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Stress, Drugs, and Alcohol Use Among Health Care Professional Students: A Focus on Prescription
Stimulants
Monica K. Bidwal, Eric J. Ip, Bijal M. Shah and Melissa J. Serino
Journal of Pharmacy Practice published online 14 August 2014
DOI: 10.1177/0897190014544824

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Research Article
Journal of Pharmacy Practice
1-8
Stress, Drugs, and Alcohol Use Among ª The Author(s) 2014
Reprints and permission:
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Health Care Professional Students: DOI: 10.1177/0897190014544824
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A Focus on Prescription Stimulants

Monica K. Bidwal, PharmD1, Eric J. Ip, PharmD, BCPS, CSCS, CDE1,

Bijal M. Shah, BPharm, PhD1, and Melissa J. Serino, PharmD1

Abstract
Objective: To contrast the characteristics of pharmacy, medicine, and physician assistant (PA) students regarding the prevalence of
drug, alcohol, and tobacco use and to identify risk factors associated with prescription stimulant use. Participants: Five hundred
eighty nine students were recruited to complete a 50-item Web-based survey. Main Outcome Measures: Demographics, non-
medical prescription medication use, illicit drug and alcohol use, Diagnostic and Statistical Manual of Mental Disorders (Fourth
Edition, Text Revision; DSM-IV-TR) psychiatric diagnoses, and perceived stress scale (PSS) scores. Results: Medicine and PA students
reported greater nonmedical prescription stimulant use than pharmacy students (10.4% vs 14.0% vs 6.1%; P < .05). Medicine and
PA students were more likely to report a history of an anxiety disorder (12.1% vs 18.6% vs 5.9%; P < .05), major depressive
disorder (9.4% vs 8.1% vs 3.3%; P < .05), and attention-deficit hyperactivity disorder (ADHD; 4.0% vs 9.3% vs 0.7%; P < .001) than
pharmacy students. PSS scores for all 3 groups (21.9-22.3) were roughly twice as high as the general adult population. Conclusion:
Illicit drug and prescription stimulant use, psychiatric disorders, and elevated stress levels are prevalent among health care
professional students. Health care professional programs may wish to use this information to better understand their student
population which may lead to a reassessment of student resources and awareness/prevention programs.

Keywords
prescription medication misuse, abuse, stimulants, medical professional students

The misuse of prescription medications is not a new phenom-
enon; during World War II, prescription stimulants were
widely consumed by the armed forces and industrial workers
to enhance alertness.1 A reported 25 million individuals world-
wide used amphetamines in 2004, and approximately 1 in 10
Americans between the ages of 18 and 25 reported nonmedical
use of opiate analgesics.1,2 Nonmedical use of prescription
medications is a growing concern among undergraduate col-
lege students in the United States and has been reported in mul-
tiple national surveys. Monitoring the future stated that misuse
of prescription medications by college students was at the high-
est level in 2004, and rates have remained steady since 2006.3
According to the National Survey on Drug Use and Health
2012, adults 18 to 25 years old had the highest prevalence of
illicit prescription drug use among all age-groups surveyed.2
Prescription opioid analgesics and stimulants were among the
most widely misused medications among this age-group.2-4
Prescription drug use and diversion represents a significant
problem among undergraduate college students.3-9
There is limited information about these types of behaviors
among health care professional students. Prior studies have pri-
marily analyzed trends at a single institution or a few programs
across 1 state.4,10 As health care professional students will
likely have influence on patient health outcomes in the future,
the presence of such behaviors may potentially affect the qual-
ity and type of care they provide to their patients. Of note, pre-
scription opioid analgesics and stimulants are the most
commonly misused medications among pharmacists and
nurses.10 The purpose of this study is to contrast the character-
istics of 3 groups of health care professional students in
California: pharmacy (Doctor of Pharmacy), medicine (Doctor
of Medicine/Doctor of Osteopathic Medicine), and physician
assistant (PA) regarding drug, alcohol, and tobacco use and
to identify risk factors associated with prescription stimulant
use. To our knowledge, this study represents the first multi-
school and multidisciplinary comparison among these groups
of future health care professionals.
1
Department of Pharmacy Practice, Touro University College of Pharmacy,
Vallejo, CA, USA
Corresponding Author:
Monica K. Bidwal, Department of Pharmacy Practice, Touro University College
of Pharmacy, 13010 Club Dr, Vallejo, CA 94592, USA.
Email: monica.bidwal@tu.edu

