How can something that is prescribed by a doctor, or available for purchase without a prescription at Wal-Mart and Walgreens, be so bad or cause such devastating problems for teenagers?
How can something that is prescribed by a doctor, or available for purchase without a prescription at Wal-Mart and Walgreens, be so bad or cause such devastating problems for teenagers? Unfortunately, Corey Suazo, a 17-year-old high school student had been to a “pharm” party before he died. Cocaine and the painkiller OxyContin were found in his system. A pharm party is similar to a bring-your-own-bottle party, except kids substitute pills for bottles. Kids bring whatever they can get their hands on and they may not be sure about what they have. The pills are thrown into a communal bowl and the participants grab handfuls to consume, often washing them down with alcohol. They wait for what's next, which may be death. One could call it prescription roulette.1
Unauthorized use of pharmaceutical and over-the-counter (OTC) drugs by teenagers is a growing national problem.2 This latest trend in drug abuse by adolescents is called pharming, or the nonmedical use of prescription and OTC
cough and cold medications.3 It is a concerning risky behavior that allows for the ability to get high with disregard for the type of drug that is being ingested, often along with alcohol.4
Pharming parties may also be referred to as "Skittles parties” or “skittling" by comparing the pill-popping behavior with the small hard candies that come in multiple colors and flavors.4 "Robo-tripping," referencing the cough suppressant Robitussin, is the abuse of cough medications containing dextromethorphan, in which the cough syrup, often left over from earlier illnesses, is drunk alone or in combination with other substances to obtain a high.
The purpose of this article is to explore the risk-taking behaviors of adolescents who engage in pharming parties; the effects that pharming parties, with indiscriminate use of prescription and nonprescription drugs, have on children and teenagers; and the approaches that healthcare providers (HCPs) can employ to guide young persons and their families to prevent negative outcomes from this growing epidemic.
Nearly 50% of all Americans take at least 1 prescription medication.5 The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices quadrupled in a little over a decade, from 1999 to 2010.6 In 2010, enough prescription analgesics were prescribed to medicate every American adult around the clock for 1 month. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) reports that after marijuana, prescription medications are the drugs most commonly abused by the adolescent population with the biggest growth of abuse among persons aged 12 to 24 years.5 Alarmingly, the abuse of prescription and OTC medications has surpassed the use of illegal drugs such as crack, cocaine, ecstasy, and heroin. An estimated 14% of high school seniors have used prescription drugs for nonmedical reasons at least once.
Students report that prescription pills often can be bought for less than other drugs such as marijuana and cocaine. However, costs can increase when these medications are in high demand, such as when students use them to cram before midterm and final exams.5 One study of intentional drug abuse in teenagers and children aged 6 to 19 years revealed that 38% of intentional drug abuse involved nonprescription drugs, with dextromethorphan, caffeine, antihistamines, and nonprescription stimulants identified as the most commonly abused nonprescription drugs (Table6).8 The Partnership for Drug-Free Kids estimates that 15% of teenagers have abused nonprescription cough or cold medications to get high.9
Teenaged girls, in particular, see prescription pills as “cleaner” than other drugs and equal their male counterparts in prescription drug use, but girls are less likely to use marijuana or cocaine compared with boys.5 Student athletes may see pills as a way to enhance sports performance or may self-medicate with opiates for pain related to sports injuries. Seventy percent of all persons who abused prescription pain relievers obtained them from friends or relatives, often without permission.9 Parents are advised to watch out for their own children as well as for their children’s friends who may be searching through the medicine cabinets when visiting the home.7
A national effort to reduce illicit drugs such as heroin and cocaine has seen a slight decline in overall drug use among young adults in recent years.5 However, as prescription drug sales continue to soar, pharming or prescription drug abuse is on the rise, with adolescents now dubbed the “Ritalin generation.” Pills are available to sell or share more than ever before, with more prescriptions written every year for antianxiety drugs, sleeping pills, and stimulants such as Ritalin, which is used to treat attention-deficit/hyperactivity disorder.
Skittling or pharming is a party game in which teenagers indiscriminately mix drugs together, putting themselves at risk for stroke, heart attack, or irreversible brain damage.9 Children have easy access to medications from medicine cabinets in their own homes and homes of their families and friends (Figure6). Gathering unused or expired medications often goes unnoticed by family members and does not cost the child anything. Emergency departments (EDs) may have difficulty discerning the combination of medications that an individual has ingested, resulting in delay and uncertainty of treatment.8 Experts report that it is difficult to identify a teenager who abuses prescription drugs because these medications are odorless and can be easily hidden, and the abuser may not manifest with unusual behavior such as stumbling or slurred speech.10
Under federal law, it is illegal to possess controlled substances without a prescriptiion.5 However, prosecutions for possession are rare, especially when minors are involved. Although many schools ban students from carrying medications without a prescription, rules can be difficult to enforce.
