International Journal of Drug Policy 44 (2017) 12–22

Contents lists available at ScienceDirect

International Journal of Drug Policy

journal homepage: www.elsevier.com/locate/drugpo

Motives for illicit prescription drug use among university students: A

systematic review and meta-analysis
Trevor Bennett* , Katy Holloway
University of South Wales, Pontypridd, CF37 1DL, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: There is a growing body of research on the motives for prescription drug misuse (PDM)
Received 30 August 2016 among university students. However, the overall findings of this research are hard to decipher. Studies
Received in revised form 28 January 2017 use different methods, they examine different drug types, the motives are phrased in various ways, and
Accepted 24 February 2017
the results differ widely. In order to make sense of this body of knowledge, it is necessary to synthesise
the results across studies and draw out conclusions.
Keywords: Methods: The research comprises a systematic review and meta-analysis of studies on the motives of
Prescription drug misuse
university students for illicit use of four different types of prescription medication (stimulants,
University students
Systematic review
analgesics, tranquillisers and sedatives). The search for studies was conducted on six bibliographic
Meta-analysis databases with stated criteria governing search eligibility and inclusion in the final review.
Results: Overall, the most prevalent motives for PDM among university students cover some kind of
personal enhancement to the user in terms of performance (in relation to sports, and academic
outcomes), mental health (ability sleep, to reduce anxiety), or physical health (manage pre-existing
illnesses). Fewer than half of users said that they were involved in PDM for pleasure purposes (to party, to
get high, or to experiment).
Conclusion: PDM among students might be viewed as a means of self-improvement when other means of
achieving desired objectives are unavailable or restricted. A more thorough understanding of motives for
PDM, especially in relation to their influence on behaviour, might help in devising university-based
treatment and prevention programmes.
Crown Copyright © 2017 Published by Elsevier B.V. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Methods . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Search strategy . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Criteria for inclusion of studies ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Attrition of studies . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Data extraction and coding . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Statistical procedures . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Results . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Stimulants . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Analgesics . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Tranquillisers . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Sedatives . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Discussion . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Summary . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Previous reviews . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Strengths . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

* Corresponding author.
E-mail address: trevor.bennett@southwales.ac.uk (T. Bennett).

http://dx.doi.org/10.1016/j.drugpo.2017.02.012
0955-3959/Crown Copyright © 2017 Published by Elsevier B.V. All rights reserved.
 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22 13

Limitations . . . ......... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Conclusion . . . . . . ......... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Conflicts of interest statement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . ......... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Introduction The research literature is replete with reviews on the motives

