Substance Use Among College Students

For 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.

Clinical Context

Substance Use on College Campuses

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).

Risk Factors Specific for Substance Use on College Campuses

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.

Members of fraternities and sororities have some of the highest rates of substance use on college campuses. Compared with nonmembers, fraternity and sorority members are more likely to use alcohol, cannabis, and other drugs, as well as binge drink more frequently and smoke cigarettes, (38, 39). Members also suffer from more negative consequences from substance use compared with nonmembers, including a higher prevalence of driving under the influence, being physically injured, experiencing memory loss, and having unprotected sex (40, 41). Males who live in fraternity houses during college not only have a heightened risk of binge drinking but are also at higher risk of an alcohol use disorder later in adulthood (45% reporting symptoms that meet criteria) (42). Living in a fraternity or sorority house is also associated with a higher prevalence of cigarette smoking (38). Students who engage in substance use behaviors during high school are more likely to join fraternities and sororities when they enter college (43). Male students demonstrate a greater increase in alcohol use after pledging into fraternities, compared with nonmembers (44). Members who are more actively involved or who have taken leadership positions are also more likely to hold positive thoughts about alcohol use, including the facilitation of bonding between brothers, having fun, and enhancing sexual appeal (45). Not surprisingly, students who later disaffiliate with Greek life demonstrate a decrease in heavy drinking and alcohol-related consequences (46).

The relative ubiquity of prescription stimulant medication on college campuses places at risk students who are academically underperforming or experiencing significant academic pressure. A recent longitudinal study found that approximately one-third of students were offered stimulants for nonmedical use in the past year. Of those who were offered stimulants, more than one-third misused them (47). In 2016, approximately one in ten college students reported nonmedical use of dextroamphetamine-amphetamine (Adderall) in the past 12 months (1). The risk is especially elevated for female college students, who are twice as likely as their noncollege female counterparts to use stimulant medications for nonmedical purposes (1). The risk is also higher among college students with lower GPAs and those who have skipped more classes (14). The number of first-time stimulant users typically peaks in April and November, coinciding with college final-exam weeks (48). Despite popular beliefs by college students that the nonmedical use of stimulants will facilitate earning higher grades (49), nonmedical use has not been found to be associated with an improvement in academic performance as reflected by GPA (50).

Substance Use and Sexual Assault

Sexual assault is a significant problem on college campuses. Alcohol and other drug use is a strong predictor of an increased risk of committing and experiencing sexual assault among college students (51). Unfortunately, being involved in Greek life and binge drinking are added risk factors for experiencing a sexual assault in college (52). Among a survey of 23,980 college women, 4.7% endorsed having been raped since the beginning of the school year (53). Three-quarters reported being intoxicated when the perpetration happened. Female students who reported binge drinking (defined by the investigator as having six or more drinks on one occasion) at least monthly were more than twice as likely as those who did not report monthly binge drinking to experience a sexual assault (52). The amount of alcohol consumed is also linearly correlated with the perpetrator’s aggressiveness (54). Unfortunately, alcohol consumption by victims can impair their ability to stay alert to the perpetrator’s intent and makes it harder to resist or escape the sexual assault.

Treatment Strategies and Evidence

Overview

Each clinical situation requires a specific treatment plan that is tailored to an individual’s current set of circumstances, level of motivation for treatment, and financial and social resources. Table 1 provides a summary of screening tests and treatment recommendations by substance category. Many of these screening tools provide a simple and straightforward way of assessing a college student’s risk of developing a substance use disorder. Additional information to determine the severity of substance use should be obtained by an interview if a student’s screen indicates an elevated risk.

