"Where There Are Stars, There Is Also Darkness": Young Icelandic Men's Experience of Prescription Drug Misuse.

Misuse of prescription drugs is a public health problem in many places around the world, including Iceland. It is considered most common among 18- to 25-year-olds, various risk factors and motives explain this trend. The purpose of this study was to examine young Icelandic men's experience of prescription drug misuse. Participants in this study were seven Icelandic males, 18-26 years old, mean age was 20.9. Data were collected through 14 interviews and then processed using a qualitative methodological approach based on Vancouver's school of phenomenology. The overriding theme of the study "Where there are stars, there is also darkness" refers to the common thread in participants' experiences of misuse of prescription drugs that were initially positive but quickly turned negative. Four main themes were identified: influence factors, reasons, onset, and continued drug misuse. The influencing factors were social influence, social group, lack of knowledge, and curiosity. The main reasons for the drug misuse were to suppress distress, improve capacity and efficiency, or have fun and avoid boredom. The onset of prescription drug misuse was characterized by quick fixes, misuse of one's own medication or medication from a friend/family member. Continued misuse was characterized by a vicious circle, black market, medical visits on false pretenses, and symptoms of dependence and addiction. It is necessary to highlight this public health problem that prescription drug misuse among young Icelandic males appear to be and it needs to be considered as a multifarious problem as the results indicate that its nature is truly complex.

Misuse of prescription drugs is a public health problem in many parts of the world. In the United States, this has been described as a serious problem and there has been a considerable rise in misuse in Europe (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA], 2017; National Institute on Drug Abuse [NIDA], 2018; Novak et al., 2016). The most frequently misused medication classes are opioids, stimulants, and central nervous system depressants, that includes hypnotics, sedatives, and tranquilizers (NIDA, 2018).

Prevalence of Prescription Drug Misuse

The statistical prevalence of misuse of prescription drugs appears to vary somewhat between studies as well as between countries (Maskína, 2019; Novak et al., 2016; Substance Abuse and Mental Health Services Administration [SAMSHA], 2019). The lifetime prevalence of misuse of prescription sedatives in Europe, is estimated about 6%, but the gap between the highest and lowest rates is quite large. In Poland it is 17% but in Denmark and Romania 1% to 2%. The world prevalence of misuse of prescription opioids is estimated at 1% (United Nations Office on Drugs & Crime [UNODC], 2019). The prevalence of misuse of stimulants varies greatly between studies, ranging from 2.1% to 58.7% (Faraone et al., 2020).

It is thought that misuse of prescription drugs is most common among people who are between 18 and 25 years old and men are thought to be more likely to misuse prescription drugs compered to women (Benson et al., 2015; Cragg et al., 2019; Kerridge et al., 2015; McCabe et al., 2019; NIDA, 2018; Schepis et al., 2018).

Risk Factors and Motives for Misuse of Prescription Drugs

A systematic review by Nargiso et al. (2015), reviewed researches related to the misuse of prescription drugs among young people in the United States, and especially in relation to risk and protective factors. The review presents that those individuals who show aggressive behavior and have a previous history of drug use are more likely to misuse prescription drugs. If friends, acquaintances, or family members with whom the person in question misuses prescription drugs, it can predict that the person in question will do the same. If there is dissatisfaction from parents or peers regarding misusing prescription drugs, it can reduce the likelihood of drug misuse. Easy access to prescription drugs by various means was also stated at a risk factor as well as trivial societal attitude toward prescription drug misuse. The risk factor for misuse of prescription drugs among young people can also be related to the nature of the community in which the person lives. Low social restraint and poor social capital can increase the likelihood of drug misuse (Ford et al., 2017).

The study by Cochran et al. (2017) addresses certain personality traits as a risk factor for misuse of prescription drugs, the results suggest that anxiety sensitivity is associated with the misuse of sedatives and sensation seeking is associated with the misuse of stimulants. A U.S. qualitative study interviewed 20 people between the ages of 13 and 17. The results identified that the participants believe that various factors influenced their misuse of prescription drugs. These are individual factors, such as mental health, influences from family and friends, for example, social pressure and their attitudes toward misuse. Also, environmental factors, such as the school environment and societal attitude toward prescription drug misuse on the World Wide Web, television, and music (Conn & Marks, 2017).