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2 Journal of Pharmacy Practice
Methods
Health care professional students attending pharmacy school,
medical school, or a PA program in California with Internet
access who received the e-mail announcement were included in
the study. The following subjects were excluded from the study:
health care professional students without Internet access or who
did not receive the e-mail announcement; individuals who opened
and viewed the survey link but decided not to participate; and
individuals who began but did not complete the survey.
A 50-item Web-based survey, administered through Qualtrics
Labs Inc (Provo, Utah), was used to assess several characteristics
of health care professional students. Specific variables assessed
included the following: demographics; lifestyle/study habits;
prescription stimulant use, motivations for its use, and acquisi-
tion history; use of other medications, illicit drugs, tobacco, and
alcohol; Diagnostic and Statistical Manual of Mental Disorders
(Fourth Edition, Text Revision) psychiatric conditions diag-
nosed by a health care professional; and perceived stress scale
(PSS). The PSS is a validated psychological instrument that mea-
sures the degree to which situations in one’s life are appraised as
stressful. There are 10 questions based on a 0- to 4-point scale
that asks about feelings and thoughts during the last month to
measure perceptions of stress.11
Data Collection and Data Security
Participants were recruited via e-mail between February 15 to
April 15, 2011. The Associate Dean of Student Affairs or pro-
gram coordinator of each pharmacy, medical, and PA school in
California was contacted to obtain consent for student partici-
pation. Of the 27 schools contacted, 5 of the 8 pharmacy (3 pri-
vate and 2 public) schools, 2 of the 10 medical (1 private and 1
public) schools, and 5 of the 9 PA (4 private and 1 public) pro-
grams agreed to allow student participation. Students were con-
tacted via e-mail through their Associate Dean of Student
Affairs or program coordinator with a description of the study
and directions to access the online survey Weblink using Qual-
trics. One additional reminder was sent to the students 21 days
after the initial start date of the study.
The survey Weblink directed potential subjects to an
informed consent page providing additional information
regarding the study and assuring confidentiality and anonym-
ity. No individually identifiable data were collected, Internet
provider addresses were not logged, and data transfer was
encrypted. All researchers had previously completed a National
Institutes of Health human subjects training program. The
study received institutional review board approval from Touro
University, California.
Statistical Methods
All statistical analyses were conducted using SPSS for
Windows version 14. Since the survey was primarily descrip-
tive in nature, categorical data were reported as frequency and
percentages of respondents, and continuous data were reported
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as mean + standard deviation. The Pearson’s chi-square test
and analysis of variance were used for comparisons of catego-
rical and continuous data, respectively. The Bonferroni test was
used for comparisons of variables with equal variances, while
the Games-Howell test was used for comparisons of variables
with unequal variances. Logistic regression analysis was used
to identify the risk factors for nonmedical use of prescription
stimulants. A P value of less than .05 was considered a statis-
tically significant difference.
Results
When the survey closed on April 15, 2011, there were 730 sur-
vey attempts. Among these, 103 were excluded for filling out
an incomplete survey, 11 did not disclose which health care
professional program they attended, and an additional 27 were
excluded for attending other programs not specified in the
inclusion criteria (3—Pre-Pharmacy, 17—Masters of Public
Health, 1—Education, and 6—other). This resulted in a final
analytical cohort of 589 subjects who fully completed and sub-
mitted a valid survey. A total of 309 pharmacy, 173 medicine,
and 107 PA students were included in this analysis.
Demographics
The demographic data comparing pharmacy, medicine, and PA
students are summarized in Table 1. Pharmacy students were
approximately 1 year younger than medicine and PA students
(26.4 vs 27.2 vs 27.6, P ¼ .016). The majority of pharmacy,
medicine, and PA students were female (71.5% vs 59% vs
78.5%, respectively, P ¼ .001) and never married (84.1% vs
67.4% vs 64.5% respectively, P < .001). Although the largest
proportion of both medicine and PA students were caucasian
(64.7% and 65.4%), the largest proportion of the pharmacy stu-
dents were Asian or Pacific Islander (53.1%). Most students
were in their didactic portion of their curriculum as opposed
to clinical rotations. Pharmacy students were more likely than
medicine and PA students to be in a fraternity/sorority (29.0%
vs 14.5% vs 2.8%, respectively, P < .001).
Regarding study habits, the majority of pharmacy, medi-
cine, and PA students reported procrastinating in their studies
(79.9% vs 80.3% vs 73.8%, respectively, P ¼ .360). Pharmacy,
medicine, and PA students all averaged less than 7 hours of
sleep (6.6 vs 6.8. vs 6.9 hours, respectively, P ¼ .004). During
examination periods, pharmacy students reported the least
amount of sleep (4.9 hours) compared to medicine or PA (5.8
vs 5.4 hours respectively, P < .001). Medicine students reported
seeing their primary care provider for annual check-ups less
frequently than both pharmacy and PA students (39.5% vs
48.9% vs 58.7%, respectively, P ¼ .008).
There were no significant differences between the 3 groups
regarding reported history of physical abuse. However, medi-
cine and PA students were more than 4 times as likely to report
a history of sexual abuse than the pharmacy students (11.0% vs
11.2%, 2.6%, respectively, P < .001). Similarly, medicine and
PA students were more likely to report having a primary
Bidwal et al 3

Table 1. Demographics and Background.