Prevention and Brief intervention

Multiple prevention and intervention strategies have been implemented for selected at-risk students on college campuses. The Substance Abuse and Mental Health Services Administration has created a national registry of evidence-based programs and practices designed for substance use–related interventions. The database contains several programs tailored to the college student population. One example includes the Brief Alcohol Screening and Intervention for College Students (BASICS) program, which is based on a motivational-interviewing style of interaction that uses cognitive-behavioral therapy skills to reduce alcohol consumption among college students who are at risk of alcohol-related problems (55). BASICS consists of two 1-hour interviews and an online survey assessment (56). BASICS aims to motivate students to reduce risky behaviors and has been shown to be effective in reducing alcohol use among heavy-drinking students (57, 58). The College Drinker's Check-up (CDCU) is a 90-minute computer-based brief intervention targeted toward college students who are episodic drinkers. The CDCU has demonstrated effectiveness in reducing heavy alcohol use among college students (59). Additional prevention and intervention programs that target college students are described in Table 2 (60–84).

Treatment Considerations

The true confidentiality of patient records can be complicated in this patient population. When treating an adolescent under age 18, a parent or guardian has the right to obtain copies of the medical record without the patient’s consent. For young adults, written consent must be obtained from the identified patient (with special consent required to obtain substance use history and treatment) in order to share any information. Because many students remain under their parent or guardian’s insurance plan at this age, itemized billing statements and summaries of coverage may be disclosed to the subscriber of the insurance plan, placing an additional barrier to completely confidential treatment.

Screening and evaluation of substance use are important, given the relatively low rates of help-seeking behaviors within the transitional youth population (the prevalence of help seeking among those with a substance use disorder is estimated to be only about 8%) (2). Screening also provides an opportunity for early intervention and education for those who need it, given the low perceived risk of harm from trying substances once or twice and the relative ease of access to substances on the college campus (85).

Campus Recovery Programs

Students in recovery may feel as though they are missing out on their college experience by needing to avoid high-risk social situations and certain school-related functions, in addition to having to attend treatment. Collegiate Recovery Programs (CRPs) or Collegiate Recovery Communities are college-based drug and alcohol–free programs that provide recovery support to students and an outlet to socialize in safe settings (86). These supports often include access to substance-free housing, in-person meetings, group activities, support during recovery-related crises, and overall guidance in navigating college life while abstinent. CRPs vary in size, funding capability, and level of supervision from employed staff members (87), but they share the goals of creating posttreatment communities that help to prevent relapse and promote abstinence. As of 2014, a total of 600 students were enrolled in 33 CRPs across the United States (86). A national survey of 29 CRPs demonstrated that students enrolled in these programs had a mean age of 26.2. Over a third of these individuals had spent time in jail or prison, and three-quarters had been treated for chronic mental health problems (88). Students have been found to participate in CRPs for an average of seven semesters, with approximately half already enrolled when they started college (64). CRPs have also demonstrated encouraging outcomes both in terms of relapse rates and academic performance (86, 89). According to Texas Tech University, of the 80 students enrolled in its CRP, 82.5% had a GPA higher than 2.75, and nearly half of the students planned to pursue a professional degree after graduation (87). Another study found that 87.5% of the CRP alumni had no relapse following graduation (90). However, more research needs to be conducted to elucidate the ideal characteristics of these programs, compare recovery outcomes of students in these programs versus those not enrolled, and examine longer-term follow up data.

Special Circumstances

There are additional considerations when treating students in a college mental health facility. In certain circumstances, a student may have to agree to allow sharing of protected information between practitioner and the dean of the college in order to maintain good academic standing. Students may understandably be reluctant to share information about their substance use history with a practitioner who works in a health services facility on campus with this type of arrangement, although the same federal laws of confidentiality and consent technically apply in these cases. However, if the college or university already has knowledge of an identified mental health or substance use concern within its student body, it can compel students to receive treatment under the threat of expulsion and may require students to meet contingencies in order to return to school. This may include mandatory urine drug screens, a medical leave of absence, or designated mental health visits in the student mental health center on campus. If the individual is an international student in the United States on a visa, a request for a medical leave of absence can be obtained in most cases (either for treatment within the United States or abroad). Students treated near their college or university may encounter additional challenges over the summer months when school is not in session, especially if they live geographically far from campus.