The reasons for misusing prescription drugs are, to some extent, limited to different categories of medication. Sedatives are misused most often to improve sleep, cope with anxiety, or to get high (Votaw et al., 2019). Misuse of stimulants is largely limited to enhancing work and school performance, for example, by improving concentration (Blevins et al., 2017; Compton et al., 2018; Sales et al., 2019). The reason for misuse of opioids is mostly related to relieving pain and achieving euphoria (Abraham et al., 2019).

Distribution of Prescription Drugs Intended for Misuse

A summary study by Novak and colleagues (2016) reported that individuals most often obtain the prescription drugs they misuse from friends or family members that got a prescription for the medication. It is also stated that people commonly take medication from others without their knowledge, obtain it under false pretenses from doctors and through online sales.

Prescription Drug Misuse in Iceland

Prescription drug misuse is a serious public health problem in Iceland (Velferðarráðuneytið [Ministry of welfare], 2018). An Icelandic survey was submitted in August 2019, where the sample was prepared in such a way that it reflected the Icelandic nation in terms of gender, age, and place of residence according to Statistics Iceland. The study reported that 4% of the respondents said that they had misused prescription drugs to get high. In the age group 18 to 29 years, the proportion was higher or 6.4%. There was a total of 897 participants, 18 years and older (Maskína, 2019).

The frequency of misuse of prescription drugs among upper secondary school students in Iceland was investigated with a questionnaire submitted in 2018 by the Icelandic Center for Social Research & Analysis. The results of that study stated that 12% of adults 18 years old and older have misused opioid painkillers without a prescription, 10% have misused hypnotics and/or sedatives once or more in a lifetime and 8% have misused stimulants (Rannsókn og greining [Icelandic Center for Social Research & Analysis], 2018). Misuse of stimulants among university students in Iceland has also been studied and results show that 13% of respondents have misused prescription stimulants (Gudmundsdottir et al., 2020).

SÁÁ is a non-governmental organization that operates a detoxification hospital, treatment center and an outpatient service in Iceland. According to their health records, the situation regarding prescription drug misuse among their patients has changed considerably for the worse in recent years. In 2018, 625 or 37.4% of the patients who came to Vogur, detoxification hospital, were diagnosed with addiction to sedatives, stimulants, and opioids. Different challenges also apply to young people who sought help from SÁÁ, as the main substances that adolescents aged 19 and younger had a problem with, had changed completely. In 1995, 46% of them were due to alcohol problems, but only 5% in 2018. In 2018, there were problems due to other substances, for example, opioids and sedatives (SÁÁ, 2019).

Purpose of the Study and Research Question

The purpose of this study was to examine young Icelandic men’s experience of misuse of prescription drugs. This will increase the understanding of how to improve reactions with the aim of preventing and reducing drug misuse in Iceland. The research question was: What is the experience of misuse of prescription drugs among young Icelandic men?

Method

This study was conducted using the research method of the Vancouver School of Phenomenology, which aims to increase understanding of human phenomena, among other things. The method aims to improve human services such as health care. The ideology is based on the concept that each individual sees the world with their own eyes, that their vision is shaped by previous experience and their own interpretation of the experience and that affects how they experience the world and live their lives. The research process goes through seven main cognitive elements that are constantly repeated in the research process. Data collection takes place through conversations between the participants and the researcher (Halldórsdóttir, 2000, 2013a).

The phenomena examined in this study was misuse of prescription drugs among young Icelandic men. The definition of prescription drug misuse that was employed for this study was as follows, taking a medication in a manner or dose other than that prescribed. It could be that a person ingests a larger dose of a medication than prescribed, a medication is taken to feel euphoria or to get high or taking someone else’s prescription medication (NIDA, 2018).

