Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Welsh, Shentu); Adolescent Acute Residential Treatment, McLean Hospital, Harvard Medical School, Belmont, Massachusetts (Sarvey).
Corresponding author. Justine W. Welsh: Send correspondence to Dr. Welsh (ude.yrome@hslew.enitsuj). Copyright © by the American Psychiatric AssociationSubstance use among college students is associated with negative outcomes, and several risk factors, such as academic and peer pressure, are specific to this population. This article describes specific challenges and approaches to treatment for this population, including screening tests and interventions for specific substances and evidence-based programming.
Keywords: Alcohol, drug use, college studentsU.S. college campuses have witnessed a national increase of cannabis, stimulant, and illicit drug use among students over the past decade. Substance use among college students is associated with numerous negative outcomes including lower academic performance, a higher probability of unemployment after graduation, and an increased risk of committing and experiencing sexual assault. Several risk factors for substance use are specific to this population, including an affiliation with Greek life, perception of high academic pressure, and peer pressure. Students with problematic substance use also face unique challenges in planning treatment, including aspects of confidentiality, financial constraints, and potential university oversight and involvement. This article highlights the prevalence of substance use on college campuses and describes some of the specific challenges and approaches to treatment in this population, including screening tests and interventions for specific substances used on college campuses and evidence-based substance use programming for college students.
Keywords: Alcohol, drug use, college studentsFor many youths, college enrollment is a distinct life event that symbolizes the transition from adolescence to independence and adulthood. It also represents a vulnerable period for increased exposure to a variety of illicit and prescribed substances.
Although attending college has historically been considered a protective factor against the development of substance use disorders, in recent decades substance use has become one of the most widespread health problems on college campuses in the United States (1). In a study by Caldeira et al. (2), nearly half of 946 college students who were followed from freshman to junior year met criteria for at least one substance use disorder during that time. Students who regularly use substances are more likely to have lower GPAs, spend fewer hours studying, miss significantly more class time, and fail to graduate or to be unemployed postgraduation (3–6). Substance use is also associated with significant general medical and psychiatric morbidity and mortality for many students (7, 8).
One of the most significant challenges with addressing substance use on college campuses is related to its history of integration into the normative tradition and fabric of the college experience. Alcohol use is a prime example. National survey data indicate that over 60% of full-time college students have consumed alcohol, and a staggering 39% report engaging in binge drinking (consuming five or more drinks) over the past month (9). Surprisingly, both past-month and past-year alcohol use are higher for college attendees than for age-matched cohorts who do not attend college (1). Binge drinking can lead to dangerously elevated blood alcohol levels and is associated with an increased risk of illicit drug use (10). The challenges associated with beginning college life, such as separation from family members, participation in new social networks, and more intense academic pressures, may significantly contribute to increased alcohol consumption.
The escalation and normative acceptance of the use of prescription stimulants for cognitive enhancement purposes have also increased on college campuses over the past decade (1). Annual prevalence of nonmedical dextroamphetamine (Adderall) use among college students is higher (9.9%) than for age-matched youths not enrolled in college (6.2%) (1). College students often seek out dextroamphetamine prescriptions from mental health practitioners, with the intention of enhancing their ability to focus and study for exams. This presents a unique challenge for prescribers, who must ensure that those who need stimulant medication for a diagnosed condition receive it while not overprescribing to those who may be using it for nontherapeutic purposes.
The use of cocaine among college students presents another challenge to health care providers. According to the 2016 Monitoring the Future survey, 4.0% of full-time college students surveyed used cocaine in the past year, and 1.4% used cocaine in the past month (1). A longitudinal study of 1,253 college students found that more than 20% were exposed to opportunities for cocaine use in the past year (11). The substantial presence of stimulants on college campuses warrants the continued attention of clinicians and school administrators.
