inviting students to
ier access to drugs (Dyrbye, Thomas, & Shanafelt, 2006). self-administer a web survey by using a URL. The final
Misuse of prescription drugs, mainly for self-treatment response rate was 59.1% (n = 591), and the completion
purposes, among medical students and practicing physi- rate was 100% (participants were required to answer all
cians has long been reported (McAuliffe et al., 1986); how- survey questions prior to submission). No incentives
ever, recent data concerning NUPM among medical stu- were provided to the students for completing the survey.
dents is sparse(Abbasi-Ghahramanloo, Fotouhi, Zeraati,
& Rahimi-Movaghar, 2015; Akvardar, Demiral, Ergor,
Compliance with ethical standards
& Ergor, 2004; Buchanan & Pillon, 2008; Ihezue, 1988;
Petroianu, Reis, Cunha, & Souza, 2010). The lifestyles of The study received the approval of the Bioethics Commit-
medical students, the doctors of tomorrow who will be tee of the Faculty of Medicine of the Aristotle University
involved in the future of health care, is of interest, consid- of Thessaloniki.
ering that substance use by medical students may affect
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their future professional behavior.

Sample
Furthermore, despite the increase in prevalence of
NUPM, data on the motivations to use is limited among The final sample consisted of 591 undergraduate medical
student populations, especially among medical students. students (56.3% women and 43.7% men; 37.2% preclin-
The understanding of the motivation to use is impor- ical level students and 62.8% clinical level students). In
tant to fully comprehend the risks associated with NUPM Greece, the clinical level studies at the Medical school
because persons who engage in self-treatment may face start at the fourth year of study. The demographic char-
different consequences than those who misuse for recre- acteristics of the sample closely resembled the overall
ational purposes (McCabe, Boyd, & Teter, 2009). Within student population of this university. The mean student
the context of NUPM, self-treatment is motivated by age in the sample was 21.7 years old (SD = 1.8 Range =
the desire to alleviate symptoms consistent with the pri- 18–28 years).
mary pharmaceutical indication of the prescription drug
and does not involve coingestion with alcohol or other
Measures
drugs or nontherapeutic routes of administration (Boyd,
McCabe, Cranford, & Young, 2006). Assessment of lifetime and past-year prevalence
The objectives of this study were to (1) estimate the To assess lifetime and past-year use the questions used
lifetime and past-year prevalence of nonmedical use for were based on similar questionnaires reported previ-
four classes of prescription drugs (opioid painkillers, ously (McCabe et al., 2009). The lifetime prevalence of
tranquillizers, sleeping, and stimulant medications) NUPM was assessed with the following question: “Have
among medical students in Greece and examine gender you ever used (not under a doctor’s order) the following
and preclinical/clinical level differences and (2) identify types of drugs?.” The past-year prevalence was assessed
the motivation for NUPM and classify the misusers with the question: ‘In the past 12 months have you
into three subtypes (self-treatment, recreational, and used the following types of drugs, not under a doctor’s
mixed). The study group consisted of medical students order? How many times?” There were separate ques-
from the Medical School of Thessaloniki, the second tions for each of the following four classes of prescription
largest city in Greece. To our knowledge, this is the first drugs: (a) opioid painkillers (e.g., codeine-paracetamol,
study conducted in Greece assessing both prevalence and tramadol, and fentanyl); (b) tranquillizers (e.g., alprazo-
motivation of NUPM among medical students. lam, diazepam, and bromazepam); (c) sleeping medica-
tion (short-acting tranquillizers, e.g., temazepam, tria-
zolam, and Z-drugs, e.g., zolpidem and zopiclone); and
Materials and methods
(d) stimulant medication (methylphenidate). It is impor-
tant to note that among opioid painkillers, semisyn-
Study design
thetic opioid formulations (e.g., hydromorphone, oxy-
The present cross-sectional study was conducted in 2014, codone, and hydrocodone) widely misused worldwide
drawing on a total student population of over 3500 under- are not legally available in Greece. Similarly, the only
graduates attending the Medical School of the Aristotle licensed stimulant in Greece is methylphenidate, while
 SUBSTANCE USE & MISUSE 3