The Research Process

The cognitive work processes of the Vancouver School (Figure 1) were followed in each step of the research process, which is divided into 12 main stages. Each step was followed up in detail, Registration took place in parallel with the work (Table 1), the first author oversaw data collection and data analysis.

Figure 1.

The Cognitive Work Processes of the Vancouver School.

Table 1

The 12 Steps of the Research Process of the Vancouver School of Phenomenology, What it Entails and How They Were Followed in the Present Study.

Steps in the research process	What the step entails	How it was followed in this study
Step 1. Sample	Selection of study participants.	7 young men, 18-26 years, average age of 20.9 years. The minimum age was at the age of consent in Iceland, 18 years (Jurisdiction Act no. 71/1997). The maximum age limit set at 29 years, as the Office of the Icelandic Medical Director of Health classifies its statistics from the mortality register (Embætti Landlæknis [Directorate of Health, 2019). A purposive sample was used, conditions were set for participation to have experience of the phenomenon but were not misusing prescription drugs any more. When selecting participants, the first author looked for an individual he knew who had experience of the phenomenon, met the criteria and age limit. The selection of more participants was made with a snowball count. Not all participants in the same group of friends, for a varied experience.
Step 2. Silent reflection	Silent reflection before conversations begin so that preconceived notions can be set aside.	Much effort was made to push aside preconceived notions about the phenomenon. The interviews were conducted with an open mind.
Step 3. Data Collection	Information obtained through interviews/ conversations.	Fourteen interviews were conducted, two interviews with each participant. The interviews took place where the participants requested. Open interviews were used, but with a pre-determined interview framework. The first interviews were 47 to 50 min long, or an average of 48.4 min. The second interviews were much shorter, or about 15 min. The interviews were recorded.
Step 4. Data analysis	Data is analyzed where the words of the participants are analyzed, and the main ideas and concepts are highlighted.	Interviews were transcribed verbatim on a computer but made impersonal immediately by giving participants pseudonyms and deleting locations, and special features that could identify participants Recordings were deleted immediately after the interviews were transcribed. The data were then printed out and sorted according to what was stated in each case. Colored post it notes were used to mark when the same elements appeared in the interviews.
Step 5. Coding	Search of the essence of the case and the meaning in the data.	The use of colored post it notes continued. Elements that formed one color were grouped together. Their content included the subthemes. The color analysis made it easier to see which elements were the core of the phenomenon.
Step 6. Individual analytic framework	An analytical model is prepared from each participant’s data, where the main themes are presented. Each diagnostic model is individually designed.	An analysis model was created for each participant, where the color analysis was used again and again to build up the main and subthemes for each individual.
Step 7. Individual verification	Confirmation is sought from the participants regarding each individual’s analytical model in order to be assured that it is presented correctly.	Confirmation of the individual diagnostic models was obtained from each individual to obtain the assurance that the researcher had understood the participant correctly. Presented in the later interview.
Step 8. Final analytic framework of the phenomenon	All individual analysis models are put together and an overall analysis model is built that sheds light on the phenomenon.	All the analysis models were compared and commonalities were sought. They were then assembled to form an overall analysis model that described the phenomenon.
Step 9. Comparison of the analytic framework with the data	The main themes in the overall analysis model are compared with the research data (the interviews). This is done to ensure that there is consistency between the two.	The overall analysis model was compared with the color analysis presented at the beginning of the data analysis. The interviews were also re-read to ensure consistency in the interviews and results.
Step 10. Interpreting the meaning of the phenomenon	An overriding theme which describes the essence of a phenomenon is identified.	“Where there are stars, there is also darkness”—Young Icelandic men’s experience of misusing prescription drugs. An overriding theme was found that was thought to aptly describe the phenomenon.
Step 11. Verifying the essential structure	Confirmation is received from some of the participants about the main results of the overall analysis model and the overriding theme of the phenomenon to be assured that the correct results are being presented.	The overall analysis model was presented to two participants and confirmation was obtained that the data were correctly interpreted.
Step 12. Writing up the findings	The results of the study are presented, and it is ensured that the voices of each participant can be heard in the results.	The results were presented, and it was ensured that there was an equal number of quotations and discussions between the participants. All voices were heard, loud and clear.