for PDM in that publications on the topic typically include brief
There is a growing body of research on prescription drug misuse reviews of the literature by way of an introduction. However, there
(PDM) among university students. Studies have shown that drug have been few systematic reviews that have attempted to
misuse prevalence increases at a higher rate among university summarise the body of research as a whole. We found three
students than their same age, non-university, peers (Bachman, dedicated reviews that provided a summary of research on motives
O’Malley, Johnston, & Freedman, 2008; Bennett, 2014; Johnson, for PDM among university students.
O’Malley, Bachman, & Schulenberg, 2012). There is also evidence Benson et al. (2015) conducted a systematic review of illicit
that students might be at particularly high risk of PDM as a result of prescription stimulant use among college students covering:
factors associated with university life, such as academic stress prevalence of use, sources of supply, perceived availability, and
(Eickenhorst, Vitzthum, Klapp, Groneberg, & Mache, 2012). motives for use. While the title of the study refers to use of a meta-
Understanding the motives for PDM is important as it can help analysis, this method was not used in the investigation of motives.
explain why young people in university environments begin or Instead, 15 studies were analysed by identifying the ‘most
continue PDM. It has been found, for example, that students who commonly endorsed’ motives based on the percentage of students
believe that PDM is safer than other forms of drug misuse are more citing them. The most common group of motives was referred to as
likely to use them (Judson & Langdon, 2009). Conversely, students ‘academics’ covering: ‘to concentrate better while studying’, ‘to
who are aware of the harms of illicit prescription drug use are less improve study skills’, ‘to stay awake to study longer’ and ‘to
likely to use them (Benson, Flory, Humphreys, & Lee, 2015). In improve concentration’. Less commonly endorsed motives were
addition, research has shown that motives for PDM can predict summarised under the heading of ‘non-academic’ reasons and
other forms of substance use behaviour. Students who report illicit included: ‘to get high’, to prolong the effects of other substances,
use of prescription stimulants to ‘get high’, for example, are more and ‘to lose weight’.
likely to use cocaine than those who mention ‘academic’ motives Dennhardt and Murphy (2013) included one short section on
(Teter, McCabe, Cranford, Boyd, & Guthrie, 2005). motives for PDM in a review that focused mainly on the findings of
PDM is also important because it is associated with a range of research on prevention and treatment of illegal drug use among
harms including: addiction (All-Party Parliamentary Drug Misuse college students. The method used was to report sections from the
Group, 2009), psychiatric disorders (Spoth, Trudeau, Shin, & conclusions of the individual studies. In this case, there was no
Redmond, 2008), and poisoning and death (Office for National synthesis of the findings. The review reported that one study
Statistics, 2015; Giraudon, Lowitz, Dargan, Wood, & Dart, 2013). showed that the primary motives for illicit use of prescription pain
There is also some evidence that motives for PDM might be medication among students were ‘to get high’ and ‘to alleviate
associated with alcohol and drug-related problems. A study pain’. Another found that the most common motives for
conducted in the United States (US), for example, found that nonmedical use of prescription stimulants were ‘to help concen-
users who reported motives other than ‘to relieve pain’ for tration’ and ‘to increase and sustain alertness’. The absence of
nonmedical use of prescription opioids had fifteen times the odds integration of the results of the studies limits the conclusion that
of experiencing three or more substance-related problems (e.g. can be drawn from the review.
alcohol dependence, inability to stop using drugs, illegal activities, Drazdowski (2016) conducted a systematic review of motives
and blackouts) (McCabe, Cranford, Boyd, & Teter, 2007). Hence, for PDM among young adults including college-aged students.
motives for PDM are a relevant topic to investigate as they can help Thirty-seven articles were selected for inclusion in what the
understand PDM as well as provide ideas for treatment and author described as a ‘qualitative synthesis’. The review
prevention. included studies on stimulants, prescription opioids, and CNS
While research on motives has produced several important depressants. The author summarised the results under the
findings, there is still much more to be learned. It has been heading of the three main drug types investigated, broken
argued, for example, that a large majority of studies to date have down by whether they were conducted in the United States
been conducted in the United States, with much less known about (US) or elsewhere. The method used for synthesising the results
motives for PDM in other countries (Dennhardt & Murphy, 2013). of the studies was first to identify the ‘main’ motives and then
It has also been noted that studies have focused almost solely on report on other ‘common’ motives, based on the relative
the misuse of prescription stimulants with less attention paid to percentage of users reporting the motive. The ‘main motive’
other medications such as anxiolytics, analgesics, and anti- cited for prescription stimulant use was for ‘academic reasons’
depressants (Drazdowski, 2016). Further, there have been limited and a ‘common’ motive was for ‘recreational purposes’. The
breakdowns of motives by student types beyond differences in main motives for non-medical use of prescription opioids and
gender and (mainly in the United States) student athletes versus CNS depressants were described as difficult to determine given
non-athletes. the limited literature on the topic.
One of the more troubling features of existing research on In combination, the three reviews provide a useful overview of
motives is that the overall findings of the body of knowledge as a the literature. However, the main method of synthesising the
whole are hard to decipher. Studies use different methods, they results in all cases was a qualitative assessment based on the most
examine a variety of drugs, the motives are phrased in different common motives. It is not possible from the reviews to provide an
ways, and the results vary widely. As a result, it is difficult to overall percentage of users who report particular motives for PDM
determine the overall conclusions to be drawn from the research. or to identify a ranked hierarchy of their importance.
In order to make sense of this body of knowledge, it is necessary to The aim of the current paper is to summarise what has been
synthesise the results across studies. learned from research on the prevalence of motives for PDM
14 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22