amphetamine/dextroamphetamine, the most common Table . Prevalence of lifetime and past-year nonmedical use of
prescription stimulant in most countries, is not available. each prescription class.
The response scale for all prescription drug classes was (1) Lifetime Past-year
no use, (2) 1–2 times per year, (3) 1–2 times per month, Drugs (N) (%) (N) (%)
(4) 1–2 times per week, and (5) every day.
Opioid painkillers  .  .
Tranquilizers  .  .
Assessment of motivation to use Sleeping med  .  .
Motivations for prescription drug misuse were assessed by Stimulant med  .  .
∗ ∗
Any prescription drug  .  .
asking respondents to provide the reasons why they used
∗ Represents nonmedical use of any of the four prescription drug classes.
each class of prescription drugs not under a doctor’s order.
Based on previous studies, respondents who reported
nonmedical prescription drug misuse were asked to select respondents. The Chi-square test was used for univariate
all that apply from a list of motives (McCabe et al., 2009). analysis of qualitative variables. Logistic regression anal-
Seven motivations were listed for all four prescription ysis was used to identify factors independently associ-
drug classes: “because it helps decrease anxiety,” “because ated with the lifetime use of each nonmedical prescription
it helps me sleep,” “because it gives me a high,” “because class. Estimated associations are described in terms of rel-
it counteracts the effects of other drugs,” “because it is ative risks (RR) and odds ratios (OR) with 95% confidence
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safer than street drugs,” “because of experimentation,” intervals (CIs). The level of statistical significance was set
and “because I am addicted.” In addition, for opioid at 0.05. All statistical analyses were performed using Sta-
painkillers, one other motivation was provided: “because tistical Package for Social Science (SPSS) v. 22.0.
it relieves the pain.” For stimulant medication, three addi-
tional motivations were provided: “to increase alertness,”
Results
“to help me concentrate,” and “to help me stay awake”).
Using a variable-centered approach, if respondents only The prevalence of lifetime use was 10.7% for at least
endorsed the motivation that was most consistent with the one of the four prescription drug classes (19.3% for opi-
drug’s primary pharmaceutical indication (i.e., sleeping oid painkillers, 7.3% for tranquillizers, 14.7% for sleeping
medication to sleep, tranquillizer medication to decrease drugs, and 1.4% for stimulants) (Table 1). Approximately
anxiety, opioid painkillers to relieve pain, and stimulant 9% of the respondents reported lifetime misuse of multi-
medication to increase alertness), they were characterized ple categories of prescription drugs, 7.2% reported misuse
as demonstrating self-treatment motivations. In addition, of two prescription drug classes, and 1.5% reported mis-
respondents were considered engaging in self-treatment use of three classes. The past-year prevalence was approx-
motivations if they endorsed the primary indication and imately 7.7% for at least one of the four prescription drug
an additional motivation that was related to the pharma- classes (13.2% for opioid painkillers, 6.4% for tranquil-
ceutical indication of the drug (e.g., nonmedical misuse lizers, 9.8% for sleeping drugs, and 1.4% for stimulants)
of sleeping medication to help sleep and decrease anxiety, (Table 1). The majority of students misused these drugs
nonmedical misuse of tranquillizers to decrease anxiety “1–2 times per year,” while only a small percentage used
and help sleep, nonmedical misuse of opioid painkillers them “1–2 time per month” (Table 2).
to relieve pain and help sleep, and nonmedical misuse of As illustrated in Table 3, the self-treatment subtype
stimulant medication to aid in concentration). If respon- was the most prevalent of all four nonmedical prescrip-
dents only endorsed motivations consistent with recre- tion classes (18.4% for opioids, 5.4% for tranquillizers,
ational misuse, they were characterized as engaging in 10.3% for sleeping drugs, and 1.4% for stimulants). A very
recreational motivations (i.e., because it gives me a high, small number of students reported use for recreational or
because it counteracts the effects of other drugs, because it mixed purposes. The lowest frequency of use was noticed
is safer than street drugs, because of experimentation, and for stimulants; only eight students (1.4%) reported life-
because I am addicted). Finally, if respondents endorsed time misuse of stimulants, and all of them only for self-
combinations of self-treatment and recreational motives, treatment purposes (Table 3).
they were considered having mixed motivations. Concerning the lifetime and past-year use of each class,
in a univariate analysis, there were no statistically sig-
nificant differences between men and women, but there
Statistical analyses
were differences between the clinical level of students
Prevalence rates of nonmedical prescription drug-misuse and the use of tranquillizers, indicating that students
subtypes were derived by dividing the number of respon- in their fourth, fifth, and sixth year of studies misused
dents reporting each subtype by the total number of tranquillizers, mostly for self-treatment purposes (Table 4
 4 G. PAPAZISIS ET AL.

