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ORIGINAL ARTICLE

Perceptions of Harm and Reasons for Misuse of Prescription Opioid Drugs and Reasons for Not Seeking Treatment for Physical or Emotional Pain Among a Sample of College Students Deric R. Kennea , Kelsey Hamiltona , Lauren Birminghama , Willie H. Oglesbya , Rebecca L. Fischbeina , and Douglas L. Delahantyb a Department of Health Policy & Management, Kent State University, Kent, Ohio, USA; b Department of Psychology, Kent State University, Kent, Ohio, USA

ABSTRACT

Background: Since the early 1990s, the United States has seen a significant increase in the prevalence of prescription opioid misuse. Despite benefits prescription opioids provide, misuse can be fatal. Objectives: The current study was designed to investigate the prevalence of prescription opioid misuse, perceived harm of misuse, and reasons for misuse for physical or emotional pain instead of seeking professional medical or mental health treatment. Methods: Survey data were collected in the fall of 2013 via an online survey to a random sample of 668 students from a public Midwestern university. Results: Lifetime prevalence of prescription opioid misuse was 9.5%. Misusers of prescription opioid drugs generally reported lower ratings of perceived harm as compared to individuals not reporting misuse of prescription opioid drugs. Primary reasons for misuse of prescription opioid drugs was to relieve pain (33.9%), “to feel good/get high” (23.2%) and experimentation (21.4%). Lifetime misuse of a prescription opioid drug for physical or emotional pain was reported by 8.1% and 2.2% of respondents, respectively. Primary reasons for misuse for physical pain included because pain was temporary, immediate relief was needed, and no health insurance/financial resources. Primary reasons for misuse for emotional pain included not wanting others to find out, embarrassment and fear. Conclusions/Importance: Reasons for misuse of prescription opioid drugs vary by type of prescription opioid drug. Reasons for not seeking treatment that ultimately lead to misuse, vary by type of pain being treated and may be important considerations in the effort to stem the misuse of prescription opioid drugs among college students.

During the period 1991–2010, prescriptions for opioid drugs increased to nearly 210 million annually in the United States (Volkow, 2008; Volkow & McLellan, 2011). During that time the United States experienced a substantial increase in the prevalence of prescription opioid misuse (Green, Black, Grimes Serrano, Budman, & Butler, 2011). Prescription drug misuse, also referred to as prescription drug abuse or nonmedical use, generally indicates use of a prescription drug that is inconsistent from which it is prescribed and/or using a prescription drug for which an individual does not have a legal prescription. In 2008, almost 5 million Americans over the age of 12 reported the misuse of prescription opioid drugs (Centers for Disease Control and Prevention [CDC], 2011). The misuse of prescription drugs, including opioid drugs, has become so far-reaching that many, including the CDC and the Office of National Drug Control Policy (ONDCP), consider the problem to be at epidemic levels (CDC, 2011; ONDCP, 2012).

KEYWORDS

Prescription opioid misuse; reasons for opioid misuse; perceived harm; prescription drug misuse; college students

Despite the many benefits of prescription opioid drugs, misuse use can be harmful or fatal. Emergency department visits related to the misuse of prescription opioid drugs more than doubled between 2004 and 2008, with an increase of 29% from 2007 to 2008 alone (CDC, 2010; Cai, Crane, Poneleit, & Paulozzi, 2010). Accidental drug overdose deaths in the United States between 1999 and 2006 increased threefold, with the number of fatal poisonings caused by prescription opioids at nearly 14,000 in 2006 (Warner, Chen, & Makuc, 2009; Paulozzi, 2012; CDC, 2012). Prescription drug overdoses among young adults have increased over the past several years to between 2,700 and 2,900 deaths annually from 2007 to 2010 (National Institue on Drug Abuse, 2013). In addition to the acute adverse effects (e.g., overdose) that can occur as a result of prescription opioid misuse, it has been suggested that misuse of opioid drugs can transition to drug addiction (Siegal, Carlson, Kenne, & Swora, 2003; Daniulaityte, Carlson, & Kenne, 2006; Peavy, Banta-Green,