There has been limited response from state and federal governments, as well as from pharmaceutical companies.5 The Bush administration introduced an effort to control prescription drug abuse, however, most of the plan focuses on the reduction of sales of narcotic medications online or by HCPs who write pain prescriptions indiscriminately.
The US Food and Drug Administration (FDA) and SAMHSA have instituted media ad campaigns that highlight the dangers of prescription drug abuse among young persons, and the manufacturer of OxyContin introduced a public campaign about the dangers of abusing the drug after reports of misuse. However, some fear that antidrug television ads can add to the problem by telling kids that they can find illicit drugs in their own medicine cabinets!9
The 2008 Office of National Drug Control Policy reported the disturbing statistic that more than 1 in 4 parents (27%) believe that prescription and OTC medications are much safer to abuse than street drugs.11 Research shows that teenagers whose parents discuss and express strong disapproval of drug use are less likely to abuse alcohol and drugs. Unfortunately, many adolescents report that parents do not discuss the dangers of such drugs.10 Parents need to understand that legal does not equal safe when it comes to OTC and prescription medications. Providers’ instructions should encourage families to routinely assess the content of their medicine cabinets and “if you don’t need it, get rid of it.”9 Anticipatory guidance stressing that parents talk to their kids, watch for behavioral changes, and be vigilant is necessary to counteract this epidemic problem.12
Significant morbidity and mortality result from the recreational abuse of prescription medications, nutritional supplements, and nonprescription products that go undetected in the younger population in the absence of regular interaction with HCPs.6 Routine office screening must incorporate prescription drug, pharming, and skittling screening in all risk-taking behavior assessments. Providers should discuss recreational drug use with young patients as part of standard pediatric care, in response to the challenge in recognition, detection, and management of nonprescription drug abuse in children and adolescents.7
Healthcare providers can play a key role in providing anticipatory guidance regarding pharming parties and in emphasizing the importance of the parent-child relationship as a protective factor in keeping children safe. They can educate parents about the skills necessary to detect drug abuse and discuss ways in which parents can engage their children in open communication. Also, they need to educate families to keep medicine cabinets locked and keep prescription drugs out of reach or out of range for both their children and friends who may be visiting. It is important to educate families on how to prevent accidental ingestion by children, pets, or anyone else, and that certain expired, unwanted, or unused medicines have specific disposal instructions that indicate if they should be flushed down the sink or toilet as soon as they are no longer needed, or when they should be disposed of through a medicine take-back program.13
Healthcare providers should remain vigilant and question frequent refills or multiple prescriptions for commonly abused medications.2 They need to be cognizant of patients who “doctor shop” or “ED hop.” Supporting the placement of dextromethorphan-containing products behind counters in pharmacies or the prohibition of the sale to minors could also reduce abuse. Finally, HCPs share a responsibility to support legislation that might curb access to nonregulated Internet pharmacies and the sale of medications without prescriptions. They should be conservative and prudent when prescribing not only painkillers and controlled substances but also all medications.
Healthcare providers can ensure that public policies and clinical practice take into consideration the unique characteristics of the adolescent population that is vulnerable to drug abuse. Engaging schools and communities in health forums can educate teenagers and parents about the magnitude of prescription and OTC drug abuse. Providers can work with local community partners to provide awareness, education, and prevention opportunities for patients and families. For example, the Community Action Network for Drug-free Lifestyle Empowerment (CANDLE), a locally, nationally, and internationally recognized, award-winning nonprofit program located throughout the United States, has developed a unique parent-child drug prevention program called the Reality Tour, in which children aged 10 years and older participate in an interactive educational program with their parents to learn and acquire tools to reduce the risk of substance abuse.14
Healthcare providers can support public health policies and initiatives such as nationwide drug disposal stations.15 They can partner with the public sector to advertise drug take-back programs that are sponsored in local communities by the US Department of Justice Drug Enforcement Administration (DEA) where patients and families can dispose of unused prescription drugs.16 The DEA and local law enforcement have coordinated a nationwide Prescription Drug Take-Back Day each year as an opportunity to highlight the safest and most responsible ways to dispose of unwanted, unused, and expired medicines.17
Many states, commonwealths, and counties have created drug task forces to examine drug issues and abuse. Of significance are several local counties that have established special drug courts to address the rising drug epidemics and the number of drug-addicted defendants who steal and commit other crimes to support their habits.18 The DEA is also set to approve new regulations that implement the Secure and Responsible Drug Disposal Act of 2010, which amends the Controlled Substances Act to allow an “ultimate user” (a patient, family member, or pet owner) of controlled-substance medications to dispose of them by delivering them to those authorized by the US Attorney General to accept them.18 The Act also allows the Attorney General to authorize long-term care facilities to dispose of their residents’ controlled substances in certain circumstances as well.