among university students using meta-analysis. The main reason motive importance was presented in terms of percentages and the
for this choice is that meta-analyses can pool prevalence rates numerical data from which the percentages were calculated were
across studies and summarise the results with a single percentage. provided.
As far as we know, motives have not been previously analysed
using meta-analytic methods.
Data extraction and coding
Methods
The data were extracted from the selected studies and entered
into an Excel spreadsheet. The spreadsheet included the names of
The current research comprises a quantitative systematic
the original motives and data relating to the numerator and
review of the research literature on motives among university
denominator that made up the percentage of respondents
students using meta-analytic techniques with the aim of
mentioning the motive.
identifying a weighted prevalence estimate for each of the most
The original motives described in the study were sometimes
common motives for PDM. The main elements of the approach are:
worded in slightly different ways. The motive ‘to get high’, for
(1) a search strategy for identification of relevant studies, (2)
example, was sometimes referred to as: ‘gives me a high’, ‘high
criteria for inclusion and exclusion, (3) a record of attrition of
feeling’, and ‘to become high’. While these phrases cover
studies, (4) a method of data extraction, and (5) a summary of
essentially the same meaning, they would appear as different
statistical procedures (Higgins & Green, 2006).
motives if they were included as such in the statistical analysis. In
order to avoid this, motives with similar meanings were combined
Search strategy
into broader categories. The motive category academic outcomes,
for example, included: ‘to improve academic performance’, ‘to
The search for studies was based on six bibliographic databases:
receive better grades’, ‘to improve intellectual performance’, and
Web of Science, ASSIA, PsycInfo, ProQuest, PubMed and Medline.
‘to increase concentration’. (See Table 1 for a full breakdown of
These were chosen as they are known bibliographic sources of
how the motives were coded.) The coding was done by one
studies on prescription drug misuse. Each database was searched
researcher completing the first round of classification and a second
using the same search term, adjusted for method of searching
checking the results and, where necessary, proposing a revised
required by the database (see note below.1 )
coding. Inconsistencies were discussed until a consensus was
reached.
Criteria for inclusion of studies
The method of classifying types of prescription drug varies
across studies. The titles of the studies referenced at the end of
The main eligibility criteria were that the studies must be:
the paper show some of the variations in drug categories
investigated. In relation to stimulants, these include: amphet-
 based on university or college students (excluding primary and
amine and non-amphetamine prescription stimulants (e.g.,
secondary school children),
Adderall, Dexedrine, Dexamfetamine, lisdexamfetamine, methyl-
 written in English, Spanish or French,
phenidate, Ritalin and Concerta) primarily used to treat ADHD
 published between the period 1992 and 2015,
and Modafinil used mainly for treatment of narcolepsy, sleep
 accessible during the research period,
disorders, and excessive daytime sleepiness. Similar variations
 included data on the prevalence of motives,
exist in relation to CNS depressants (covering sleeping aids,
 based on specific prescription drugs or groups of drugs.
anxiolytics, sedatives, and tranquillisers) and analgesics (also
referred to as pain relievers, prescription opioids, and analgesics).
The only criterion of methodological adequacy was that the
In this paper, we have divided prescription drug misuse into
study should be based on a cross-sectional or longitudinal survey
four categories, which encompass the various classifications
of university students.
mentioned above: stimulants, analgesics, tranquillisers and
sedatives. Stimulants cover ADHD medications, and Modafinil.
Attrition of studies
Analgesics cover mainly prescription opioids, but also nonsteroidal
anti-inflammatory drugs (NSAIDs), which are also used and
The initial selection resulted in 531 unique (non-duplicated)
misused, albeit less frequently, for pain relief (Ussai et al., 2015;
and potentially suitable, studies (see Fig. 1). The abstracts or full
Warden, 2009). Tranquillisers refer to CNS depressants that are
text of the studies were obtained and read by both authors and
commonly prescribed to reduce anxiety (e.g. diazepam). Sedatives
assessed for potential inclusion based on the selection criteria. This
include CNS depressants that are prescribed mainly to aid sleep
resulted in 112 studies that included an assessment (in the forms of
(e.g. zopiclone). The analysis includes all medications falling
percentages, means, or rank position) of the relative importance of
within these categories and does not differentiate them by class of
various motives for illicit prescription drug use. Twenty-nine were
drug.
selected as suitable for the meta-analysis on the grounds that

1
TI = (universit* OR college* OR “higher education” OR student*) AND TI = (drug*
OR substance* OR medicat* OR antidepress* OR “pain relie*” OR stimulant* OR
“sleeping pill*” OR “sleeping aid*” OR tranquil* OR depressant* OR benzo* OR
tranquil* OR sedative* OR analgesic* OR actiq OR adderall OR alprazolam OR ambien
OR amphetamine* OR ativan OR biphetamine OR concerta OR darvon OR demerol
OR dexedrine OR dextroamphetamine OR dextromethorphan OR diazepam OR
dilaudid OR diphenoxylate OR dolophine OR duragesic OR fentanyl OR gabapentin
OR hydrocodone OR hydromorphone OR klonopin OR lomotil OR meperidine OR
methadone OR methadose OR methylphenidate OR modafinil OR nembutal OR
opana OR oxycodone OR oxycontin OR oxymorphone OR pentobarbital OR percocet
OR percodan OR pregabalin OR propoxyphene OR ritalin OR sublimaze OR tramadol
OR tylox OR valium OR vicodin OR xanax OR opiate* OR opioid*) AND TS = (motiv*
OR reason* OR explan*) NOT TS = (school OR antibiotic*).
Statistical procedures
The aim of the meta-analysis was to pool the results of the
29 studies included in the analysis into a single finding for each
motive for each of the drug types investigated. This involved
combining the percentage of users reporting a particular motive
into a single percentage that best represented the combined
findings of the individual studies. There are two methods for doing
this: the fixed effect (FE) and random effect (RE) models. The FE
method is based on the principle that there is a single underlying
population that the samples reflect. The RE analysis is based on the
assumption that there are several populations and the samples
 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22
Records identified through database
searching
(n=661)
Records after duplicates removed
(n=531)
Records screened
(n=531)
Full text articles obtained
(n=112)
Full text articles assessed for
eligibility
(n=83)
Studies included in the meta-analysis
(n=29)
Fig. 1. Flow chart of studies identified through the systematic literature search.
Adapted from: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement. PLoS Med 6(7).
estimate the mean of the distribution of these various populations
(Lipsey & Wilson, 2001).
There are advantages and disadvantages to each method. The FE
model gives greater weight to larger studies and produces more
precise estimates. However, it requires that the assumption that
there is a single underlying population is correct, which on some
occasions might be difficult to prove. The random effect model
requires that a constant representing the between-study variance
is added to the study weights. This lessens the impact of larger
studies which tend to have narrower confidence intervals and
produce more accurate estimates. As a result of the various
advantages and disadvantages, the current meta-analysis uses
both approaches.
Data for the meta-analysis were extracted from the Excel
spreadsheet and entered into a statistical software package
(MedCalc). A separate meta-analysis was conducted for each drug
investigated and for each motive used. The results comprised an FE
and RE pooled proportion of all motives, along with their
confidence intervals.
Results
The characteristics of the studies included in the meta-analysis
are shown in Table 2. The first half of the table shows the main
details of the studies including: author, year, country, drug types
investigated, and sampling method used. The second half provides
relevant numerical information on the sample investigated
including: original sample size, number and percentage of
15
Records excluded (n=419)
Full-text articles excluded with
reasons (n=54)
16 covered illegal/street drugs
14 no motives
7 no prevalence data on motives
5 review or discussion paper
4 no adequate survey
4 motives for self-medication only
2 duplicated data
2 not students
students responding, the characteristics of the sample in terms
of gender, the number of drug users included in the prevalence
estimate, and the period of time covered by the drug use or
motives.
The table shows that the majority of studies were conducted in
the United States, most were conducted during 2010–2015 (19 of
29), most investigated motives for illicit stimulant use (27 of 29),
most were based on populations (everyone in a specific group),
followed by convenience sampling and random sampling, and
most prevalence estimates (sometimes more than one per study)
were based on user samples of under 100 cases (26 of 41 results),
and most covered drug use or motive periods over the whole
lifetime (20 of 29).
The main aim of the analysis was to determine the rank order of
the pooled percentages of users mentioning specific motives in
relation to specific prescription drugs. The results of the meta-
analyses for illicit use of stimulants, analgesics, tranquillisers and
sedatives, using both the FE and RE methods, are shown in Fig. 2.2
The chart shows a forest plot for each of the four drug types
with the motives displayed on the y-axis and the mean prevalence
percentage on the x-axis. The right-hand axis gives the number of
studies that were used in the meta-analysis for that motive. The
pooled prevalence estimate for each motive is shown as a filled-in
circle and the error bars show the confidence interval of estimate.
2
All the results presented in this paper are based on the percentage of users who
mentioned specific motives rather than the percentage of respondents.
16 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22