Questions and Controversy

Two of the most common questions that colleges and universities have faced include how to approach alcohol use on campus and how to control the nonmedical use of prescription stimulants. In an effort to reduce morbidity and mortality, some colleges have banned alcohol consumption for all students on campus, regardless of their age. Colleges with alcohol bans have been found to have higher rates of abstinence, compared with other colleges without such policies (29% versus 16%) (91). However, students who choose to consume alcohol at colleges with alcohol bans have similar rates of quantity and frequency of alcohol consumption. Implementing alcohol-free fraternity and sorority housing has not been found to be effective in reducing overall alcohol use (92, 93). Despite the effort to restrict alcohol use inside fraternity and sorority houses, members will often seek alternative drinking settings off campus (92).

The focus on preventive measures for the nonmedical use of prescription stimulants on college campuses has been less uniform across the United States. However, certain universities and colleges have implemented policies in their designated mental health facilities in an effort to reduce overprescribing and availability. Some college mental health facilities have stopped offering testing to establish new attention-deficit hyperactivity disorder (ADHD) diagnoses because of the high volume of requests. Others require significant documentation of a current diagnosis in order to provide prescriptions (including prior neuropsychological testing), and the institutions often closely monitor supplies, without permitting early refills (94, 95). Many have also started no-prescription policies for controlled stimulant medication, without exception. If patients with a history of substance use require prescription stimulants for a medical indication, clinicians should closely monitor their prescription use and consider providing smaller supplies in an effort to reduce the risk of diversion or personal nonmedical use. Switching to a nonstimulant option (atomoxetine) for treatment of ADHD is another reasonable option for this population.

Although drug testing is not uncommon in other settings in colleges and universities, such as for college athletes and medical and dental school admissions, it is relatively rare for undergraduate universities to require students to take drug tests. The implementation of mandatory universal drug screening has resulted in a class-action lawsuit and a ruling by a federal appeals court that this form of testing is unconstitutional (96). In addition, mandatory drug testing can be viewed as an invasion of privacy and consumes a significant portion of school resources. One can argue that college students over age 18 should be allowed to make decisions for themselves, even if such decisions might result in severe consequences. Conversely, drug testing allows schools to identify at-risk students and intervene at an early stage to protect them from unnecessary risks, such as alcohol-related accidents and overdose. Whether colleges and universities should be allowed to implement mandatory drug testing remains controversial. However, urine drug screening should be a routine part of any clinical mental health assessment when working with this higher-risk population. Urine drug screening is often most beneficial when used as part of daily practice and not ordered only following suspicion of substance use or a known substance-related incident.

Recommendations

Even though problematic substance use has a marked presence on college campuses, many struggling students continue to go unrecognized. Treatment of this population presents specific challenges, but it can also be highly rewarding. Summary recommendations are provided below for psychiatrists working with the college-age youths both on and off college campuses.

Recommendation 1: Be Clear About Confidentiality Limitations

Offer a clear explanation of confidentiality limitations, especially as they apply to college students who are still under their parents’ insurance plans. This is the best way to begin to foster trust and to strategize with the patient about how to best protect his or her health information moving forward. Consider referral to an off-campus provider if the student understands the confidentiality protections but is still concerned about disclosing information to an on-campus provider. Because most college students presenting for a mental health evaluation will not express concern about a primary substance use disorder, it is important to carefully screen for co-occurring substance use (both concurrent and past use).

Recommendation 2: Screen for Past Sexual Assault and Violence

Screening for past sexual assault and violence is important when assessing a student who has a history of any substance use, particularly alcohol. Although most young adults will not typically volunteer information about prior sexual encounters during a general interview, sensitive but direct questioning about potential past assault (“Have you ever been taken advantage of when under the influence?”) increases the probability that the individual will report this information. Those who report past sexual assault and violence should be offered the option of further medical screening for sexually transmitted diseases, as well as a thorough safety assessment and assistance with law/campus enforcement, when appropriate.