Pharmacy Medicine Physician assistant P

(n ¼ 309) (n ¼ 173) (n ¼ 107) value

Demographics
Current age, Mean + SD, y 26.4 + 3.6 27.2 + 3.6 27.6 + 4.4 .016
Gender, no. (%) of respondents
Female 221/309 (71.5) 102/173 (59.0) 84/107 (78.5) .001
Male 88/309 (28.5) 71/173 (41.0) 23/107 (21.5)
Race, no. (%) of respondents
Asian or Pacific Islander 163/307 (53.1) 41/173 (23.7) 12/107 (12.1) N/A
American Indian or Alaskan Native 0 0 1/107 (0.9)
Black, not of Hispanic origin 9/307 (2.9) 0 3/107 (2.8)
Hispanic 12/307 (3.9) 5/173 (2.9) 10/107 (9.3)
White, not of Hispanic origin 86/307 (28.0) 112/173 (64.7) 70/107 (65.4)
Other 37/307 (12.1) 15/173 (8.7) 11/107 (10.3)
Marital status, no. (%) of respondents
Never married 217/258 (84.1) 97/144 (67.4) 60/93 (64.5) .001
Married 38/258 (14.7) 47/144 (32.6) 30/93 (32.3)
Separated/divorced 3/258 (1.2) 0 3/93 (3.2)
Institution, no. (%) of respondents
Type of institution
Private 200/308 (64.9) 171/173 (98.8) 88/107 (82.2) N/A
Public 108/308 (35.1) 2/173 (1.2) 19/107 (17.8)
Full time or part time
Full time 306/308 (99.4) 171/172 (99.4) 107/107 (100) .711
Part time 2/308 (0.6) 1/172 (0.6) 0
Portion of program, no. (%) of respondents
Didactic 208/309 (67.3) 107/170 (62.9) 60/106 (56.6) .130
Rotations 101/309 (32.7) 63/170 (37.1) 46/106 (43.4)
Live off or on-campus, no. (%) of respondents
On-campus 28/306 (9.2) 2/173 (1.2) 2/107 (1.9) N/A
Off-campus 278/306 (90.8) 171/173 (98.8) 105/107 (98.1)
Fraternity/sorority, no. (%) of respondents
Yes 89/307 (29.0) 25/173 (14.5) 3/106 (2.8) <.001
No 218/307 (71.0) 148/173 (85.5) 103/106 (97.2) <.001
Year in school, no. (%) of respondents
First year 92/309 (29.8) 66/173 (38.2) 52/105 (49.5) N/A
Second year 78/309 (25.2) 42/173 (24.3) 36/105 (34.3)
Third year 72/309 (23.3) 31/173 (17.9) 16/105 (15.2)
Fourth year 67/309 (21.7) 33/173 (19.1) 1/105 (1.0)
Other 0 1/173 (0.6) 0
GPA (4.0 scale), no. (%) of respondents
<2.0 1/306 (0.3) 1/172 (0.6) 0 <.001
2.0-2.49 5/306 (1.6) 1/172 (0.6) 0
2.5-2.99 25/306 (8.2) 10/172 (5.8) 3/107 (2.8)
3.0-3.49 148/306 (48.4) 82/172 (47.7) 36/107 (33.6)
3.5-3.99 83/306 (27.9) 73/172 (42.4) 63/107 (58.9)
4.0 3/306 (1.0) 1/172 (0.6) 4/107 (3.7)
Residency/fellowship, no. (%) of respondents
Yes 204/309 (66.0) N/A N/A
No 105/309 (34.0)
Procrastinate to study, no. (%) of respondents
Yes 246/308 (79.9) 139/173 (80.3) 79/107 (73.8) .360
No 62/308 (20.1) 34/173 (19.7) 28/107 (26.2)
Regular doctor or primary care provider, no. (%) of respondents
Yes 150/307 (48.9) 68/172 (39.5) 61/104 (58.7) .008
No 157/307 (51.1) 104/172 (60.5) 43/104 (41.3)
Physically abused, no. (%) of respondents 16/308 (5.2) 17/173 (9.8) 9/98 (8.4) .140
Sexually abused, no. (%) of respondents 8/308 (2.6) 19/172 (11.0) 12/107 (11.2) <.001
Primary relative with substance abuse/dependence, no. (%) of respondents 27/208 (8.8) 40/173 (23.1) 28/107 (26.2) <.001
Driven vehicle intoxicated or under influence of drugs, no. (%) of respondents 84/307 (27.4) 51/173 (29.5) 33/107 (30.8) .760
Sleep—average (h) per night, mean + SD 6.6 + 1.1 6.8 + 0.9 6.9 + 1.1 .004
Sleep—exams (h) per night, mean + SD 4.9 + 1.5 5.8 + 1.3 5.4 + 1.4 <.001
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Abbreviations: GPA, grade point average; SD, standard deviation.
4 Journal of Pharmacy Practice