CONTACT Deric R. Kenne [email protected] Kent State University, Center for Public Health and Policy, College of Public Health, Department of Health Policy & Management,  Hilltop Drive,  Lowry Hall, Kent, OH , USA. ©  Taylor & Francis Group, LLC

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Kingston, Hanrahan, Merrill, & Coffin, 2012; Lankenau, Teti, Silva, Bloom, Harocopos, & Treese, 2012). In the United States, substance abuse treatment admissions for prescription opioids have increased substantially (Ling, Mooney, & Hillhouse, 2011). Since 1999, drug treatment admissions for prescription opioid drugs have quadrupled to four admissions per 10,000 persons in 2010 (SAMHSA, 2010). Misuse of prescription opioid drugs has quickly become one of the most common forms of drug use among young adults and college students, second only to marijuana (Johnston, O’Malley & Bachman, 2003; McCabe, 2008; Mohler-Kuo, Lee & Wechsler, 2003; SAMHSA, 2010). Cotto and colleagues found past year misuse of prescription drugs to be highest among individuals 18-25 years of age, followed by individuals 1217 years of age and individuals 26 or older (Cotto, Davis, Dowling, Elcano, Staton, & Weiss, 2010). According to the 2010 National Survey on Drug Use and Health (NSDUH), misuse of prescription opioid drugs (“pain relievers”) among young adults 18 to 25 years of age was 23.8%, 11.1%, and 4.5% for lifetime, past year and past month misuse, respectively (SAMHSA, 2011). A 2001 study of prescription opioid misuse among a representative sample of students at 119 US colleges found that nearly one in four of the colleges had an annual prevalence rate of at least 10% for past year misuse of prescription opioids (McCabe, Teter, Boyd, Knight, & Wechsler, 2005). Low perceived harm of drugs has been shown to be a contributing factor to increased likelihood of drug use (Johnston, O’Malley, Miech, Bachman, & Schulenberg, 2014). However, few studies have specifically examined the relationship between perceived harm of prescription opioid drugs and misuse among college students. Arria and colleagues found college students perceived prescription drugs as being less risky than cocaine, but more risky than marijuana and binge drinking every weekend (Arria, Caldeira, Vincent, O’Grady, & Walsh, 2008). Reasons for misuse of prescription opioids include desires to “get high,” to relieve anxiety or stress, to relieve pain, and to experiment (McCabe, Cranford, Boyd, & Teter, 2007; Rigg & Ibanez, 2010). Among college students, research has shown an increase of 85.7% in prescription opioid misuse from the first year of college to the second (Arria, Caldeira, O’Grady, et al., 2008). Despite this trend, much remains unknown regarding perceptions of harm and reasons for prescription opioid misuse among college students. Further, to our knowledge research has not examined reasons for misuse by specific prescription opioid drug R R vs. OxyContin⃝ ). For example, individu(e.g., Vicodin⃝ ⃝ R als may misuse Vicodin to relax or relieve tension, while R reserving OxyContin⃝ , which may be perceived as more

potent and potentially dangerous, only for instances of severe pain. Knowing that individuals misuse certain prescription opioids for specific reasons can inform prevention efforts and potentially target certain populations of users. Also lacking in the literature are studies examining reasons why individuals who do misuse prescription opioid drugs for physical or emotional pain do not instead seek treatment for those issues. Given the increased freedom that college generally affords young adults, the ease at which prescription drugs, including prescription opioid drugs, can be obtained (McCabe & Boyd, 2005; Manchikanti, Fellows, Ailinani & Vidyasagar, 2010; ONDCP, 2012), documented increased rates of misuse, and the potential acute (e.g., overdose) and long-term (e.g., addiction) risks of prescription opioid misuse, it is vital that research focused on this at-risk population of young adults continues. Research will provide a foundation for the development of more effective prevention and intervention efforts, including efforts tailored to gender and ethnic differences, and differences by specific type of prescription opioid drug, if warranted. The objectives of the present study were to assess: (1) the prevalence of prescription opioid misuse among a random sample of college students from a Midwestern public university, (2) the perceived harmfulness of prescription opioid drugs, (3) the reasons for prescription opioid misuse, and (4) conduct an exploratory analysis regarding reasons for not seeking medical or mental health treatment when misusing prescription opioid drugs for physical and emotional pain.