Table . Frequency of past-year nonmedical use of the four prescription classes.

Frequency of use Opioid painkillers Tranquillizers Sleeping med Stimulant med

No use .% (n = ) .% (n = ) .% (n = ) .% (n = )

–/year .% (n = ) .% (n = ) .% (n = ) .% (n = )
–/month % (n = ) .% (n = ) .% (n = ) .% (n = )
–/week .% (n = ) .% (n = ) .% (n = ) .% (n = )
Every day .% (n = ) .% (n = ) .% (n = ) .% (n = )

and Table 5). In a multivariate model, the clinical level of socioeconomic status, have better education and have
students was independently associated with the lifetime more social support (Dobbin, 2014). The report from the
[p = .012, OR = 2.744 (95%CI: 1.248–6.032), Table 4] and United Nations office of drugs and crime on NUPM notes
past-year [p = .003, OR = 4.178 (95% CI: 1.606–10.873), that individuals who report using prescription drugs non-
Table 5] use of tranquillizers. Senior students (fourth year medically tend to be highly educated. The NUPM serves a
of study or higher) tended to use tranquilizers more than number of different purposes for people who are in higher
junior students. education, including self-medication, socio-recreation,
As indicated in Table 6, there were differences in the and academic functioning. University settings are often
prevalence of tranquillizer misuse subtypes and gender highly competitive, and academic performance influences
(p = .029). Self-treatment and mixed subtypes of tran-
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career opportunities (UNODC, 2011). Other vulnerable

quillizer misuse tended to be more prevalent among groups include young persons (including children, ado-
women than men. In contrast, the recreational sub- lescents, and young adults) and health-care professionals
type was more prevalent among men than women for (Merlo & Gold, 2008; SAMHSA, 2013). Considering
this drug class. Additionally, there were no differences that medical education has been reported to be one of
between the prevalence of nonmedical prescription drug the most stressful academic curricula worldwide, which
misuse subtypes and the study level. can negatively affect the physical and mental health of
students, medical students may be at a higher risk for
licit and illicit substance misuse (Abbasi-Ghahramanloo
Discussion
et al., 2015). The study of substance abuse by medical
Nonmedical prescription drug misuse has risen to students is important because the perception and detec-
unprecedented levels over the past decade worldwide. tion of patients with substance abuse problems may be
In the United States, for example, the past two decades influenced by the personal experiences of physicians with
have been characterized by increasing levels of abuse of substance abuse (Roncero et al., 2014).
exceedingly diverse group of prescription drugs, includ- To the best of our knowledge, there are no studies
ing opioid medications; an estimated 25 million people assessing fully the prevalence of and the motivation for
initiated nonmedical use of pain relievers between 2002 NUPM among medical students in Greece. A previously
and 2011 (SAMHSA, 2013). According to the Centers published, small study among 114 medical students found
for Disease Control and Prevention, “The United States a 5.8% prevalence of lifetime benzodiazepine use, which is
is in the midst of a prescription painkiller overdose epi- lower than our observed 7.3% (Spyridi et al., 2011). Exten-
demic,” considering that since 1999, the amount of opioid sive evidence, although limited to adolescents (mean age
painkillers prescribed and sold in the United States has of 15.8 years), comes from the ESPAD survey, which
nearly quadrupled (CDC, 2015). Based on this evidence, found that the lifetime nonmedical use of sedatives and
a new, hidden population dependent on prescribed tranquillizers was more common among the Greek stu-
medicines is emerging due to the increased exposure dents compared with the ESPAD average (9% and 6%,
to available psychoactive drugs and formulations. This respectively) (ESPAD, 2012).
hidden population may differ from the usual drug user According to our results, the past-year prevalence
stereotypes and be more highly functioning, have higher of NUPM was 13.2% for opioid painkillers, 6.4% for