Table 2. Diagnosed Psychiatric Conditions.

Pharmacy (n ¼ 270) Medicine (n ¼ 149) Physician assistant (n ¼ 86) P value

Anxiety disorder, no. (%) of respondentsa 16/270 (5.9) 18/149 (12.1) 16/86 (18.6) .002
Major depressive disorder, no. (%) of respondentsb 9/270 (3.3) 14/149 (9.4) 7/86 (8.1) .027
Substance-dependence disorder, no. (%) of respondents 0 3/149 (2.0) 1/86 (1.2) .077
Schizophrenia, no. (%) of respondents 0 0 0
Body dysmorphic disorder, no. (%) of respondents 1/270 (0.4) 1/149 (0.7) 1/86 (1.2) .911
ADHD, no. (%) of respondents 2/270 (0.7) 6/149 (4.0) 8/86 (9.3) <.001
Anorexia nervosa, no. (%) of respondents 0 5/149 (3.4) 1/86 (1.2) .010
Bulimia nervosa, no. (%) of respondents 2/270 (0.7) 5/149 (3.4) 2/86 (2.3) .140
Bipolar disorder, no. (%) of respondents 1/270 (0.4) 2/149 (1.3) 2/86 (2.3) .245
Narcolepsy, no. (%) of respondents 0 0 0
Insomnia, no. (%) of respondents 6/270 (2.2) 6/149 (4.0) 6/86 (7.0) .110
None, no. (%) of respondents 230/270 (85.2) 101/149 (67.8) 54/86 (62) <.001
Perceived stress scale (PSS), mean + SD 22.3 + 6.0 22.2 + 6.2 21.9 + 6.8 .858

Abbreviations: ADHD, attention deficit hyperactivity disorder; GAD, generalized anxiety disorder; MDD, major depressive disorder; OCD, obsessive–
compulsive disorder; PTSD, posttraumatic stress disorder; SD, standard deviation.
a
GAD, panic disorder, PTSD, OCD, and social phobia.
b
Typical MDD, atypical MDD, psychotic MDD, melancholic MDD, and dysthymia.

relative with a history of substance abuse or substance depen-
dence than pharmacy students (23.1% vs 26.2% vs 8.8%,
respectively, P < .001). Over 25% of pharmacy, medicine, and
PA reported driving a motor vehicle while intoxicated or under
the influence of drugs.
Diagnosed Psychiatric Conditions and PSS
As shown in Table 2, both medicine and PA students were
more likely to report a psychiatric diagnosis made by a health
care professional. Significant differences were noticed for self-
reported histories of an anxiety disorder, a major depressive
disorder, and attention-deficit hyperactivity disorder (ADHD).
For instance, medicine and PA students were more than twice
as likely to report a history of an anxiety disorder than phar-
macy students (12.1% vs 18.6% vs 5.9%, respectively, P ¼
.002). Medicine and PA students were also more than twice
as likely to report a history of a major depressive disorder than
pharmacy students (9.4% vs 8.1% vs 3.3%, respectively, P ¼
.027) and more than 5 times as likely to report a history of
ADHD (4.0% vs 9.3% vs 0.7%, respectively, P < .001).
Regarding stress, there were no significant differences in PSS
scores among the 3 groups (mean scores were 22.2, 21.9, and
22.3, for medicine, PA, and pharmacy students, respectively;
P ¼ .858). As a reference, the average PSS score for the United
States adult population is 12 to 13.11
respondents admitted to use. Among those admitting to pre-
scription stimulant use, only 32.7% reported having a valid pre-
scription in their name. The most commonly used agents were
amphetamine-dextroamphetamine (Adderall, Adderall XR)
and methylphenidate (Ritalin, Ritalin LA/SR). Regarding fre-
quency of prescription stimulant use, 9.6% reported using it 2
to 3 times/month, 13.5% daily, and 11.5% only during exami-
nation periods.
The most common route of administration of prescription
stimulants was oral (98.0%). A smaller percentage of users
(6.0%) reported intranasal use (not an indicated route of admin-
istration). More than half (58.8%) of the users planned the
duration/dose prior to using their prescription stimulant, and all
of these users adhered to their original plan they had set out.
When asked about how the prescription stimulant affected their
academic performance, 38.8% noticed an improvement, 61.2%
reported performance staying the same, while no subjects
reported a decline.
Acquisition of Prescription Stimulants
A majority reported obtaining their prescription stimulant from a
friend/classmate (52.0%). Other methods of acquisition included
a community/outpatient pharmacy (32.0%), a family member
(14.0%), a local acquaintance (8.0%), and transportation from
a foreign country (2.0%). A minority of users (8.0%) admitted
to selling or giving out their prescription stimulants to others.