Materials and method Sample A sample of 2,000 currently enrolled undergraduate (n = 1,500) and graduate (n = 500) students was randomly selected from the total population of the main campus of a Midwestern university during the spring of 2013 and asked to complete an online survey regarding drug and alcohol use. The University’s Office of Institutional Research conducted the sample selection. The online survey was available for 20 days between April 17th and May 6th; respondents received five follow up reminder emails during that time. In an attempt to increase response rates, respondents were also incentivized to complete the surR Mini, vey via a prize drawing that included an iPad⃝ ⃝ R ⃝ R Beats headphones, ten iTunes gift cards valued at $15 R gift cards valued at $25 each, and each, five iTunes⃝ ⃝ R four Amazon gift cards valued at $50 each. Of the 2,000 students contacted, 35% initiated the survey and 33.4% completed it. The final sample consisted of 668 college students (69.3% female). Mean age was 24.1 years

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(SD = 8.26) and 31.8 years (SD = 9.20) for undergraduate and graduate students, respectively; overall mean age of respondents was 26.4 years (SD = 9.24 years). Caucasian students accounted for 82.4% of the sample and undergraduate students comprised 69.6% of the sample. For comparison, demographic data from the university for the 2012–2013 academic year indicated that the mean age of students was 22.1 for undergraduate students and 32.9 for graduate students. Overall mean age of students was 24.4. The majority of students were female (60.9%) and Caucasian (78.0%). Undergraduates comprised 85.3% of enrolled students at the university. Measures Lifetime and past year misuse of prescription opioid drugs was assessed with survey items asking the respondent to indicate which opioid drugs from a list of eleven different opioid drugs had ever been misused and misused in the past year. Misuse was defined for respondents as taking a prescription drug without a valid prescription, taking a prescription drug given to them by someone else or taking a larger dose of a prescription drug than prescribed by a doctor or healthcare provider. A second survey item asked respondents to provide their age of first misuse for each opioid drug reported as ever misused. Reasons for prescription opioid misuse was assessed by asking respondents to provide the main reason why prescription opioid drugs were misused the first time and the main reason why prescription opioid drugs were misused in the past year. Respondents were provided a list of 18 possible reasons from which to select. The list was compiled from reasons found in similar studies (see, for example, McCabe, 2008; McCabe, Boyd, & Teter, 2009) and pilot studies conducted by the authors. Two separate questions asked respondents if they had ever misused a prescription opioid drug to relieve physical pain (e.g.,

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backache, tooth pain) or emotional pain (e.g., depression, sadness, nervousness). Respondents answering in the affirmative for physical pain were then asked why they did not instead seek help from a hospital, doctor, dentist or other healthcare provider. Respondents answering in the affirmative for emotional pain were asked why they did not instead seek help from a hospital, doctor or other healthcare provider. For both questions, respondents were asked to select all that apply from a list of nine reasons for not seeking help for their pain, including the option to select “other” and type in a response. Perceived harm of regular misuse of prescription opioid drugs was assessed by asking respondents to rate each of the 11 opioid drugs on a scale from 0 (“Very Safe”) to 6 (“Very Dangerous”) in terms of how dangerous or safe they believed it was for someone who regularly misused each drug. Respondents were also given the option of selecting “Don’t Know” for each drug.