Table . Motivations of lifetime nonmedical use of the four prescription classes.

∗
Motivation of use Opioid painkillers Tranquillizers Sleeping med Stimulant med
No use (n = ) (n = ) (n = ) (n = )

Self-treatment .% (n = ) .% (n = ) .% (n = ) % (n = )

Recreational .% (n = ) .% (n = ) .% (n = ) % (n = )
Mixed .% (n = ) .% (n = ) .% (n = ) % (n = )
∗ Percentages are not mutually exclusive since a medical student could endorse more than one reason to use.
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Table . Factors associated with the lifetime nonmedical use of each prescription class (univariate analysis in terms of Relative risk and % CI and multivariate logistic regression in terms of
odds ratio and % CI; CI: confidence interval; RR: relative risk; OR: odds ratio).
Opioid painkillers Tranquillizers Sleeping medication Stimulant medication
RR (% CI) OR (% CI) RR (% CI) OR (% CI) RR (% CI) OR (% CI) RR (% CI) OR (% CI)

Female . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . .–.)
Male Reference Reference Reference Reference
Clinical . (.–.) . (.–.) . (.–.)∗ . (.–.) . (.–.) . (.–.) . (.–.) . (.–.)
∗∗
Preclinical Reference Reference Reference Reference
∗ p = ., ∗∗ p = ..
SUBSTANCE USE & MISUSE
5
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6
G. PAPAZISIS ET AL.

Table . Factors associated with the past-year nonmedical use of each prescription class (univariate analysis in terms of Relative risk and % CI and multivariate logistic regression in terms
of odds ratio and % CI; CI: confidence interval; RR: relative risk; OR: odds ratio).
Opioid painkillers Tranquillizers Sleeping medication Stimulant medication
RR (% CI) OR (% CI) RR (% CI) OR (% CI) RR (% CI) OR (% CI) RR (% CI) OR (% CI)

Female . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.)
Male Reference Reference Reference Reference
∗ ∗
Clinical . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.) . (.–.)
Preclinical Reference Reference Reference Reference
∗ p = ., ∗∗ p = ..
 SUBSTANCE USE & MISUSE 7

Table . Gender (female/male) and study level (clinical/preclinical) differences in prevalence of nonmedical prescription drug misuse
subtypes (% among those who reported any lifetime nonmedical misuse).
Opioid painkillers (n = ) Tranquillizers (n = ) Sleeping medication (n = ) Stimulants (n = )
Self- Self- Self- Self-
treatment Recreation treatment Recreation treatment Recreation treatment Recreation
% % Mixed % % % Mixed % % % Mixed % % % Mixed %
∗ ∗ ∗

Female            
Male            
Clinical            
Preclinical            
∗ p = . based on Chi-square tests.