Source. Halldórsdóttir (2000, 2013b).

The first step in the research process was the selection of participants. In Step 2 there was silent reflection before the conversations begin so that preconceived notions could be set aside. In Step 3, data collection was started, 14 interviews were conducted with 7 young Icelandic men. The interviews took place where participants requested. Two interviews were conducted with each participant. The interviews took place where the participants requested. Open interviews were used, but with a pre-determined interview framework. The first interviews were 47 to 50 min long, or an average of 48.4 min. The second interviews were much shorter, or about 15 min. The interviews were recorded and later in Step 4, they were transcribed verbatim on a computer, the recordings were deleted immediately after the interviews had been transcribed. The data were made impersonal immediately by giving participants pseudonyms and deleting locations, and special features that could identify participants. Data analysis then continued where the data were printed out and sorted according to what was stated in each case. Colored post it notes were used to mark when the same elements appeared in the interviews. In Step 5, the use of colored post it notes continued. Elements that formed one color were grouped together. Their content included the subthemes. The color analysis made it easier to see which elements were the core of the phenomenon. In Step 6, An analysis model was created for each participant, where the color analysis was used again and again to build up the main and subthemes for each individual. In Step 7, confirmation of the individual diagnostic models was obtained from everyone to obtain the assurance that the researcher had understood the participant correctly. All participants believed that the researcher had understood them correctly and therefore proceeded to Step 8 where all the analysis models were compared, and commonalities were sought. They were then assembled to form an overall analysis model that described the phenomenon.

To ensure that the overall analysis model was in accordance with the research data, we went to Step 9 where the color analysis was examined again. The interviews were also re-read to ensure consistency in the interviews and results. That was the case and therefore was continued to Step 10 where the phenomenon was interpreted. An overriding theme, “Where there are stars, there is also darkness,” was found that was thought to aptly describe the phenomenon.

At Step 11, the overall analysis model was presented to two participants and confirmation was obtained that the data were correctly interpreted. After that, the results were presented, and it was ensured that there was an equal number of quotations and discussions between the participants. All voices were heard, loud and clear.

Participants

The participants in the study were seven Icelandic men aged 18 to 26 years, mean age was 20.9 years. A purposive sample was used, as all participants had experience of the misuse of prescription drugs.

Ethics of the Study

Before the study was carried out, the Scientific Ethics Committee of Iceland was contacted, and it was determined that no permit was required for the study. No funding was provided for the study, nor did the authors have any financial benefit in conducting the study. The main aspects of research ethics were followed, and care was taken not to harm the participants. The protection of the rights and well-being of each participant were given priority, as well as confidentiality (Kristinsson, 2013). Prior to the interviews, participants received a signed confirmatory letter outlining the nature, scope, and purpose of the study. Participants signed a declaration of consent before the interviews began and could withdraw at any time during the process. Confirmatory letter and declaration of consent can be seen in Appendix.

Reliability and Validity

The cognitive work processes and the 12-step research process of the Vancouver School that were followed in the study include built-in methods that are intended to increase accuracy and reliability (Table I). Steps 7, 9, and 11 specifically support the validity of the study (Halldórsdóttir, 2013b).

