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Nonmedical Prescription Drug Use Comorbidity: Developing a Cohesive Risk Model

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Nonmedical Prescription Drug Use (NMPDU) is a growing issue world-wide. Previously, NMPDU comorbidity has been investigated using bivariate approaches, providing a piecemeal understanding of NMPDU’s relationship to other mental disorders. We investigate how NMPDU fits within the multivariate meta-structure of psychiatric comorbidity and how this might vary as a function of gender. Data were collected as part of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) in 2001–2002 on 43,093 individuals 18 years or older living in the US. The Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV version IV (AUDADIS-IV) assessed psychiatric diagnoses and sedative, tranquilizer, opioid, and amphetamine NMPDU. Using confirmatory factor analysis, NMPDU was introduced into the internalizing-externalizing model of common mental disorders to determine where it best fits. Models were examined separately for men and women and tested for gender invariance. NMPDU was strongly associated with the externalizing factor, and also showed a very small secondary association with the fear subfactor of internalizing. This structure was gender invariant. Differences between men and women’s prevalence rates originate at the level of the latent factors. Results indicate a shared liability to NMPDU and other forms of externalizing psychopathology such as other substance use disorders, as well as antisocial behaviors. Research on NMPDU can benefit from focusing on the externalizing factor, aiming to understand how risk factors for diverse externalizing disorders may also manifest as NMPDU. Prescribers should be particularly attentive to the presence of the entire spectrum of externalizing disorders, as they may signal risk for NMPDU.

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  1. We also explored race/ethnicity invariance across white and non-white participants. In both groups, fit was very similar across models that loaded NMPDU on externalizing. In the White group, the model loading NMPDU on fear and externalizing was found to have best fit according to RMSEA, CFI, TLI, sample size adjusted and unadjusted BIC, and AIC (0.011; 0.991; 0.989; 134666.21; 135745.66; 135542.99). In the non-White participants, the Externalizing model fit best (RMSEA = 0.005; CFI = 0.994; TLI = 0.993; free parameters = 24; BIC = 80401.453; sample-size adjusted BIC = 80325.183; AIC = 80213.529), but fit was very similar across all models that included externalizing. Overall, this pattern was very similar to the gender analyses, with the minor difference across models likely due to reduced sample size in the non-White group (30 % non-White compared with 70 % White), which decreases the ability to capture very small effects such as the loading of NMPDU on fear.


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This work was supported by National Institute on Alcohol Abuse and Alcoholism grants U01AA018111, K05AA014223, and National Institute on Drug Abuse grants R01DA018652, and F31DA026689. NESARC was sponsored by National Institute on Alcohol Abuse and Alcoholism with support from National Institute on Drug Abuse. The views and opinions expressed in this report are those of the authors and do not necessarily represent the views of the sponsoring agencies or the United States government.

Conflict of Interest

All authors were queried, and reported no conflicts of interest.

Experiment Participants

All procedures, including informed consent, received full ethical review and approval from the U.S. Census Bureau and U.S. Office of Management and Budget. Informed consent was obtained from all participants.

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Correspondence to Robert F. Krueger.

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Ofrat, S., Krueger, R.F., Eaton, N.R. et al. Nonmedical Prescription Drug Use Comorbidity: Developing a Cohesive Risk Model. J Psychopathol Behav Assess 36, 371–379 (2014).

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