tranquillizers, 9.8% for sleeping drugs, and 1.4% for stim- published review on substance use among medical stu-
ulants. The past-month prevalence was 2%, 0.8%, 1.4%, dents that highlighted two strongly associated factors,
and 0.5%, respectively. Limited research exists world- academic year, and gender. Medical students had higher
wide on the prescription drug-use patterns of medical substance use rates during the last years of school, and
students. A recently published study conducted among women had higher substance use rates for hypnotic drugs
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1992 medical sciences students in Iran revealed that the (benzodiazepines and barbiturates). In this review, a
past-month prevalence of tranquillizers use was 0.4%, male:female ratio of 1:2 was suggested, which was consis-
while 2% of the students had used opioid drugs, and tent with international reports that indicated a greater use
2.7% had used methylphenidate (Abbasi-Ghahramanloo of tranquillizers among women in the general population
et al., 2015).Our results on past-month use of opioids (Roncero et al., 2015). According to the European School
were similar (2%) but significantly lower for stimulants Survey Project on Alcohol and Other Drugs, tranquilliz-
(0.5%). Petroianu et al. reported a 12% past-year preva- ers or sedatives are a widely used group of prescription
lence for anxiolytics and 7.5% for stimulants among med- medication, but they may also, depending on the country,
ical students in Brazil (Petroianu et al., 2010), which was be more or less easily obtained without a prescription for
higher compared to our observed rates (6.4% tranquil- the purpose of “getting high” rather than for medical rea-
lizers, 1.4% stimulants). However, some studies reported sons. Lifetime nonmedical use of these drugs is most com-
lower past-year prevalence for tranquillizers. In a study monly reported in Lithuania, Monaco and Poland (14%),
among Turkish medical students, the past-year preva- while the lowest levels of use are reported in Faroe Islands,
lence for tranquillizers was 3.8% across senior students, Germany, Liechtenstein, Moldova, the Russian Federa-
while none of the junior students reported using this tion and Ukraine (2%). Sex distribution showed that on
class of drugs (Akvardar et al., 2004). In a sample of 260 average, slightly more girls than boys report use without
medical students in Honduras, the past-year prevalence a prescription (8% vs. 5%). Notably, of all the substances
of the tranquillizer diazepam was 3.8%, while the past- assessed by this survey, sedatives/tranquillizers were the
year prevalence of sleeping pills was 8.8% (Buchanan & only class predominantly used by girls (ESPAD, 2012).
Pillon, 2008). Finally, considering lifetime prevalence, the As mentioned earlier, a notable finding in our study
results from an older study among undergraduate medical was the very low percentage of stimulant misusers (1.4%);
students in Nigeria described the lifetime prevalence of only eight students reported lifetime misuse of stimu-
tranquillizers was 12.6%, and the majority of the misusers lants, and all of them just for self-treatment purposes.
took them two to three times per month (Ihezue, 1988). In This percentage is not surprisingly low, considering that
our study, the prevalence of lifetime use of tranquillizers the overall percentage of medically prescribed stimulants
was significantly lower (7.3%). The misuse of tranquilliz- in Greece (only methylphenidate is available on the
ers by medical students is an important issue, especially in market) is also low. Our findings are in contrast with the
Western societies where these substances are used heavily worldwide growing trend of nonmedical use of stimulants
(EMCDDA, 2013). Tranquillizer misuse by future physi- among students. Recent reviews identified that 5–35%
cians could affect the detection of addiction and related of college students use stimulants without prescriptions,
problems in the general population (Roncero et al., 2014). with a high proportion of children and young adults
Based on our results, senior students (fourth year of obtaining these drugs from off-market sources (Kollins,
studies or higher) used tranquilizers more than junior 2008; Wilens et al., 2008). The results of an online survey
students, and self-treatment and mixed subtypes of tran- of stimulant use among 1115 medical students in Chicago
quillizer misuse was more prevalent among women than indicated that on average, 18% of students had used stim-
men. Our findings are consistent with those of a recently ulants at least once in their lifetime, 60% reported using
 8 G. PAPAZISIS ET AL.