Results

Benzodiazepines were most frequently misused by the participants in this study. Participants who had experience with the misuse of benzodiazepines, used the name Xanax for that type of drug and defined it as a prescription drug, even though benzodiazepines under that brand name cannot be prescribed by a doctor in Iceland. When they talked about misusing Xanax they described that they were misusing either a benzodiazepine that has the active pharmacological ingredient alprazolam or a Xanax that was bought on the black market after it was imported or a drug that was homemade by dealers and sold by that name. Participants mentioned that Xanax sold on the black market was mainly homemade, substances had been mixed and compressed into tablet form to mimic the original drug. Some of the participants mentioned in that context the danger behind that kind of drugs, as there is no way to know what is in those tablets as various things are put in them. Six participants out of seven had a history of benzodiazepine misuse, four of them mainly misused such drugs. All participants had misused prescription stimulants such as methylphenidate. Misuse of opioids was also reported among five participants, two of them mainly misused such drugs. All the prescription drugs that the participants had experience with were in tablet form, so all participants ingested the drugs orally. None of the participants had misused prescription drugs or other substances by injecting them intravenously. Most participants had ingested several types of drugs on the same day, both prescription drugs and other substances. Polydrug use was therefore common among participants. Some of the participants described that they took more than one type of drug to treat withdrawal symptoms, they also described the need to take stimulants during the day to stay active and benzodiazepines at night to relax, different substances for different situations. Other described that the desire for intoxication had become so dominant that there was no special reason for the polydrug use, as the types of drugs that they took had become irrelevant. Substances other than prescription drugs that were most mentioned were cannabis and cocaine. Alcohol consumption was also frequently mentioned in combination with prescription drug misuse.

Participants in the study had varying experience regarding the length of time they had misused prescription drugs. One had only misused prescription drugs few times to experiment, three had experience spanning several years, including daily misuse of prescription drugs and/or other substances for more than a year. The other three had several months of experience, but not daily. All of them had stopped misusing prescription drugs at the time of the study. Two had undergone appropriate treatment, one received support and help from the health care system. The others stopped without assistance. The participants felt that the experience of stopping the misuse of prescription drugs was very difficult. Some of them felt that they had experienced negative physical, mental, social, and financial consequences after they stopped misusing prescription drugs.

The overriding theme of the study “Where there are stars, there is also darkness” comes from one participant and refers to the common thread that was present in all participants’ experiences of misusing prescription drugs: experiences that changed rapidly from being positive in the beginning, to negative with continued drug misuse. The participants’ experience was that for the time being, the misuse of the drugs gave them ease; they managed to maintain a vigilant state longer, relieved pain, and so on. However, as time went on, the misuse of the drugs began to make them more uneasy, both physically and mentally.

Four main themes were identified in the participants’ experiences. They were influencing factors, reasons, onset, and continued prescription drug misuse. Each main theme was divided into three to four subthemes. The influencing factors were social influence, social group, lack of knowledge, and curiosity. The main reasons for the misuse were to suppress distress, improve capacity, and efficiency or have fun and avoid boredom. The onset of misuse was characterized by quick fixes, misuse of own personal prescription drugs or drugs from a friend/family member. Continued misuse was characterized by a vicious cycle, black market, medical visits on false pretenses, and symptoms of dependence and addiction.

An overall analysis model of the young Icelandic men’s experience of misuse of prescription drugs, are presented in Figure 2, identifies how the phenomenon was set up as a kind of process. The first part of the process concerns the participants’ experience of how the influencing factors and reasons for drug misuse played a part in the onset and the continued misuse of prescription drugs, that is the second part of the process.

Figure 2.

An Overall Analysis Model of the Young Icelandic Men’s Experience of Misuse of Prescription Drugs.

Influencing Factors for Prescription Drug Misuse

Participants’ experiences of the factors that they believed had influenced the onset and continued misuse of prescription drugs were many. The same influencing factors were widely cited between participants, but they placed different weights in each factor. In no case did the participants’ experience only one factor, they all described multiple contributing factors. Participants also felt that the influencing factors had sometimes varied depending on whether it was the onset or continued misuse of prescription drugs.