Table 1
Examples of original motives and their allocation to a motive category.

Motive category Original motive Reference

Academic outcomes To improve academic performance Bossaer et al. (2013)
To receive better grades Ott and Biller-Andorno (2014)
To improve mental focus Gallucci and Martin (2015)
Studying for exams Brandt, Taverna and Hallock (2014)
To concentrate on your work DeSantis, Webb and Noar (2008)

Addiction Because I’m addicted McCabe et al. (2007)

Enhance sport To improve athletic performance Gallucci and Martin (2015)

To play sport Holloway and Bennett (2012)
To enhance exercise Judson and Langdon (2009)

Experiment To experiment Lord et al. (2009)

Experimentation Ghandour, Sayed and Martins (2012)
Curiosity/experimentation Clegg-Kraynok, McBean and Montgomery-Downs (2011)
To try a novel experience Micoulaud-Franchi, MacGregor and Fond (2014)
Out of curiosity Ott and Biller-Andorno (2014)

Get high To get high Lord, Brevard and Budman (2011)

For the high (the good feeling) DeSantis et al. (2008)
To feel good or get high Gallucci and Martin (2015)
Get high Garnier-Dykstra, Caldeira, Vincent, O’Grady and Arria (2012)
High Feeling Ghandour et al. (2012)

Handle stress Reduce feeling overwhelmed Herman et al. (2011)

Relax Lord et al. (2009)
Because I am stressed Ott and Biller-Andorno (2014)
To destress or relax Lord et al. (2011)

Lose weight To lose weight Judson and Langdon (2009)

To suppress your appetite DeSantis et al. (2008)
Weight control Hartung et al. (2013)
Lose weight Holloway, Bennett, Parry and Gorden (2014)
Because it helps me lose weight Teter et al. (2005)

Party Socialising and partying Brandt et al. (2014)

For pleasure Holloway and Bennett (2012)
To have fun DeSantis et al. (2008)
At parties Verdi (2014)
Partying White, Becker-Blease and Grace-Bishop (2006)

Reduce anxiety Decrease anxiety Ghandour et al. (2012)

Because it helps decrease anxiety McCabe et al. (2007)

Reduce pain Relieves pain Ghandour et al. (2012)

To relieve pain Holloway and Bennett (2012)
To deal with chronic pain Lord et al. (2011)
Manage chronic pain Lord et al. (2009)
Because it relieves pain McCabe et al. (2007)

Safer drugs Safer than street drugs Tuttle, Scheurich and Ranseen (2010)
Because it’s safer than street drugs Teter, McCabe, LaGrange, Cranford and Boyd (2006)

Self-medicate Counteract other drugs Teter et al. (2005)

