Adolescence can be an exciting period of life, but it can also be one of great instability. As they test the boundaries of their changing world, teens are vulnerable to substance use and its many risks. Troubling trends like the current opioid epidemic have alerted school communities to the dangers of prescription painkillers, as overdoses among young adults in the United States have quadrupled in the past decade. Without appropriate health literacy skills, misinformed parents and students can overlook or downplay many of the risks of substance use.
The common narrative in schools and beyond is that students from a lower socioeconomic status are at greater risk for substance use, but this understanding ignores the complex determinants at play behind the scenes. School nurses and family nurse practitioners are in a unique position to educate families and students about these complexities, dispel myths about prescription drugs and increase health literacy in school communities. The graphic below illustrates some of the most essential social determinants that influence adolescent substance use.
While there are a variety of social determinants that influence — sometimes inconspicuously — the way that teens use drugs and alcohol, some determinants are more pivotal than others to students at such a vulnerable age. In an interview with Rebecca King of the National Association of School Nurses (NASN), we discussed a few social determinants that make a noticeable difference in the substance habits that teens develop through adolescence.
In the past, research has shown a relationship between substance use and teenagers with a low socioeconomic status. More recent studies, however, suggest that parents with higher income and higher educational levels are also likely to have teens who binge drink, smoke marijuana and use cocaine. Teenagers in higher socioeconomic status households often have access to more financial resources, so they have more spending money to drink excessively, purchase fake IDs and pay people to obtain drugs or alcohol. Students in wealthier families may also have greater access to prescription drugs used by their parents or other family members.
Administrators at schools that serve students of a higher socioeconomic status, therefore, are at risk of overlooking the danger of substance use in their schools if they continue to abide by the assumptions that substance use is only a problem for kids who live in low socioeconomic status households. Drug abuse is also on the rise in private schools, with 54 percent of private students in one survey reporting their school was “drug infected.”
Parent involvement and their perception of the dangers of drugs and alcohol can play a huge role in student drug use. Teens who are left alone at night without adult supervision are twice as likely to use marijuana or drink alcohol. However, those who feel that their parents would be “extremely upset” if they used drugs or alcohol were at decreased risk for abuse.
The content of parent-teen talks about drugs and alcohol can also influence substance use outcomes. Many parents talk to their teens about the risks of illegal drugs, but only 16 percent of teens report that their parents have discussed prescription drugs with them.
“There are parents who are highly involved, and they do educate their kids,” said Rebecca King, who is the Delaware director and member of the Executive Committee at NASN. “But the piece they are missing is that if you use prescription drugs, you can become addicted from just a very small amount.”
Lack of concern about abusing medication is a significant predictor for teen substance use, with children who were educated about drugs and alcohol at home being 50 percent less likely to use them. If children see their parents using prescription medication incorrectly or perceive that their parents don’t mind if they take medication for which they have no prescription, the risk for nonmedical use increases.
Though many parents have conversations about the risks of illegal drugs and alcohol, they may lack health literacy when it comes to prescription drugs. “Parents think, ‘My kid would never get addicted,’’’ King said. “But that’s a false sense of security … . It can happen to anyone.” For example, parents may not lock up or properly dispose of the medications because they don’t expect them to be a hazard.
The extent of misinformation about using prescription medication among parents is alarming. A 2013 study found that one-third of parents surveyed believed stimulants such as Ritalin or Adderall can help their child’s academic performance even if their child has not been diagnosed with ADHD. Sixteen percent of parents surveyed believed it is safer to get high from prescription medication than it is from illegal drugs.
Social and Community Context
Social pressures abound in middle and high school, and a school environment that gives way to misbehavior, rebelliousness and absenteeism is conducive to drug and alcohol use. More than half of high school students report that they know locations on or near school grounds where their peers use drugs or alcohol during the school day. Also, researchers have noted that peer pressure from the internet is a growing influence for teen substance use. Teens who see photos of their peers getting high or drunk on social media are four times more likely to use marijuana and three times more likely to drink alcohol than those who do not.
“I think a lot of it comes from self-esteem,” King said. “There’s a lot of pressure from society on them, and I think when they abuse substances, they feel some relief from that anxiety.”
Research has demonstrated that students with lower levels of academic achievement are at higher risk for abusing drugs and alcohol. However, school staff cannot overlook the reality that pressure to perform well, both athletically and academically, can influence teen drug use. In particular, abuse of prescription painkillers is increasing among student athletes, who are more likely to use drugs illegally than their non-athletic counterparts. Students stressed about academic performance may turn to nonmedical use of prescribed stimulants or other “study drugs” to increase their energy even though there is no proof that the drugs, which put students at risk for psychosis or heart failure, help with academic performance.
The extent to which drug and alcohol use during the teenage years is — or is not — addressed can have a significant impact on behaviors and overall health in adulthood. Ninety percent of people who are addicted to drugs or alcohol started using before the age of 18. Teens with limited health literacy skills are at risk for hospitalization and decreased access to preventive services later in life. Substance use early in life also can lead to a cycle of poor academic achievement throughout high school and college. Those who use “study drugs” because of academic pressure are likely to become part of the 20 percent of college students who report abusing them. Early education is essential, as interventions targeting prescription drug use in middle school have resulted in a 20 to 65 percent reduction in abuse in high school and beyond.
Identifying these determinants among teens is key to preventing drug and alcohol abuse, and school nurses in particular are in a unique position to educate students and their families. Unfortunately for many students, less than half of American public schools employ a nurse on staff, which limits access to medical information for students whose families cannot regularly visit a clinic.
Family nurse practitioners have an essential role in educating students and families about drug use at every possible opportunity. “Medical professionals need to counsel families when they’re prescribing narcotic painkillers,” King said. “They can be misused, and they have the potential for addiction.”
The physical presence of nurses provides opportunities to promote health literacy for families who may not have health care coverage, and their training in cultural competency can help students and families feel heard and understood when it comes to their concerns and experiences. School nurses can also coordinate with educators, public health officials and social workers as they create cross-sector and holistic approaches to addressing these risks.
Citation for this content: Nursing@USC, the online FNP program from the University of Southern California