Social Impact

Participants all asserted that societal factors had influenced their misuse of prescription drugs. In particular, the trivial manifestation of the misuse of prescription drugs in music and television was discussed, as well as the community’s view of general prescription drug use. Participants also had experiences of stress in Icelandic society that they believed had influenced their misuse of prescription drugs. With new times comes new challenges, was frequently mentioned or as David put it:

. . . people arguing, follow on Instagram and everything has become so artificial and technology is developing so fast in a short time, then this. . .it’s just going worse . . . it is rising, the group which is taking [drugs] and there is also off because it’s been stressing all with such climate issues, there is so much Instagram, Snapchat, Facebook, this is so much stimulus, this is all related to harassment and stress, thousand things are changing around the person, after the internet was so connected to everyone, so a lot of pressure. It’s just not easy to live today.

Participants often cited their experiences of culture and influences from that. One of the main references was to music culture and that lyrics in music had aroused a desire to quench curiosity regarding the misuse of the drugs that the musicians sang about. Mark described it: “I certainly would not have taken a lot of this [drugs] if it had not been advertised so much, such as Xanax, this is a very known drug.” Most of the participants thought that music was a social mirror, and the musicians were quoting the issue that was going on in Icelandic society as well as abroad. David described it as “music can promote the subconscious, but not the direct effect, not the reason why people have to try it.” Participants believed that music culture was an influential factor and that it had affected them, but they did not believe that musicians should be to blame as they were only telling what is going on in the society. In their opinion, the problem was much more complex, and it would be impossible to extract one influential factor that was the cause of the problem. They also felt that other factors such as movies and television shows, where misuse of prescription drugs were often shown should not be overlooked. As John described “this has just become the norm, on TV, just everywhere.”

They also wondered if society was too drug-oriented and that we as a nation were too fond of prescriptions, but they made it clear that they believed that prescription drugs were vital for many people, Stuart described it,

There is so much that medication has improved or live and had a positive effect on humanity over the years, but as with everything else, there is always something bad that accompanies everything good and vice versa. . .medication has saved an incredible number of lives over the years, but also taken a lot of them.

And David mentioned,

A lot of drugs are being pumped into Icelanders, especially children, and they are over-diagnosing so much. . . the children are maybe taking Concerta [stimulant] during the day, then a sedative to go to bed . . . in fact, I am one of these individuals, and I was born to use drugs later.

Social Group

Most participants had experience of their social group influencing their misuse of prescription drugs. It was mentioned that the drug misuse of friends gave the idea that the person in question could do the same. As Mark said “. . . if you are in a group with friends and many are taking some drug and you want to try, experience what they are experiencing.” David also mentioned his social group and that their actions gave him the idea that he could do the same:

I always said, I’m never going to use drugs . . . then I saw my friends do it and I just thought this cannot be harmful . . . but [they] never pushed me, see, more curiosity from me, if all the boys are doing it then maybe just like that, I’m going to try this but they never told me to do it, they were rather trying to warn me if anything.

Lack of Knowledge and Curiosity

Most of the participants had experienced curiosity influencing them to misuse prescription drugs. Those who reported curiosity also usually talked about a lack of knowledge. Their experience was that they had not been given sufficient and reliable information regarding addictions and drugs, especially regarding the misuse of prescription drugs, like George said, “I just did not know that it is this dangerous.” David also mentioned “. . . when I was starting to take [misuse] my prescription drugs I didn’t even look at it as a narcotic, to begin with.”

Participants also felt that the discussion in the community was confusing, particularly discussion of the legalization of cannabis and the decriminalization of drugs. Axel said,

There’s nothing more confusing than to have a local community that preaches that drugs are bad, but on the other hand you have a big group in your society that wants to make these substances legal, it completely confuses you.

Axel’s experience was also that he felt that there was a lack of counterbalance against the wrong manifestation of the issue and described it:

I think it’s disgustingly dangerous if the only manifestation you’ve seen on this issue is in pop culture, no matter what the issue is . . . It’s not realistic that we could take out all the negative influences, no matter who they are, culture, environment, and such, we cannot take it all out, we cannot block google, we cannot wrap the kids in cotton all their lives, it does not work out. I think that with open discussion, education and general awareness raising, we have a good chance of reducing this to some extent, I think that is actually the best way. If this is in the general sense, then things must get better. Just in case, for example, if you know Xanax is dangerous, you might rather help a friend if he’s using it. . .You should also be able to ask questions and of course there are questions because this is in the culture around you.

