Adolescent Dating Violence and Nonmedical Prescription Drug Use

In this issue of Pediatrics, Clayton et al¹ report on the associations between adolescent dating violence (DV) victimization and the nonmedical use of prescription drugs (NMUPD) using the Youth Risk Behavior Surveillance System. Given our national focus on the opioid epidemic, studies on associations of NMUPD with other health risk exposures among adolescents, such as DV victimization, are timely. Because most researchers conducting studies on NMUPD among adolescents have relied on emergency department samples or limited geographic areas, researchers conducting a study using nationally representative data to estimate prevalence ratios add needed perspective. With a sample of 10 443 male- and female-identified US high school students who had dated in the past 12 months, Clayton et al¹ provide sex-stratified analyses revealing that experiencing both physical and sexual DV victimization is associated with NMUPD for both sex categories. Stratifying by sex category identifies some subtle but important differences. Among boys, there is an association of lifetime NMUPD with sexual violence victimization, whereas among girls, lifetime NMUPD is associated with physical DV victimization. Among girls, NMUPD is associated with a higher frequency of sexual violence victimization (4 or more times in the past year) but not a lower exposure to sexual violence victimization.

Since 1999, the national Youth Risk Behavior Survey led by the Centers for Disease Control and Prevention has provided estimates of physical DV victimization. In 2013, with input from DV experts and practitioners, the physical DV survey item was revised to add frequency of experiencing such victimization. Additionally, an item that asked specifically about sexual DV and had the same response choices was added, which allowed students to report how many times they had experienced such victimization.² These changes in the measurement of DV revealed a substantial sex category difference in prevalence estimates, with female students reporting a significantly higher frequency of DV victimization (either physical or sexual) compared with male students (20.9% vs 10.4%). Clayton et al¹ report similar prevalence estimates from the 2015 data (21.4% vs 9.6%). The merits of adding this sexual DV item are especially apparent in this study, in which a higher frequency of sexual violence exposure appears to be associated with NMUPD among both male and female students. Although sexual violence victimization is more commonly reported by female students (15.6% vs 5.4%), it is notable that such victimization is associated with NMUPD for male students. Because sexual minority youth have a higher prevalence of violence victimization as well as substance use,³ sexual minority status may be relevant. However, in this study the association of NMUPD with DV victimization remained even after adjusting for sexual identity, suggesting other potential mechanisms to explain this relationship. Further studies are needed to elucidate the contexts of sexual violence exposure for male students and how this may be related to NMUPD.

The associations between DV victimization and adolescent substance abuse are well documented.⁴ Because NMUPD is likely to co-occur with other drug use, other substances (ie, cigarettes, alcohol, marijuana, and other illicit drugs) were added to the adjusted models; the prevalence ratios remained significant for the most part, albeit with smaller point estimates, suggesting some unique ways in which NMUPD may be related to violence victimization. Because the study was cross-sectional, it was not possible to make causal inferences in the analyses. Particularly challenging is that the NMUPD measure asks about lifetime use only (not past year use), precluding examination of temporal associations. The NMUPD measure is also not specific to a particular drug (ie, stimulant versus pain medication). The DV victimization items are restricted to the past 12 months, but many respondents may have much longer histories of physical and/or sexual abuse. The authors note that the relationship is likely to be bidirectional: NMUPD may increase vulnerability to violence victimization, and such victimization may increase the likelihood of maladaptive coping strategies, including substance abuse. It is also possible that both DV victimization and NMUPD share common causes. For instance, in a previous study, we analyzed retrospective data on the temporal ordering of mental disorders, the initiation of dating, and the occurrence of DV.⁵ We found that mental disorders that preceded initiation of dating (including but not limited to substance use disorders) were associated with subsequent physical DV victimization (as well as perpetration). Other psychiatric disorders predictive of physical DV included attention-deficit/hyperactivity disorder. Thus, early-onset mental disorders may predispose youth to NMUPD as well as DV victimization. Longitudinal, ethnographic, and social network studies are needed to understand patterns of NMUPD and how these may or may not be related to violence victimization in intimate relationships and other poor behavioral health outcomes.

Clinicians and frontline providers serving adolescents should recognize that young people at risk for substance use, including NMUPD, are likely to have exposure to unhealthy and abusive relationships, which can further exacerbate substance misuse. Positive youth development approaches known to reduce adolescent substance abuse and violence may be especially pertinent for tackling this nexus of NMUPD and DV victimization.

• Copyright © 2017 by the American Academy of Pediatrics