The percentage of college students using cannabis daily has increased, nearly doubling between 2007 and 2014 (1). According to the 2016 National Survey on Drug Use and Health, 20% of full-time college students reported using marijuana in the past month (12). There is considerable evidence of the short-term impact of heavy cannabis use on memory and learning, and it plays a negative role in academic and health outcomes on college campuses (4, 13). The likelihood of cannabis use increases during the college years, with some studies demonstrating an escalation in prevalence with each successive year (14).
Fortunately, tobacco use has been on the decline over the past 20 years across U.S. college campuses. However, campuses have witnessed a relative explosion of electronic cigarette/vaporizer devices, which offer the ability to use more concentrated amounts of nicotine (15), as well as cannabis oil (sometimes known as “dab pens”). Although college students are still somewhat less likely than noncollege cohorts to use vaporizer devices (6.9% versus 9%), the trend suggests that use of electronic vaporizer devices represents a new and potentially more discrete means of acquiring physiologic nicotine dependence (1). For example, the Juul is a very small and popular vaporizer device sold online, advertising its compact nature and colorful nicotine pods to youths as fun and convenient (including a charging station that fits onto the side of a laptop computer). One pod contains as much nicotine as a full pack of traditional cigarettes. Relatively short-term use can lead to significant symptoms of nicotine withdrawal. Youths who initiate experimentation with electronic cigarettes are also more likely than those who do not to progress to tobacco products (16). In some cases, youths are also experimenting with alternative modes of cannabis delivery with vaporizing devices. Cannabis oil cartridge sales have escalated in states where cannabis is legal, such as California, while traditional sales of the cannabis plant product have simultaneously declined (17).
MDMA, LSD, and other psychedelic drugs are also gaining popularity in the club and rave scenes among college students. The annual prevalence of MDMA use among college students more than doubled from 2004 to 2016 (1), and the rate of emergency room visits resulting from MDMA use in this age group continues to increase (18). College students reported taking hallucinogens and MDMA for reasons such as curiosity, a desire to escape or to achieve a novel experience, and social pressures (19, 20). In recent years, “microdosing” has also gained popularity among college students. Microdosing describes the act of consuming a small amount of hallucinogen in order to achieve a subtle psychedelic effect but not to fully alter consciousness. Research on the prevalence and potential adverse effects of microdosing is unfortunately scarce (21).
In the midst of the opioid crisis, college students are particularly vulnerable to opioid misuse. According to the National Survey on Drug Use and Health, young adults ages 18 to 25 report the highest past-year opioid use prevalence of all age groups (22). The risk for opioid use disorders commonly begins during adolescence and young adulthood (23, 24), coinciding with the college years. Results from a recent study suggest that opioid misuse among college students is associated with several factors, such as living off campus and having a low GPA (25). Unfortunately, individuals in this age group are often reluctant to enter treatment. Even for those who receive treatment, retention rates are lower than for older adults (26–28). Unfortunately, although the American Academy of Pediatrics supports the use of medication-assisted treatment for opioid use disorder, prescribing rates remain relatively low for young adults (24). Buprenorphine-naloxone is approved for patients ages 16 and older and has been found to be a cost-effective treatment in this age group. Methadone or extended-release injectable naltrexone may also be options; however, some have cautioned about the perceived stigma of methadone in this age group (29), and to date there is limited data directly supporting extended injectable naltrexone in this population (30, 31).
In addition to general risk factors, such as certain psychiatric conditions and family history of substance use disorders (32, 33), there are a number of risk factors for substance use specific to the college campus. Figure 1 summarizes these factors. Peer influence and the perception of harm play a significant role in the decision to engage in substance use on college campuses. This is especially true during the first year of college, with less of an effect in each consecutive year (34). Students who perceive substance use by their peers to be normative are more likely to be at risk themselves of developing a substance use disorder (35). This perception is confounded by a general overestimation of peer substance use within the college-age population (35–37). According to the American College Health Association, among 26,139 undergraduate students from 52 schools, 9% had used cigarettes in the past 30 days, yet most believed that about 71% of their counterparts had smoked cigarettes in the past 30 days (36). The results were also similar for cannabis use. The drastic overestimation of peer use has been found to be present in nearly all categories of substance use.