Characteristics of Prescription Stimulant Medication Use

Characteristics of prescription stimulant use are summarized in
Table 3 and shown collectively among the 3 health care profes-
sional groups since the numbers in each individual group were
relatively small for comparison. The breakdown among the 3
health care student group is as follows: 6.1% pharmacy,
10.4% medicine, and 14.0% PA students (P ¼ .032). When
asked about lifetime use of prescription stimulants, 8.8% of all
Adverse Effects of Prescription Stimulants
The most common adverse effects reported by prescription
stimulant use were decreased appetite (79.1%), sleep
disturbances/insomnia (69.8%), mood changes (30.2%), pal-
pitations (30.2%), irregular heart rate (25.6%), anxiety
(23.3%), weight loss (14.0%), nausea/vomiting (11.6%), and
high blood pressure (11.6%). Almost half (47.1%) of users

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Bidwal et al 5

Table 3. Prescription Stimulant Utilization. were concerned about their long-term health from stimulant
use. Considering these adverse effects and concerns, only
No. (%) respondents
20.0% of prescription stimulant users planned to continue use
Background after graduation.
Lifetime use 52/589 (8.8)
Valid prescription in your name 17/52 (32.7)
How often stimulant used in past 12 months Disclosure of Prescription Stimulant Use
Never 25/52 (48.1) Most students were not secretive about prescription stimulant
Once a year 4/52 (7.7)
use. Almost two-thirds (64.7%) of users informed a friend,
Once a month 1/52 (1.9)
2-3 times/month 5/52 (9.6) 43.1% informed a family member/spouse, 39.2% informed a
Once a week 1/52 (1.9) colleague/classmate, 33.3% informed a physician/health care
2-3 times/wk 3/52 (5.8) provider, and 7.8% informed a professor/preceptor. Only
Daily 7/52 (13.5) 7.8% of users had not informed anyone.
Only during examination periods 6/52 (11.5)
Administration
Oral 49/50 (49.0) Motivations for Prescription Stimulant Use
Intranasal 3/50 (6.0)
‘‘Improve concentration/help focus’’ was ranked as an impor-
IV 0
SQ/IM injection 0 tant reason for using prescription stimulants. The following
Who have you informed about stimulant use were ‘‘somewhat important reasons’’ for use: improve alertness
No one 4/51 (7.8) (pharmacy and medicine) and perform better scholastically
Physician/health care provider 17/51 (33.3) (pharmacy and PA). The following were not highly rated rea-
Family member/spouse 22/51 (43.1) sons for using prescription stimulants among the 3 groups: per-
Friend 33/51 (64.7) form better on rotations, lose weight, stay up all night, peer
Colleague/classmate 20/51 (39.2)
pressure, physical dependence, gain an academic edge over
Professor/preceptor 4/51 (7.8)
Plan duration/dose prior to use 30/51 (58.8) other students, or economic worries/financial pressure.
Stick with original plan 30/30 (100.0)
Sold/given your prescription 4/50 (8.0)
Plan to continue use after graduation
Awareness of Prescription Stimulant Use
Yes 10/50 (20.0) A majority (87.1%) of all students reported being aware that
No 40/50 (80.0) prescription stimulants were being used to enhance aca-
Noticed improvement in academics demic performance at their academic institution. Roughly
Yes 19/49 (38.8)
two-thirds (67.3%) of the students believed that faculty at
No, grades are the same 30/49 (61.2)
No, grades have declined 0 their institution were also aware that prescription stimulant
Adverse effects abuse was occurring.
Concerned about long-term side effects 24/51 (47.1)
Irregular heart rate 11/43 (25.6)
High blood pressure 5/43 (11.6)
Risk Factors for Nonmedical Use of Prescription
Mood changes 13/43 (30.2) Stimulants
Palpitations 13/43 (30.2)
Sleep disturbance (ie, insomnia) 30/43 (69.8)
Potential risk factors for nonmedical use of prescription stimu-
Decreased appetite 34/43 (79.1) lants are summarized in Table 5. Hispanic (5.66, P ¼ .017) or
Nausea/vomiting 5/43 (11.6) caucasian decent (2.85, P ¼ .014), heavy alcohol use (3.83, P ¼
Weight loss 6/43 (14.0) .015), and smoking (3.88, P ¼ .005) were identified as risk fac-
Anxiety 10/43 (23.3) tors or predictors for nonmedical use of prescription stimulants.
Acquisition
Community/outpatient pharmacy 16/52 (30.8)
Family member 7/52 (13.5) Use of Prescription Medications, Over-the-Counter Prod-
Friend/classmate 26/52 (50.0) ucts, Illicit Drugs, Tobacco, and Alcohol
Internet supplier (not registered pharmacy) 0
Internet registered pharmacy 0 Use of prescription medications, over-the-counter products,
Mail order from foreign country 0 illicit drugs, tobacco, and alcohol consumption patterns in the
Transported from foreign country 1/52 (1.9) past 12 months are described in Table 6. Over 40% of all 3
Purchased from local acquaintance 4/52 (7.7) groups consumed caffeinated energy drinks. No differences
From health care setting (without a rx) 1/52 (1.9)
were seen regarding tobacco or alcohol use; however, over
Other 2/52 (3.9)
30% of all groups reported binge alcohol drinking. Medicine
Abbreviations: IV, intravenous; IM, intramuscular; SQ, subcutaneous. students were more than twice as likely to report marijuana use