Reduce hyperactivity White et al. (2006)
To self-medicate your ADHD DeSantis et al. (2008)
Because I am stressed Ott and Biller-Andorno (2014)
To feel better Rabiner et al. (2009)

Sleep Help sleep Ghandour et al. (2012)

To improve sleep Lord et al. (2011)
Because it helps me sleep McCabe et al. (2007)
To sleep Holloway and Bennett (2012)

Stay awake Stay awake Holloway and Bennett (2012)

To stay awake for a long time Bavarian, Flay, Ketcham and Smit (2013)
To stay awake Lord et al. (2011)

Notes: The table shows examples of each of the 14 motives used in the meta-analysis. Duplicates (the exact phrasing) have been removed. Five original motives per motive
category were selected (when more than five were available) on the basis on their uniqueness. Motives include both ‘endorsed’ motives (phrased by the researchers) and
response motives (phrased by the users).
 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22 17

Table 2
Details of the studies included in the meta-analysis.

Author(s)/Year Country Drug types Sampling Students Students Calculated Characteristics Users of the Period of drug
investigated method initially responded response of the sample drug studied use/motivesa
Population contacted (n) (n) ratec Gender % (n) 1 = lifetime/
random Female ever
sample 2 = since
Convenience entering
self- university
selectionb 3 = last
12 months
4 = not stated
1. Barón et al. (2011) Columbia Stimulants Population 615 234 38 60 120 2
2. Barrett, Darredeau, Bordy Canada Stimulants Self- 50 50 100 54 50 1
and Pihl (2010) selection
3. Bavarian et al. (2013) USA Stimulants Random 520 520 100 55 133 2
sample
4. Bossaer et al. (2013) USA Stimulants Population 621 372 60 Not stated 44 1
5. Brandt et al. (2014) USA Analgesics Random 900 303 34 59 55 1
Stimulants sample 84
Tranquillisers 46
6. Clegg-Kraynok et al. USA Stimulants Convenience Not stated 492 No data 65 71 1
(2011)
7. DeSantis et al. (2008) USA Stimulants Convenience 1733 1733 100 51 585 1
8. Gallucci and Martin (2015) USA Stimulants Convenience 697 682 98 58 95 3
9. Garnier-Dykstra et al. USA Stimulants Random 3401 1253 37 51 230 1
(2012) sample
10. Ghandour et al. (2012) Lebanon Analgesics Convenience 950 570 60 52 89 1
Stimulants 19
Tranquillisers 28
Sedatives 34
11. Hartung et al. (2013) USA Stimulants Not stated Not stated 1153 No data 65 274 3
12. Herman et al. (2011) USA Stimulants Convenience 897 308 34 45 32 1
13. Holloway and Bennett UK Analgesics Population 14,839 1614 11 62 240 1
(2012) Stimulants 28
Tranquillisers 110
Sedatives 71
14. Holloway et al. (2014) UK Analgesics Population Not stated 558 No data Not stated 65 1
Stimulants 17
Tranquillisers 44
Sedatives 41
15. Judson and Langdon USA Stimulants Not stated 3400 333 10 72 67 1
(2009)
16. Lord et al. (2011) USA Analgesics Convenience 2583 689 27 64 416 3
17. Lord et al. (2009) USA Stimulants Self- 1538 954 62 41 64 1
Analgesics selection 75
18. Low and Gendaszek USA Stimulants Convenience 160 150 94 50 53 4
(2002)
19. McCabe et al. (2007) USA Analgesics Random 5389 4580 85 50 640 1
sample
20. Micoulaud-Franchi et al. France Stimulants Population Not stated 206 No data 58 12 3
(2014)
21. Ott and Biller-Andorno Switzerland Stimulants Population 8642 1765 20 62 114 1
(2014)
22. White et al. (2006) USA Stimulants Population 11,897 1025 9 52 164 1
23. Rabiner et al. (2009) USA Stimulants Random 9825 3407 35 66 291 2
sample
24. Rezahosseini, Iran Stimulants Population 6500 1260 19 75 43 3
Roohbakhsh, Tavakolian
and Assar (2014)
25. Schelle et al. (2015) Netherlands Stimulants Self- 245,000 1572 1 70 52 1
selection
26. Teter et al. (2006) USA Stimulants Random 5389 4580 85 50 382 1
sample
27. Teter et al. (2005) USA Stimulants Random 19,278 9161 48 56 689 1
sample
28. Tuttle et al. (2010) USA Stimulants Self- 388 326 84 44 33 1
selection
29. Verdi (2014) USA Stimulants Population 854 807 95 72 149 1
a
Information relates to either the period of the motive (first choice) or the period of the drug use (second choice), depending on the information available.
b
Population = all students at a university; Random sample = a method of selecting an unbiased sub-set of the university population using a randomising procedures;
Convenience = selected by the researcher from among students within a university (e.g. criminology students); Self-selection = selection by an indirect method of contact (e.g.
Facebook or a poster).
c
Calculated response rate = the response rate derived from the data in the previous two columns. The author(s) might calculate the response rate differently.
18 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22

Fig. 2. Motives for illicit prescription drug use pooled across studies.