them during medical school, and 19% reported daily approximately 75% of past-year nonmedical users of pre-
use (Emanuel et al., 2013). A Canadian study revealed scription stimulants, tranquillizers, and opioids endorsed
that 15% of medical students admitted to nonmedical more than one motive for use (McCabe & Cranford,
use of one or more pharmaceutical stimulants, of whom 2012).
4% had used stimulants within the last year (Kudlow,
Naylor, Xie, & McIntyre, 2013). Finally, a recent study
reported that the estimated 12-month prevalence of using Limitations
cognitive-enhancing drugs was 20% among German uni- There are several limitations of the present study that
versity students (Dietz et al., 2013). Medical school is a need to be considered. First, the study design was cross-
challenging environment characterized by large volumes sectional, so we could not investigate a cause and effect
of study material, late nights of studying, and competitive relationship. Second, the study was questionnaire based,
classmates. Consequently, the prevalence of stimulant so some information bias may have occurred, such as
use, especially use intended for performance enhance- under or overreporting of misuse. Third, our results
ment, is worth being studied among medical students; cannot be generalized to all health profession students
however, only a few studies have examined stimulant use in Greece. In addition, the survey did not distinguish
in this population. between medications that were prescribed by a doctor,
To fully comprehend the risks associated with the mis- but used nonmedically or medications that were illicitly
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use and abuse of prescription medications, it is nec- obtained. Finally, our sample has a lower number of pre-
essary to understand the motivations of that use. The clinical level students compared with the clinical level,
present study revealed that the self-treatment subtype and the response rate differed among the years of study,
was the most prevalent for all four drug classes, espe- so some selection bias may have occurred.
cially for pain medication (18.4%). Among the substances
used for self-treating pain, the majority of the students
reported use of the paracetamol-codeine combination Conclusion
and the rest reported fentanyl, pethidine and tramadol
To the best of our knowledge, this is the first study con-
use. A very small number of students reported use for
ducted in Greece assessing NUPM and the motivation to
recreational or mixed purposes. Among the small num-
misuse prescription drugs among medical students. Our
ber of stimulant misusers (1.4%), all of them reported a
results indicate a high prevalence of misuse for some cat-
self-treatment motive (to increase alertness and to help
egories of prescription drugs, mostly for self-treatment
concentrate). There is a lack of published international
purposes. Opioid painkillers and sedatives are the most
studies among medical students assessing motivation sub-
commonly misused drugs, while the percentage of stu-
types of opioid painkillers and tranquillizer misuse; thus,
dents using stimulants is low. Further international stud-
a clear comparison with our results cannot be performed.
ies among medical students are needed to further clarify
Results from the quantitative analysis of a review of self-
the epidemiology of NUPM and to extensively study stu-
medication in physicians and medical students showed
dent attitudes toward this risky behavior.
that self-treatment is deeply ingrained in medical cul-
ture and is acquired as early as medical school for aspir-
ing physicians. In this review, the qualitative analysis of Declaration of interest
the literature indicated that inappropriate self-treatment
The authors report no conflicts of interest. The authors alone
is rooted in avoiding the patient role, occupational norms are responsible for the content and writing of the paper.
about self-treatment, the pressure to perform at work,
and the need to keep things within the profession (Mont-
gomery, Bradley, Rochfort, & Panagopoulou, 2011). Data ORCID
exists, however, for undergraduate US university students
Georgios Papazisis http://orcid.org/0000-0003-1641-9095
(McCabe et al., 2009) and high school seniors (McCabe
& Cranford, 2012). In the first study, among those who
reported nonmedical prescription drug misuse, approx- References
imately 13% were classified into the recreational sub-
type, while 39% were in the self-treatment subtype, and Abbasi-Ghahramanloo, A., Fotouhi, A., Zeraati, H., & Rahimi-
48% were in the mixed subtype (McCabe et al., 2009). Movaghar, A. (2015). Prescription drugs, alcohol, and
illicit substance use and their correlations among med-
The second study surveyed a nationally representative ical sciences students in iran. International Journal of
sample of US high school seniors and revealed a great High Risk Behaviors and Addiction, 4(1), e21945. doi:
deal of heterogeneity associated with NUPM because 10.5812/ijhrba.21945
 SUBSTANCE USE & MISUSE 9