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6 Journal of Pharmacy Practice

Table 4. Rating of Motivations for Prescription Stimulant Use.a in our study may be a result of different trends in illicit drug use
patterns or perhaps regional differences.
Physician
Pharmacy Medicine assistant
Medicine and PA students in the current study were more
likely to report nonmedical use of prescription stimulants, dex-
Improve concentration/help focus 4.2 + 1.3 4.4 + 1.0 4.5 + 1.1 tromethorphan, marijuana, tobacco (smokeless and cigarettes)
Improve alertness 3.2 + 1.5 3.3 + 1.4 2.9 + 1.4 as well as binge alcohol and heavy alcohol compared to phar-
Perform better scholastically 3.7 + 1.4 2.8 + 1.6 3.3 + 1.8 macy students. Possible risk factors and associations may con-
Perform better on clinical 1.1 + 0.2 1.6 + 1.3 2.2 + 1.8
tribute to these findings. For instance, this finding may be
rotations
Lose weight 1.2 + 0.5 1.3 + 0.6 1.7 + 1.3 influenced by cultural differences. A majority of medicine and
Stay up all night 2.4 + 1.6 2.2 + 1.3 2.1 + 1.6 PA students were caucasian when compared to a majority of
Due to peer pressure 1.00 + 0 1.2 + 0.5 1.3 + 0.7 pharmacy students were Asian or Pacific Islander. In 2012, the
Due to physical dependence 1.00 + 0 1.00 + 0 1.00 + 0 national rates of illicit drug, alcohol, and tobacco use among cau-
To gain an academic edge over 1.6 + 1.2 1.00 + 0 1.6 + 1.0 casians (9.2%, 57.4%, and 29.2%, respectively) were higher than
other students Asians (3.7%, 36.9%, and 10.8%, respectively).2 Furthermore,
Economic worries or financial 1.00 + 0 1.00 + 0 1.00 + 0
medicine and PA students were 5 times more likely to report sex-
pressure
ual abuse, 3 times more likely to report a primary relative with
Abbreviation: SD, standard deviation. substance abuse or substance dependence disorder, twice as
a
Data are mean + SD. likely to report a history of an anxiety disorder or major depres-
sive disorder, and 5 times as likely to report a diagnosis of
Table 5. Risk Factors for Nonmedical Use of Prescription Stimulants. ADHD compared to pharmacy students. Whether these factors
were the direct cause or result of the above-mentioned drug and
Odds ratio, confidence interval P value alcohol use behaviors cannot be determined from this study and
would be of interest to explore in the future.
Age 8.91, 0.77-1.03 .127
Gender (male vs female) 0.49, 0.20-1.22 .125 Compared to the undergraduate population, health care pro-
Hispanic vs non-Hispanic 5.66, 1.37-23.34 .017 fessional students appear less aggressive in nonmedical use of
Caucasian vs noncaucasian 2.85, 1.24-6.54 .014 prescription medications, illicit drugs, tobacco, and alcohol.
GPA 1.40, 0.97-2.00 .071 Collectively, the health care professional students reported lower
Fraternity vs nonfraternity 0.77, 0.32-1.85 .559 nonmedical use of opioid analgesics or anxiolytics compared to
Binge alcohol 1.55, 0.66-3.64 .319 the undergraduate population. Only 2% to 4% of health care pro-
Heavy alcohol 3.83, 1.30-11.32 .015
fessional students in the current study reported past-year use of
Smoking 3.88, 1.49-10.10 .005
Procrastination 1.16, 0.45-2.98 .754 either opioids or benzodiazepines as opposed to 7% past-year
Major depressive disorder 1.97, 0.50-7.50 .332 use among college-aged students.5 Similarly, the health care pro-
Anxiety 1.29, 0.42-3.95 .652 fessional students in the current and prior studies reported less
tobacco, binge alcohol drinking, cocaine, and marijuana use than
Abbreviation: GPA, grade point average.
the undergraduate population.4,10 Despite this, the health care
professional students in our survey still reported higher mari-
compared to pharmacy and PA students (20.8% vs 7.4% vs juana use than the 4.8% national rate in adults 26 year or older.2
8.4% respectively, P < .001). Perhaps marijuana is not perceived as harmful or addictive to the
body as other types of illicit drugs.
For prescription stimulants, roughly 9% of all students in
Discussion our study reported using a prescription stimulant in their life-
The current study confirms the presence of nonmedical use of time, with 4.6% using it in the past year. In comparison, col-
prescription medications (in particular stimulants) as well as lege students reported a lifetime prescription stimulant use of
illicit drugs, tobacco, and alcohol use among health care pro- approximately 8% and past-year use of 5% to 6%.3,12 The
fessional students in the state of California. These findings are majority of health care professional students obtained their
similar to 2 Northeastern-based studies involving pharmacy prescription stimulant illegally, as more than half of the indi-
and/or nursing students by Lord and colleagues and Kenna and viduals who reported its use did not have a valid prescription
Wood.4,10 Both prior studies revealed that marijuana (21%- in their name. Most subjects reported obtaining their prescrip-
66.7%), hallucinogens (13.8%-19.7%), prescription opiates tion stimulant supply from a friend or classmate to improve
(7.9%-39.2%) and stimulants (6.7%-11.8%), and ecstasy concentration or perform better scholastically. Prescription
(7.8%-11.5%) were the most commonly used illicit agents. stimulants are considered scheduled II controlled medications
Although marijuana and stimulants were the most commonly in the United States and have strict dispensing rules due to the
used agents in the current study, the percentage of users of mar- high potential of abuse and physical dependence. The act of
ijuana, hallucinogens, prescription opiates, stimulants, and possessing a controlled substance without a valid prescription
ecstasy were all considerably lower than the 2 above- is a violation of the law.13 Interestingly, a majority (80.0%) of
mentioned studies.4,10 Possible differences seen by the subjects users stated they did not plan to continue stimulant use after