Stimulants
The most prevalent motives for illicit use of stimulants among
university students integrated across all studies were ‘academic
outcomes’ (FE 61%; RE 60%), to ‘stay awake’ (FE 50%; RE 46%),
‘experiment’ (FE 22%; RE 18%), and ‘party’ (FE 22%; RE 25%)
(See Table 3). The remaining four motives (‘get high’, ‘lose weight’,
‘enhance sport’ and ‘self-medicate’) were in the same rank order in
the FE and RE models ranging from ‘get high’ (FE 18%; RE 12%) to
‘self-medicate’ (FE 5%; RE 5%).
 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22 19

Table 3 Table 5
Pooled prevalence of motives for illicit stimulant use. Pooled prevalence of motives for illicit tranquilliser use.

Fixed effect Random effect Fixed effect Random effect

% (CI) % (CI) % (CI) % (CI)
Academic 61.4 (59.8–62.9) Academic 59.6 (51.0–67.9) Self-medicate 83.0 (74.7–89.5) Self-medicate 63.8 (0.0–92.3)
outcomes outcomes Anxiety 42.4 (34.1–51.0) Anxiety 56.9 (11.5–95.8)
Stay awake 50.17 (45.7–54.6) Stay awake 46.1 (34.5–58.0) Get high 27.9 (20.6–36.1) Sleep 31.7 (9.9–58.9)
Experiment 22.0 (19.8–24.4) Party 24.7 (16.7–33.8) Sleep 25.2 (18.2–33.2) Get high 27.9 (20.8–35.5)
Party 21.6 (19.8–23.5) Experiment 18.2 (10.3–27.7)
Note: CI = confidence interval.
Get high 18.2 (16.7–19.7) Get high 12.0 (5.5–20.7)
Lose weight 8.4 (7.1–9.9) Lose weight 8.8 (6.2–11.8)
Enhance sport 5.8 (2.8–10.3) Enhance sport 6.9 (1.8–15.1)
Self-medicate 5.4 (4.5–6.5) Self-medicate 4.6 (2.6–7.2) motives were mentioned which were ranked in roughly the same
Note: CI = confidence interval. order in the FE and RE analyses (see Table 5).
The most prevalent motive for illicit tranquilliser use was ‘self-
Overall, the figure shows the most frequently used motive for medicate’ (FE 83%; RE 64%) which covered a range of reasons for
illicit stimulant use among students was to enhance ‘academic wishing to obtain the therapeutic benefits of the drug, such as: to
outcomes’ and ‘to stay awake’, both of which were considerably counteract the effects of other drugs, to manage ADHD, and ‘to feel
more prevalent than the other motives. The next three motives (‘to better’. The second most prevalent motive referred specifically to
experiment’, ‘party’, and ‘get high’) covered primarily experiential the use of tranquillisers to reduce anxiety (FE 42%; RE 57%). These
and recreational motives, and the final three (‘lose weight’, two motives dominated the reasons given for illicit use of
‘enhance sport’, and ‘self-medicate’) concerned various forms of prescription tranquillisers. A third motive relating to the thera-
self-improvement. peutic benefits was to aid sleep, mentioned by just over one-
quarter of users. The remaining users said that they used
Analgesics tranquillisers to get high.
Overall, the findings show that three of the four motives given
The motives for illicit analgesic use included five of the motives for use of illicit tranquillers are related to obtaining the therapeutic
mentioned earlier in relation to illicit stimulant drug use (‘party’, benefits of the drug. In addition, about a quarter of users said that
‘get high’, ‘experiment’, ‘academic outcomes’, and ‘self-medicate’) they used prescription tranquillisers to get high.
and four new motives (‘reduce pain’, ‘sleep’, ‘anxiety’, and ‘safer
drugs’) (see Table 4). Sedatives
The results of both the FE and RE analyses show that the most
prevalent motive for illicit analgesic use was to reduce pain (FE Research on illicit use of sedatives (CNS depressants commonly
57%; RE 59%). The desire to reduce pain was 20 percentage points prescribed to aid sleep) among students provided even fewer
higher than the next most frequent motive in the FE analysis and motives. The dominant motives by far were to use illicit
23 percentage points higher in the RE analysis. The second motive prescription sedatives to sleep, mentioned by over 80% of users
in the rank order was ‘party’ (FE 40%; RE 39%), followed by ‘get (FE 83%; RE 84%). The second most frequent motive was to reduce
high’ (FE 32%; RE 25%) and ‘experiment’ (FE 32%; RE 25%). The anxiety and the third was to get high (see Table 6).
remaining motives were: ‘sleep’ (FE 15%; RE 15%), ‘academic Overall, the findings of the two methods are similar in showing
outcomes’ (FE 13%; RE 14%), ‘anxiety’ (FE 11%; RE 12%), ‘self- that the most common motive for illicit use of sedatives was to
medicate’ (FE 10%; RE 11%), and ‘safer drugs’ (FE 4%; RE 4%). sleep. Sedatives were also used for therapeutic purposes as a
Overall, the results suggest that illicit analgesics are used means of reducing anxiety. As with the other prescription drugs, a
primarily for their therapeutic benefits of reducing pain, but they small proportion of users used them for pleasure pursuits such as
are also used for pleasure pursuits, such as to party, to get high, and to get high.
to experiment with new drugs. Analgesics also played a less
frequently noted role in aiding academic study. Discussion