Results Perceived harmfulness of prescription opioid drugs Descriptive statistics were performed on all study variables using SPSS version 22.0 (IBM Corporation, 2013). Bivariate analysis using independent samples t-test was performed to assess differences on perceived harmfulness of prescription opioid drugs between respondents reporting lifetime opioid misuse and those not reporting opioid misuse. An independent samples t-test was also conducted to assess difference between mean lifetime frequency of misuse for physical versus emotional pain. Overall, perceived harm of regular misuse of prescription opioid drugs was high for each type of opioid drug, with respondents reporting average overall ratings between 5.61 and 5.80 on a scale from 0 (“Very Safe”) R had the to 6 (“Very Dangerous”) (Table 1). Vicodin⃝

Table . Percent reporting misuse of prescription opioid drugs, perceived harmfulness and mean age of first misuse. Perceived harm Mean (SD) Prescription opioid Vicodin⃝R OxyContin⃝R Diluadid⃝R Demerol⃝R Talwin⃝R Ultram/Ultracet⃝R Percocet⃝R Darvocet⃝R Methadone Buprenorphine/Suboxone⃝R Morphine

Total sample

Misuse

No misuse

Lifetime misuse % (N)

Past year misuse % (N)

First misuse Mean age (SD)

. (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.)

. (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.)

. (.)∗ . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.) . (.)

.% () .% () .% () — — .% () .% () .% () — — .% ()

.% () .% () — — — .% () .% () — — — .% ()

. (.) . (.) . (.) — — . (.) . (.) . (.) — — . (.)

— = No reported misuse. ∗ p < .. Note: Variations in percentages between lifetime and past year misuse due to rounding and number of individuals responding to each question. Perceived harm ranged from  (“Very Safe”) to  (“Very Dangerous”).

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Table . Primary reason for first misuse of prescription opioid drug. Reason for first misuse Relieve physical pain Feel good/get high Experiment Relax/relieve tension Have good time with friends Anger/frustration Increase effects of other drug(s) Was/am “hooked” on drug Get away from problems/troubles Control coughing

Vicodin⃝R (n = )

Percocet⃝R (n = )

OxyContin⃝R (n = )

Darvocet⃝R (n = )

Morphine (n = )

Dilaudid⃝R (n = )

Ultram⃝R /Ultracet⃝R (n = )

Total (n = )

.% .% .% .% .%

.% .% .% .% .%

.% .% .% .% .%

.% .% .% .% —

— .% — .% —

— .% — .% —

.% — — — —

.% .% .% .% .%

— —

— .%

— —

— —

.% —

— —

— —

.% .%



.%











.%

.%













.%

.%













.%

— = No report. Note: “Relieve emotional pain,” “to get to sleep.” “because of boredom/nothing to do,” “to get through the day,” “seek deeper insights/understanding,” “a substitute for heroin,” “to fit in with a group I liked,” and “decrease effects of other drug(s)” were not identified as primary reasons for first misuse of a prescription opioid drug and were excluded from the table.

lowest average rating of perceived dangerousness (5.61) and morphine had the highest average rating of perceived dangerousness (5.80). A comparison of average ratings of perceived harm between respondents reporting lifetime misuse of a prescription opioid drug and respondents not reporting lifetime misuse, indicated that ratings R of perceived harm of Vicodin⃝ were significantly greater among individuals not reporting lifetime misuse of the drug, t (658) = 3.76, p = .000. Other comparisons of perceived harm by specific opioid drug did not yield significant differences.