Recommendation 3: Consider the Student’s Time Constraints in Treatment Planning

Treatment planning should take into consideration whether a student is willing or able to take time off from his or her education to pursue more intensive options. For example, an intensive outpatient program, in conjunction with a 12-step program in the evenings, might be more feasible than a medical leave of absence for some students. Universities and colleges often require that a student taking a medical leave of absence take off more than a single semester of study, which can delay graduation and thereby incur additional financial burden.

Recommendation 4: Formalize the Procedure for Planning a Medical Leave of Absence

If medical leave is being considered for longer-term treatment, it is important to have a clear plan (i.e., referral to a designated residential treatment facility and stipulation of what the treatment goals are while on leave). A written request by the treating clinician can be submitted to the academic department within the school to allow the student to suspend his or her enrollment for a designated period. Some schools may allow a treatment re-entry plan that can reduce the required time of medical leave (i.e., one versus two semesters).

Recommendation 5: Specify Treatment Site for International Students Taking Medical Leave

To request a medical leave of absence for international students, the clinician must specify where the treatment is to occur. The request should be communicated to the designated office of international services or student affairs, as well as to the student’s specific academic department.

Recommendation 6: Plan Ahead for Treatment Occurring Outside the Academic Year

Clinicians should plan ahead for alternative treatment arrangements over the summer months if the student lives out of state, as well as create a plan for handling any crises that may arise outside of the academic year. If a student is receiving a controlled substance, consider a required local check-in with an out-of-state provider, as well as review of any available Prescription Drug Monitoring System (PDMP). Many states are now linking viewable access to out-of-state prescription fills.

Recommendation 7: Discuss Tuition Insurance With Families

Families have the option of purchasing tuition insurance if there is concern that a chronic illness may interrupt the process of completing the semester at school and inflict additional financial cost. Substance use disorders are no exception, and a recommendation to purchase tuition insurance should be considered for identified at-risk students.

Future Directions

Colleges are facing continued challenges around students’ high rates of binge drinking, nonmedical use of stimulants for performance enhancement, and nicotine use. Psychiatrists have the opportunity to influence their local colleges and universities to integrate evidence-based practices. Although promising prevention and treatment programs are available, more research is needed to better inform university administrators about the effectiveness of various programs targeted to college students.

There is a need to develop prevention programming targeted toward specific high-risk subgroups, such as fraternity and sorority members. These members play a pivotal role in influencing the substance use culture on campus. Colleges and universities should communicate and collaborate with the National Panhellenic Conference and the North-American Interfraternity Conference when enforcing substance use policies. The National Panhellenic Conferences has a strict policy on the ban of alcohol use in sorority houses.

Campus recovery programs are increasing and are a way to provide support to students who have a history of problematic substance use. The Association of Recovery in Higher Education has compiled a list of participating CRC universities (https://collegiaterecovery.org/collegiate-recovery-programs), and clinicians can work with the association to create a CRC program at their institution.

The Drug Enforcement Administration also provides resources, such as the Campus Drug Prevention (https://www.campusdrugprevention.gov), to universities and colleges. The resources include information on how to identify illicit substances and a list of federal, state, and law enforcement resources.

Clinicians should closely monitor new drug-related trends that are increasing in popularity in this age group, such as vaping and microdosing. Despite lack of conclusive long-term data about the impact of these substances on health and psychological well-being, patients should still be cautioned about potential risks of addiction and associated medical complications. These complications may include respiratory damage and physiologic nicotine dependence with vaping, and neurotoxicity with LSD microdosing. Clinicians can commit to continuing medical education on this topic and contribute to the solution by creating new prevention and intervention programs for college campuses or by providing scientific support to existing programs.