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Bidwal et al 7

Table 6. Past-Year Nonmedical Use of Medications and Illicit Drugs.

Pharmacy Medicine Physician assistant P

(n ¼ 309) (n ¼ 173) (n ¼ 107) value

Prescription stimulants, no. (%) respondents 19/309 (6.1) 18/173 (10.4) 15/107 (14.0) .032
Caffeine pills, no. (%) respondents 32/309 (10.4) 11/173 (6.4) 7/107 (6.5) .232
Caffeinated energy drinks, no. (%) respondents 141/309 (45.6) 77/173 (44.5) 52/107 (48.6) .800
Ephedrine, no. (%) respondents 2/309 (0.6) 2/173 (1.2) 0 .520
OTC pseudoephedrine for nonmedical purposes, no. (%) respondents 12/309 (3.9) 6/173 (3.5) 2/107 (1.9) .610
Dextromethorphan (ie, Robitussin) for nonmedical purposes, no. (%) respondents 4/309 (1.3) 4/173 (2.3) 3/107 (2.8) .540
Promethazine/Phenergen þ codeine for nonmedical purposes, no. (%) respondents 0 1/173 (0.6) 0 .300
Beta-blockers for nonmedical purposes, no. (%) respondents 11/309 (3.6) 4/311 (2.3) 1/107 (0.9) .330
Opioids/narcotic analgesics for nonmedical purposes, no. (%) respondents 7/309 (2.3) 7/173 (4.0) 0 .100
Anxiolytics/benzodiazepines for nonmedical purposes, no. (%) respondents 9/309 (2.9) 3/173 (1.7) 4/107 (3.7) .580
Cigarettes, no. (%) respondents 25/209 (8.1) 26/173 (15.0) 17/107 (15.9) .160
Smokeless tobacco, no. (%) respondents 23/309 (7.4) 22/173 (12.7) 11/107 (9.5) .300
Any alcohol use, no. (%) respondents 198/309 (64.1) 125/173 (72.3) 72/107 (67.3) .190
Binge alcohol use (5 or more drinks on the same occasion) 96/309 (31.1) 58/173 (33.5) 38/107 (35.5) .670
Heavy alcohol use (5 or more drinks on the same occasion on 5 or more days within a 28/309 (9.1) 19/173 (11.0) 7/107 (6.5) .460
30-day period), no. (%) respondents
Marijuana (ie, pot, weed) 23/309 (7.4) 36/173 (20.8) 9/107 (8.4) <.001
Methamphetamine (ie, meth, crystal, ice), no. (%) respondents 0 1/173 (0.6) 0 .300
Cocaine, no. (%) respondents 1/309 (0.3) 2/173 (1.2) 2/107 (1.9) .280
Crack, no. (%) respondents 1/309 (0.3) 1/173 (0.6) 0 .720
Hallucinogens (ie, LSD, PCP, mushrooms), no. (%) respondents 2/309 (0.6) 3/173 (1.7) 1/107 (0.9) .520
Anabolic steroids, no. (%) respondents 0 0 2/107 (1.9) .011
Heroin, no. (%) respondents 1/309 (0.3) 0 0 .640
Inhalants (ie, glue, solvents, gas), no. (%) respondents 1/309 (0.3) 0 1/107 (0.9) .430