Misuse and reasons for misuse of prescription opioid drugs Lifetime and past year prevalence of prescription opioid misuse was 9.5% and 3.7%, respectively. Shown in Table 1, R at least once in nearly 8% reported misusing Vicodin⃝ their lifetime and 2.5% reported misuse in the past year. R had the highest prevalence of both lifetime and Vicodin⃝ past year misuse. Mean age of first misuse of the drug was 20.5 years (SD = 7.43). Overall, age of first misuse of a prescription opioid drug ranged from as young as 18.0 (SD = 3.65) for morphine to 24.0 (SD = 2.83) for R R /Ultracet⃝ . Ultram⃝ Respondents were asked to report the primary reason for the misuse of each prescription opioid drug they reported ever misusing. Of the 52 respondents reportR , 44.2% reported misusing ing ever misusing Vicodin⃝ the drug to relieve physical pain followed by 19.2% “to feel good/get high” and 15.4% to experiment with the drug (Table 2). Of the 26 respondents reporting misuse R , 26.9% reported misuse to relieve physical of Percocet⃝ pain and 26.9% misused to experiment. Experimentation R with OxyContin⃝ was reported as the primary reason for

first misuse (38.9%), followed by “to feel good/get high” (27.8%) and to relieve physical pain (22.2%), respectively. Misuse of prescription opioid drugs for physical or emotional pain and reasons for not seeking treatment All respondents were asked to report lifetime prevalence of misuse of any prescription opioid drug to relieve physical (e.g., backache, tooth pain) or emotional (e.g., depressed, sad, nervous) pain. As shown in Table 3, 8.1% Table . Prevalence of prescription opioid misuse for physical and emotional pain and reasons for not seeking treatment. Physical Respondents indicating any lifetime misuse Mean lifetime frequency of misuse (range, SD) Needed immediate relief (couldn’t wait for doctor/hospital) Couldn’t afford treatment No health insurance Was temporary pain that would go away No transportation Too embarrassed Afraid of what might happen if I go to doctor/hospital Sure that doctor/hospital would not give me the drug I needed Did not want others to find out Other reason

 (.%) . (–, .)

Emotional  (.%) . (–, .)

.

.

. . .

. . .

. . .

. . .

.

.

.

.

.

.

Note: Respondents could select all that apply for reasons for not seeking treatment for physical and/or emotional pain. “Other”reasons provided by respondents included, dislike of the health care provider, obtained medication from family/friends, medication that was prescribed was ineffective, and had medication leftover from previous prescription.

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(n = 54) of respondents reported ever misusing a prescription opioid drug to relieve physical pain and 2.2% (n = 15) reported misuse to relieve emotional pain. Lifetime mean number of times a prescription opioid drug was misused to relieve physical pain was 6.47 times (SD = 9.62) and 8.72 times (SD = 14.52) to relieve emotional pain. However, the difference between mean number of times misused to relieve physical pain compared to mean number of times misused to relieve emotional pain was not statistically significant, t (54) = −0.64, p = .522. With regard to the misuse of prescription opioid drugs for physical pain, the majority of respondents (42.6%) indicated that they had misused a prescription opioid drug rather than seeking medical treatment because they believed the physical pain was temporary and they knew it would go away after a few days. This was followed by needing immediate relief/could not wait for a doctor/hospital (38.9%) and financial reasons (e.g., no health insurance, couldn’t afford treatment) at 25.9% each. In terms of misusing a prescription opioid drug for emotional pain rather than seeking medical treatment, more than half (53.3%) reported misuse because they did not want others to find out about their emotional pain. Closely related, 46.7% reported being too embarrassed to seek medical treatment, thus misusing a prescription opioid drug instead. More than a third of respondents reported misusing a prescription opioid drug for emotional pain rather than seeking medical treatment because they were afraid of what might happen if they went to a doctor or hospital.