According to the Centers for Disease Control and Prevention (CDC), 36 states have operational Prescription Drug Monitoring Programs (PDMPs) that are state-run electronic databases used to20:
The CDC also recommends that PDMPs link to electronic health record systems so that PDMP information is better integrated into HCPs’ daily practices.20
For patients whose use of multiple providers cannot be justified on medical grounds, state benefits programs (Medicaid) and workers’ compensation programs could monitor prescription claims information and PDMP data for signs of inappropriate use of controlled prescription drugs when warranted.20 Reimbursing claims for controlled prescription drugs from only a single designated physician and a single designated pharmacy could improve the coordination of care and use of medical services, as well as ensure appropriate access, for patients who are at high risk for overdose.6
States should ensure that HCPs are accountable and follow evidence-based guidelines for the safe and effective use of prescription analgesics, and states should take swift regulatory action against HCPs who act outside the limits of accepted medical practice, which could decrease provider behaviors that contribute to prescription painkiller abuse, diversion, and overdose.6 In addition, states should enact and enforce laws that safeguard legitimate access to pain management services while reducing prescription painkiller diversion and abuse by preventing the operation of rogue pain clinics, or “pill mills,” and doctor shopping. Finally, states should increase effective, accessible substance-abuse treatment programs that could reduce overdose among persons who struggle with dependence and addiction.
The ease of accessibility of nonprescription drugs coupled with the high-risk behaviors among teenagers add to the growing concern for harm to the adolescent population. This population is most at risk for the consequences of indiscriminate drug use. Pediatricians and other HCPs are well established to intervene on behalf of children’s health and provide much-needed guidance and prevention to patients who are at risk for drug abuse because of their developmental age. All HCPs should work with adolescents and children to increase understanding of the risks surrounding pharming parties. They should educate parents on how to reduce exposure and create sustainable, long-term public health solutions for the prevention of harmful sequelae and the promotion of public health and safety.
The authors wish to acknowledge Sheriff Jonathan Held, the Westmoreland County Sheriff’s Office, and the Westmoreland County Task Force in Greensburg, Pennsylvania, for their education and support, and for raising awareness of this growing epidemic in our youth.
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8. Partnership for Drug-Free Kids. The Partnership Attitude Tracking Study: Teens and Parents 2013. Available at: http://www.drugfree.org/newsroom/pats-2013-full-report-key-findings. Published July 22, 2014. Accessed October 23, 2014.
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12. Kisken T. People can fight drug abuse by disposing old pills. McClatchy–Tribune Business News. Available from: http://search.proquest.com/docview/864039097?accountid=10559. Published April 29, 2011.
13. US Food and Drug Administration. Disposal of unused medicines: what you should know. Available at: http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm. Updated April 28, 2014. Accessed October 28, 2014.
14. Candle Inc. Reality Tour Parent and Child Drug Prevention Program. Available at: http://www.candleinc.org/. Accessed October 28, 2014.
15. National Governors Association. Reducing prescription drug abuse: Lessons learned from an NGA Policy Academy. Available at: http://www.nga.org/files/live/sites/NGA/files/pdf/2014/1402ReducingPrescriptionDrugAbuse-Paper.pdf. Published February 2014. Accessed October 28, 2014.
16. US Department of Justice Drug Enforcement Administration. Got Drugs? National Prescription Drug Take-Back Day. Available at: http://www.deadiversion.usdoj.gov/drug_disposal/takeback/. Accessed October 28, 2014.
17. US Drug Enforcement Administration. Take Back Your Meds. Got drugs? Available at: http://www.takebackyourmeds.org/dea-events. Accessed October 28, 2014.
18. Cholodofsky R. Drug court planned in Westmoreland County. Trib Total Media. Available at: http://triblive.com/news/westmoreland/6441302-74/court-drug-judge#axzz38inlib00. Published July 14, 2014. Accessed October 28, 2014.
19. Tallman C. National Prescription Drug Take-Back Day coming up. Las Cruces Sun-News. Available at: http://www.lcsun-news.com/las_cruces-news/ci_25604359/national-prescription-drug-take-back-day-coming-up. Published April 20, 2014. Accessed October 28, 2014.
20. Healthy Investment-Improved Profit (HiiP). Dental/Medical Industry Business Consulting. FDA’s new labeling guidelines take on prescription drug abuse epidemic. California hospitals launch new policy to stop painkiller misuse. Available at: http://w.hiip.ca/?p=2328. Accessed October 28, 2014.
Ms Solecki is assistant clinical professor of nursing, Drexel University, College of Nursing and Health Professions, Philadelphia, Pennsylvania. Dr Turchi is medical director, Center for Children With Special Needs, St. Christopher’s Hospital for Children, Drexel University School of Public Health, Philadelphia. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.