Akvardar, Y., Demiral, Y., Ergor, G., & Ergor, A. (2004). Sub- Kudlow, P. A., Naylor, K. T., Xie, B., & McIntyre, R. S.
stance use among medical students and physicians in a med- (2013). Cognitive enhancement in Canadian medical stu-
ical school in Turkey. Social Psychiatry and Psychiatric Epi- dents. Journal of Psychoactive Drugs, 45(4), 360–365. doi:
demiology, 39(6), 502–506. doi: 10.1007/s00127-004-0765-1 10.1080/02791072.2013.825033
Boyd, C. J., McCabe, S. E., Cranford, J. A., & Young, A. (2006). McAuliffe, W. E., Rohman, M., Santangelo, S., Feldman, B., Mag-
Adolescents’ motivations to abuse prescription medica- nuson, E., Sobol, A., & Weissman, J. (1986). Psychoactive
tions. Pediatrics, 118(6), 2472–2480. doi: 118/6/2472 [pii], drug use among practicing physicians and medical students.
10.1542/peds.2006-1644 The New England Journal of Medicine, 315(13), 805–810.
Buchanan, J. C., & Pillon, S. C. (2008). Drug consumption by doi: 10.1056/NEJM198609253151305
medical students in Tegucigalpa, Honduras. Revista Latino- McCabe, S. E., Boyd, C. J., & Teter, C. J. (2009). Sub-
Americana De Enfermagem, 16 Spec No, 595–600. doi: types of nonmedical prescription drug misuse.
S0104-11692008000700015 [pii] Drug and Alcohol Dependence, 102(1-3), 63–70. doi:
CDC. (2015). Centers for Disease Control and Preven- 10.1016/j.drugalcdep.2009.01.007, S0376-8716(09)00030-1
tion:Prescription Drug Overdose. Retrieved 05/02/16, from [pii]
http://www.cdc.gov/drugoverdose/epidemic/index.html McCabe, S. E., & Cranford, J. A. (2012). Motivational sub-
Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Rela- types of nonmedical use of prescription medications:
tionship between nonmedical prescription-opioid use and results from a national study. Journal of Adolescent Health,
heroin use. The New England Journal of Medicine, 374(2), 51(5), 445–452. doi: 10.1016/j.jadohealth.2012.02.004,
154–163. doi: 10.1056/NEJMra1508490 S1054-139X(12)00063-8 [pii]
DAWN. (2013). Substance Abuse and Mental Health Ser- Merlo, L. J., & Gold, M. S. (2008). Prescription opioid abuse
Downloaded by [University of Florida] at 01:01 06 August 2017