Discussion The present study examined the prevalence and perceived harmfulness of prescription opioid misuse among a random sample of college students at a Midwestern university. In addition, an exploratory study regarding the reasons for misuse, including reasons for not seeking treatment for physical or emotional pain was conducted. Prevalence of lifetime and past year misuse of prescription opioid drugs was 9.5% and 3.7%, respectively. The lifetime and past year prevalence rates found in the current study were approximately 3–5% lower than rates reported in earlier studies of prescription opioid misuse among college populations (see McCabe, Cranford, Boyd, & Teter, 2007; McCabe, Boyd, & Teter, 2009). That said, earlier studies reporting lifetime and past year rates of prescription opioid misuse were conducted during or near the height of prevalence rates for prescription drug misuse. Monitoring the Future (MTF) data indicate a gradual decrease in lifetime and annual prevalence rates of prescription opioid misuse over the past several years, with a 2013 lifetime and annual prevalence rate among

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12th graders of 11.1% and 7.1%, respectively (Johnston, O’Malley, Miech, Bachman, & Schulenberg, 2014). Further, the lower prevalence rates noted in the current study could be the result of selection bias given the relatively low response rate of the survey and potential underreporting of an illicit behavior. While other studies have assessed the perceived harmfulness of prescription drugs, to our knowledge, none have assessed perceived harmfulness by individual prescription opioid drug. Earlier research tended to ask respondents to rate the perceived harm of “pain medications” or “opioid drugs” in general, with examples of such drugs only provided to respondents in the stem of the question. The approach of the current study was to assess perceived harmfulness by asking about each prescription R R , OxyContin⃝ ). opioid drug separately (e.g., Vicodin⃝ The misuse of any prescription opioid drug has the potential for acute adverse effects, including death. However, the potential can vary depending on the formulation of the specific drug. As such, the present study examined perceived harmfulness across specific types of opioid drugs. Overall, perceived harmfulness of various prescription opioid drugs was relatively high. The lowR est average rating of harmfulness was for Vicodin⃝ ; the highest average rating was for morphine. Of particular note is the significantly lower ratings of perceived R harm of Vicodin⃝ among prescription opioid drug misusers as compared to nonmisusers despite the relatively R small sample of respondents reporting misuse. Vicodin⃝ remains the most prescribed prescription drug in the United States (Aitken, Kleinrock, Lyle, & Caskey, 2014). While widespread prescribing of the drug could be contributing to perceived lower ratings of harmfulness, there is also the potential for the interaction of low perceived harm and widespread availability of the drug to drive future increases in misuse of the drug. However, interpretation of these findings is limited given the small sample of respondents reporting misuse. In addition to a larger sample size, future studies should seek to discern the impact of perceived harmfulness by specific type of opioid drug in an effort to guide health communication initiatives focused on prescribing practices and potential misuse harms. The exploratory analysis of reasons for prescription opioid misuse by specific opioid drug and reasons for not seeking treatment for physical or emotional pain, while limited in terms of its sample size, provides an interesting glimpse not only at reasons for prescription opioid misuse, but explanations for why individuals misuse prescription drugs rather than seeking treatment R was the most for physical or emotional pain. Vicodin⃝ frequently misused prescription opioid drug reported by respondents. The primary reason for first misuse was

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pain relief followed by “to feel good/get high” and to R , which was perexperiment. Interestingly, OxyContin⃝ R and which ceived as slightly more harmful than Vicodin⃝ tends to be viewed as a more potent prescription opioid drug, was primarily misused experimentally by responR for pain relief was the third dents. Use of OxyContin⃝ most commonly cited reason for misuse, behind “getting high/to feel good.” Reasons for misuse of prescription opioid drugs have potential implications for prevention programming and tailoring of health communication messages to college populations. For instance, individuals misusing in an attempt to self-medicate physical pain may misuse according to typically prescribed instructions, whereas individuals misusing experimentally or to get high may be less likely to use as typically prescribed (e.g., take more than medically recommended) and thus are at potentially greater risk of adverse consequences, including fatal overdose. While a small sample size precluded a statistical examination of differences in terms of frequency of prescription opioid misuse for physical pain versus emotional pain for each reason for not seeking treatment, it is interesting to note the variations in reasons for misuse according to physical or emotional pain. This may be due, in part, to the nature of the physical and emotional pain experienced by individuals. For example, emotional pain such as depression or anxiety is commonly stigmatized in society, while physical pain is not. Issues related to the lack of financial resources were also given as common reasons for not seeking treatment for physical pain. The potential barrier that a lack of financial resources or health insurance has as contributing to prescription opioid misuse is interesting and warrants further study. Also needed are studies examining the potential impact that limited resources or lack of health insurance has on prescription opioid misuse among college students, including research that examines the impact of various fee and payment structures (e.g., nominal fees, sliding scales, at-cost pricing) across different university settings. With regard to not seeking treatment for emotional pain, the finding that individuals misusing prescription opioid drugs for emotional pain reported not seeking treatment for reasons related to mental health stigma (e.g., too embarrassed) is equally important (see, for example, Corrigan, 2004; Corrigan et al., 2014). To our knowledge, studies examining how mental health stigma may lead to prescription drug misuse are absent. Future work is needed to identify the specific types of emotional pain that cause individuals to misuse prescription opioid drugs, the severity of emotional pain and ways to reduce stigma and fear about mental health treatment among college students. Also needed are studies of prevention and