Tranquillisers
The motives for illicit use of tranquillisers (CNS depressants
commonly prescribed for anxiety) were considerably more limited
than those described for stimulants and analgesic use. Four
The main aim of the research was to summarise what has been
learned from research on the prevalence of motives for PDM among
university students. We mentioned in the introduction that there
had been little attempt to date to conduct a quantitative summary of
the literature. In order to fill this gap, we conducted a meta-analysis
of the prevalence of PDM among university students.

Table 4 Summary
Pooled prevalence of motives for illicit analgesic use.
The results of the study showed that motives for stimulant use
Fixed effect Random effect
% (CI) % (CI) were primarily concerned with academic pursuits and staying
Reduce pain 56.9 (54.3–59.4) Reduce pain 62.1 (29.0–90.0)
Party 40.0 (36.6–43.4) Party 38.9 (6.0–79.3) Table 6
Get high 31.9 (29.5–34.4) Experiment 24.8 (11.3–41.6) Pooled prevalence of motives for illicit sedative use.
Experiment 31.5 (28.9–34.2) Get high 22.1 (3.5–50.6)
Fixed effect Random effect
Sleep 14.8 (12.4–17.4) Sleep 15.4 (12.1–18.9)
% (CI) % (CI)
Academic outcomes 12.6 (10.0–15.6) Anxiety 13.9 (5.2–26.0)
Anxiety 10.8 (8.7–13.1) Self-medicate 11.7 (2.2–27.4) Sleep 82.7 (74.1–89.3) Sleep 83.9 (70.9–93.6)
Self-medicate 9.5 (8.0–11.2) Academic outcomes 11.3 (7.1–16.3) Anxiety 12.3 (6.8–20.1) Anxiety 17.1 (0.0–55.1)
Safer drugs 3.7 (2.4–5.3) Safer drugs 3.7 (2.4–5.2) Get high 7.4 (3.2–14.1) Get high 7.4 (3.2–13.0)

Note: CI = confidence interval. Note: CI = confidence interval.