vices Administration. Highlights of the 2011 Drug Abuse and dependence among physicians: hypotheses and treat-
Warning Network (DAWN) findings on drug-related ment. Harvard Review of Psychiatry, 16(3), 181–194. doi:
emergency department visits. The DAWN Report. 10.1080/10673220802160316
Rockville, MD: US Department of Health and Human Montgomery, A. J., Bradley, C., Rochfort, A., & Panagopoulou,
Services, Substance Abuse and Mental Health Ser- E. (2011). A review of self-medication in physicians and
vices Administration; 2013. Retrieved 04/02/2016, from medical students. Occupational Medicine (London), 61(7),
http://www.samhsa.gov/data/2k13/DAWN127/sr127- 490–497. doi: 10.1093/occmed/kqr098
DAWN-highlights.htm Petroianu, A., Reis, D. C., Cunha, B. D., & Souza, D. M. (2010).
Dietz, P., Striegel, H., Franke, A. G., Lieb, K., Simon, P., & Prevalence of alcohol, tobacco and psychotropic drug use
Ulrich, R. (2013). Randomized response estimates for the among medical students at the Universidade Federal de
12-month prevalence of cognitive-enhancing drug use in Minas Gerais. Revista da Associação Médica Brasileira,
university students. Pharmacotherapy, 33(1), 44–50. doi: 56(5), 568–571. doi: S0104-42302010000500019 [pii]
10.1002/phar.1166 Roncero, C., Egido, A., Rodriguez-Cintas, L., Perez-Pazos, J.,
Dobbin, M. (2014). Pharmaceutical drug misuse in Australia. Collazos, F., & Casas, M. (2015). Substance use among med-
Australian Prescriber, 37, 79–81. ical students: a literature review 1988–2013. Actas Españolas
Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Sys- de Psiquiatría, 43(3), 109–121.
tematic review of depression, anxiety, and other indicators Roncero, C., Rodriguez-Cintas, L., Egido, A., Barral, C., Perez-
of psychological distress among U.S. and Canadian medical Pazos, J., Collazos, F., … Casas, M. (2014). The influence
students. Academic Medicine, 81(4), 354–373. doi: 81/4/354 of medical student gender and drug use on the detection of
[pii] addiction in patients. Journal of Addictive Diseases, 33(4),
Emanuel, R. M., Frellsen, S. L., Kashima, K. J., Sanguino, S. M., 277–288. doi: 10.1080/10550887.2014.969600
Sierles, F. S., & Lazarus, C. J. (2013). Cognitive enhancement SAMHSA. (2013). Results from the 2013 National Survey on
drug use among future physicians: findings from a multi- Drug Use and Health. Retrieved 16/5/2016, from http://
institutional census of medical students. Journal of General www.samhsa.gov/data/sites/default/files/NSDUHresults
Internal Medicine, 28(8), 1028–1034. doi: 10.1007/s11606- PDFWHTML2013/Web/NSDUHresults2013.pdf
012-2249-4 Spyridi, S., Diakogiannis, I., Ierodiakonou-Benou, I.,
EMCDDA. (2013). European Drug Report 2013: Trends Arsenopoulos, A., Tsiapakidou, S., Amaslidou, A., &
and developments. Retrieved 10/5/2016, from Kaprinis, G. (2011). Prevalence and sociodemographic
www.emcdda.europa.eu correlates of addictive substances use among medical
ESPAD. (2012). The 2011 European School Survey Project on school students. Hippokratia, 15(3), 280–281.
Alcohol and Other Drugs Report:Substance Use Among UNODC. (2011). The non-medical use of prescription drugs.
Students in 36 European Countries. Retrieved 05/02/2016, Policy direction issues. Discussion paper. Retrieved
from http://www.espad.org/uploads/espad_reports/2011/ 10/5/2016, from https://www.unodc.org/documents/drug-
the_2011_espad_report_full_2012_10_29.pdf prevention-and-treatment/nonmedical-use-prescription-
Ihezue, U. H. (1988). Drug abuse among medical students drugs.pdf
at a Nigerian university: Part 1. Prevalence and pattern Wilens, T. E., Adler, L. A., Adams, J., Sgambati, S., Rotrosen,
of use. Journal of the National Medical Association, 80(1), J., Sawtelle, R., … Fusillo, S. (2008). Misuse and diver-
81–85. sion of stimulants prescribed for ADHD: a system-
Kollins, S. H. (2008). ADHD, substance use disorders, and psy- atic review of the literature. Journal of the American
chostimulant treatment: current literature and treatment Academy of Child and Adolescent Psychiatry, 47(1), 21–31.
guidelines. Journal of Attention Disorders, 12(2), 115–125. doi: 10.1097/chi.0b013e31815a56f1, S0890-8567(09)62081-
doi: 10.1177/1087054707311654, 1087054707311654 [pii] 5 [pii]