Abbreviations: OTC, over-the-counter; LSD, lysergic acid diethylamide; PCP, phencyclidine.

graduating from their professional program. Unlike other illi-
cit drugs that are typically used to obtain a high, prescription
stimulants are presumably being misused primarily for aca-
demic purposes.
Various lifestyle habits may contribute to nonmedical use of
prescription medications as well as illicit drugs, tobacco, and
binge/heavy alcohol use among health care professional stu-
dents. As noted earlier, health care professional students seem
to be under greater amounts of stress (almost twice as much
based on the PSS score) than the general adult population. Per-
haps the rigors of a graduate school curriculum, poor study
habits (as indicated by the high frequency of reported procras-
tination), pressures of obtaining postgraduate residency posi-
tions, or decreased sleep (especially during examination
time) may increase the amount of stress experienced by these
students. Of note, more than 60% of the general adult popula-
tion obtain more than 7 hours of sleep per night, whereas the
majority of health professional students averaged less than 7
hours on an average night.14
Based on our study’s results, health care professional pro-
grams may wish to invest more resources to address the stress
levels and increase awareness of illicit drug use among students.
Programs may consider the need to promote and provide addi-
tional resources such as counselors, support groups, or relaxation
training. A relatively large amount of students reported various
psychiatric diagnoses, conditions which often benefit from emo-
tional and psychological support. Possible methods to promote
awareness are to incorporate topics on substance abuse into the
curriculum earlier on and to increase understanding of the poten-
tial negative legal and medical consequences of illicit drug use.
Support groups and stress coping strategies to counter stress lev-
els have been shown to be beneficial in the undergraduate pop-
ulation and nursing programs and thus may be beneficial for
health care professional students.15-17
Limitations
Several limitations should be considered before assessing the
implications of our study. First, surveys by nature lend to
recall bias since subjects must remember their past experi-
ences. Second, although responses were completely confiden-
tial, students may have chosen not to take part in the survey or
answer questions to the fullest extent in fear of potential
repercussions (ie, jeopardizing their intern license or career).
This may have resulted in an underrepresentation of actual
drug, tobacco, and alcohol use. Third, although surveys are
a useful and an efficient tool in obtaining general information
about a target population, it is difficult to assess causality.
Finally, e-mails and the Internet were the primary source for
recruitment and survey administration. This may have intro-
duced selection bias, since individuals who do not look at
their e-mail or Internet regularly would by definition be
excluded. However, consistencies of information with this
study and prior health care student surveys support the current

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8 Journal of Pharmacy Practice
results. Various sources have also demonstrated the validity
and reliability of online data collection for research when
compared to traditional methods.18-20
Conclusion
Similar to the undergraduate student population, nonmedical
use of prescription medications, binge drinking, heavy alcohol
use, cigarette smoking, and marijuana were prevalent in the
health care professional student population. Medicine and PA
students reported a higher incidence of a diagnosed anxiety dis-
order, major depressive disorder, or ADHD compared to phar-
macy students. Correspondingly, medicine and PA students
were more likely to report recent use of prescription stimulants
and marijuana than pharmacy students. All 3 health care profes-
sional students had approximately double the PSS stress score
than the general adult population. The information presented
in this study may help health care programs better understand
their student population, which may lead to a reassessment of
student resources and awareness/prevention programs.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship,
and/or publication of this article.
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