intervention efforts given our findings that reported lifetime frequency of misuse for emotional pain is was greater than frequency of misuse for physical pain, especially given the high addiction potential of most opioid drugs. The current study is not without its limitations. The study relied on self-report, including recall of historic information, and thus underestimates of misuse may have influenced findings. Further, those who did respond may have done so haphazardly in an attempt to complete the survey and enter into the incentive drawing. The online survey was administered at a single university to a relatively small randomly selected sample, which included both undergraduate and graduate students— a sample of “college students” that is not typical in the traditional sense. However, because of the exploratory nature of the study, and the relatively low prevalence rate of prescription opioid misuse, it was necessary to include graduate students (14.7% of the total sample) in the study. Hence, results may not be generalizable to other populations. Despite incentivizing participation, the response rate for the survey was 35.0% (33.4% completing the survey), which raises questions regarding the validity of the study’s findings and thus their generalizability. However, a growing body of literature challenges the assumption that low response rates equate to biased results (see, for example, Groves, 2006; Massey & Tourangeau, 2013; Peytchev, 2013). That said, empirical support for the effectiveness of online surveys as a means to collect valid data is mixed (Couper, 2001; McCabe, 2002). Several strategies were implemented to reduce non-response bias, including use of a sample drawn from an up-to-date list of currently enrolled students, incentivizing participation using a lottery with a relatively high probability of winning a prize (see, for example, Deutskens, Ruyter, Wetzels, & Oosterveld, 2004), and providing follow-up email reminders to those who had not initiated or completed the survey. Response rates for online surveys vary widely (see, for example, Shih & Fan, 2008), and nonresponse bias is likely to be more pronounced for surveys collecting sensitive information such as illicit drug using behavior. Finally, findings of the exploratory analysis regarding reasons for prescription opioid misuse by drug and reasons for not seeking treatment for physical or emotional pain are hampered by a very small sample size. However, these preliminary findings suggest that reasons for misuse vary depending on type of pain and prescription opioid drug that may need to be considered in developing more effective drug treatment prevention and intervention programming. Future studies that include larger samples of college student populations, including samples drawn from varying university settings, are needed.

SUBSTANCE USE & MISUSE

The misuse of prescription opioid drugs remains a significant public health issue. The present study adds to the overall knowledge base of prescription opioid drug misuse in that it provides additional information regarding prevalence rates of misuse among college populations and provides a preliminary exploratory look at reasons for misuse and not seeking treatment for physical and emotional pain. Findings suggest that reasons for misuse of prescription opioid drugs vary depending on the specific type of prescription opioid drug being misused. Reasons for not seeking treatment for physical or emotional pain that ultimately lead to misuse may be important considerations in the effort to stem the misuse of prescription opioid drugs among college populations.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Funding This work was supported by the Ohio Department of Mental Health and Addiction Services [Grant number 99-3402HEDUC-P-14-0007].

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