20 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22
awake. This was followed by a second group relating to the
experiential effects of the drug (to experiment, to party, and to get
high) and a third group concerning self-improvement and other
personal benefits (to lose weight, to enhance sport, and to self-
medicate). The majority of users of analgesics said that they took
them to reduce pain. A second group of motives covered the
experiential effects of the drug (to party, to get high, and to
experiment) and a third group comprised a mix of motives relating
to self-improvement and other personal benefits (academic
outcomes, self-medication, and to avoid more dangerous street
drugs). The main motives for use of prescription tranquillisers were
to reduce anxiety and to offer other forms of self-medication. They
were also used less frequently to get high and to sleep. Sedatives,
such as sleeping aids, were used almost wholly to aid sleep, with a
small proportion of users mentioning to reduce anxiety and to get
high.
Overall, the most common reasons given by users for PDM
appear to relate to self-medication, self-improvement and
perceived personal benefits for the user in terms of performance
(in relation to sports, and academic outcomes), mental health
(ability sleep, to reduce anxiety), or physical health (manage pre-
existing illnesses). Fewer than half of users said that they were
involved in PDM for pleasure motives (to party, to get high, or to
experiment). This finding contrasts with reports and some lay
interpretations that focus on hedonistic or deviant explanations.
PDM among students might be viewed as a means of self-
improvement when other means of achieving their objectives are
unavailable or restricted. This seems clear in relation to motives that
refer to self-medication and the therapeutic benefits of obtaining
illicit prescription drugs in the absence of legal prescriptions.
However, it is also visible in motives that focus on achieving other
objectives (such as improving study methods, academic outcomes,
losing weight, and enhancing sports performance).
Previous reviews
The research has built on the existing reviews of motives
described earlier by Benson et al. (2015), Dennhardt and Murphy
(2013) and Drazdowski (2016). They each conducted a qualitative
systematic review of the motives for prescription stimulant misuse
and each found that the main motive concerned academic benefits
and less frequently recreational pursuits. The current review
supports this finding and shows that the minor motives mentioned
by less than 10% of users also included ‘lose weight’, ‘enhance sport’
and ‘self-medicate’.
Motives for illicit analgesic use were investigated in two of the
reviews (Dennhardt & Murphy, 2013; Drazdowski, 2016): the first
summarised the results of one study that mentioned to get high
and to alleviate pain, and the second reported that the main
motives were difficult to determine because of the limited
literature on the topic. The current review found that pain
reduction exceeded the other motives by 17 percentage points
using the FE model and 23 percentage points for the RE model. The
current review also found recreational motives were mentioned by
about a third of users (FE model).
The reasons given for illicit use of tranquillisers were not
investigated in any other review. However, the current analysis
found that the most prevalent motive mentioned by over 80% of
users was to self-medicate such as: ‘to counteract the effects of
other drugs’, ‘to manage ADHD’, and ‘to feel better’ (FE model).
Finally, the motives for illicit sedative use were covered by one of
the reviews (Drazdowski, 2016) which concluded that the
prevalence was difficult to determine because of insufficient
literature. The current review found that the dominant motive was
to aid sleep which was mentioned by an average of over 80% of
users.
Strengths
Before discussing the limitations of the current research, we
will mention briefly the benefits of the meta-analysis. The main
advantage of investigating motives using meta-analysis is that it
can pool prevalence rates across studies and provide estimates that
are more representative of the population. This is because meta-
analysis can take into account sample size when weighing up the
results. Meta-analysis is also effective in summarising the results
of multiple studies through the use of single comparable measures.
It has been possible, therefore, to locate the results of several drug
types and several motives in a ranked hierarchy that identifies
clearly and simply the most common reasons for PDM and their
importance in relation to each other.
Limitations
The study also has several limitations. First, we limited our
searches to six databases rather than attempt a broader search (e.g.
include more databases, contact researchers in the field, or check
the bibliographies of the selected papers). This was in part a result
of limited resources available to conduct more elaborate searching
methods. That said, the databases selected covered the main
bibliographic sources on student drug misuse. Second, it was also
necessary to recode the motives rather than use the original study
coding, as it would have resulted in recording many similar
motives with slightly different names. While we used two coders
and tried to improve reliability as far as possible, we cannot be
certain that the original meanings were always accurately
reflected. Third, the meta-analysis was hampered to some extent
by the small number of studies for some drug types and the small
number of students surveyed in some of the studies investigated.
Clearly, a much larger number of studies based on larger samples
would have improved the accuracy of the population estimates.
Conclusion
The current review contributes to current knowledge by
examining motives for four different types of prescription drugs:
stimulants, analgesics, tranquillisers, and sedatives. The review
also adds to previous reviews by analysing studies using meta-
analytic techniques that provide a single figure summary of the
prevalence of use of specific motives across the research as a
whole. It has also proposed that PDM might be better understood if
it was conceptualised as a means of self-improvement when other
means of achieving users’ goals were unavailable or restricted. This
might have theoretical gains in moving away from the dominantly
deviant view of substance misuse and practical gains when
thinking about prevention or treatment interventions.
There are several ways in which a more thorough understand-
ing of motives, especially in relation to their influence on
behaviour, might help in devising university-based treatment
and prevention programmes. It has been shown, for example, that
students often say that they use illicit stimulants to cope with
academic stress. One possible solution is for universities to offer
alternative stress-reducing interventions (Eickenhorst et al., 2012).
Similar suggestions might be made in relation to use of illicit
prescription analgesics to reduce pain. Interventions might be
implemented to help develop alternative methods of pain
management, such as physiotherapy, alternative therapies, and
behavioural therapy. Studies have also shown that users who
associate PDM with positive outcomes and few negative outcomes
are more likely to engage in PDM (McCarthy, 2007). University
programmes that provide accurate information about the harms of
PDM might discourage users from starting or continuing use of
illicit prescription drugs based on false premises.
 T. Bennett, K. Holloway / International Journal of Drug Policy 44 (2017) 12–22
While the current research has helped consolidate current
research on motives, there is a strong argument for continuing
research in this area. Very little research has been done outside of
the area of prescription stimulant use. Further insights might be
gained in understanding the relevance and variation of motives
across a wider range of prescription drugs. More research is also
needed on the association between motives and other forms of
behaviour, such as alcohol, crime and illegal drug use.
There are many lessons that can be learned from past research
on motives that might inform future research. First, there is a need
for greater standardisation of the conceptualisation and phrasing
of motives. The construct ‘study methods’, for example, has been
written in the studies reviewed as: ‘help study’, ‘helps increase my
alertness’, ‘helps me concentrate’, and ‘improve study habits’. It
would improve future reviews if these motives were framed in the
same way at the point of analysis. Second, the concept of a motive
needs to be discussed more broadly. It is commonly viewed as an
objective indicator of motivation. However, motives can also be
perceived as justifications and excuses for behaviour that help
explain PDM, both to users and to those who question them. More
research should be done using both qualitative and quantitative
methods to obtain a better understanding of the usages and
meanings of motives. Third, motives might vary in response to
changes in social and personal factors. The motives for stimulant
use, for example, might sometimes be academic and sometimes
recreational depending on the context in which they are
consumed. Linked to this is the idea that motives might change
over time, which would suggest the need for more longitudinal
research to monitor variation.
Conflicts of interest statement
The authors declare that they have no conflicts of interest.
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