Reasons for Prescription Drug Misuse

The most common reason for prescription drug misuse among participants was to suppress mental discomfort or to “zone out,” as they called it and experience a feeling of bliss and relief. Next the participants said that they had been improving their abilities and performance in terms of learning. To enhance performance in sport was also mentioned, mainly to enhance the capability and capacity to participate in the sport despite injury. Having fun and avoiding boredom was also mentioned. Participants also stated that their experience was that the reasons for misuse changed to some extent depending on the type of medication in question, especially at the beginning of the misuse. For example, the reasons for the misuse of prescription stimulants were mainly related to improving academic outcomes, the misuse of benzodiazepines was related to “zoning out” as the participants called it, and the reason for the misuse of opioids was mainly related to sports injuries.

Suppress Distress

Many participants described their experiences of mental distress and strain that they associated with misusing benzodiazepine. The reason for the misuse of the medication was to respond to those factors by experiencing a certain blissful state where reality was escaped or like John said, “no worries, no stress, you are comfortable in your body and mind.” Mark described it as “closes everything bad in your head and you just feel disgustingly good.” George also described it:

You just feel better, it just turns off something negative in your thinking, you just fall into some zone, so you just do not feel bad, no matter what you have done, it does not matter . . . This is accompanied by such well-being, you do not think bad thoughts, there is nothing wrong, you just feel good. It’s such a feeling of well-being, but you still know deep down that it’s not good for a person.

Improve Capacity and Efficiency

The reason behind misuse of the stimulants was almost entirely related to boosting concentration, performance or maintaining an awake state to learn. Stuart said, “In my school, a lot of people take [misuse] ADHD medication to study and stay awake.” John also said, “There is a culture of it, taking Concerta [stimulants] for a big test and this is a little bit like . . . oh shit back up plan to get over an insurmountable amount of learning in little time.”

There was also a relationship between sports achievement and opioid misuse, as such medication misuse was carried out in the hope of being able to play sports despite injuries, George described it,

Something happened, the sports had been taken away from me and I just did everything to be able to continue, I would have been ready to do anything. But I did it [drug misuse] also at home, it was just to get rid of pain and not feel bad . . . then I got results and then I was not going to stop it. Then I couldn’t stop it and say, no it was just the tablets, I was never going to admit it and then I would have naturally lost the tablets, so I had to hide it too.

Have Fun and Avoid Boredom

Participants initially had experience of misusing prescription drugs “just for fun. . ., mostly that” like John said, and to “Fight against boredom,” like Stuart said, which was described as a way to make time go by faster. Stuart also mentioned that initially there were no motive behind misusing drugs it was “just a behavior, nothing deep behind it.”

The Onset of Prescription Drug Misuse

The onset of prescription drug misuse among participants was characterized by quick fixes in which their own medication and medication from others were misused. The participants experience of misusing prescription drugs was, in their opinion, much more positive when it came to the onset of the drug misuse compared to the continued misuse. Stuart stated,

It must not be forgotten that how you first experience it when you try [misusing prescription drugs], it can be nice, but then suddenly it turns into something fucked up. . . and then maybe some kind of darkness, all of a sudden. Where there are stars, there is also darkness, it’s just like that. The misuse of prescription drugs is very dangerous, even if you do not see it immediately. . . many people consider the misuse of prescription drugs even more dangerous than the consumption of other common substances, including me.

Quick Fix

Participants’ experiences of the onset of misuse were characterized primarily by “quick fixes” as they called it. An example they mentioned in that context was time pressure; they wanted to be able to complete certain tasks or study for exams in a short time. It was also stated that they needed less alcohol to feel intoxicated, and wanted to improve their performance in sports quickly, as well as to immediately feel mentally better. Leo described a quick fix and said that he believed that most people have something they want to fix, improve, or suppress:

Quick fix works for everyone, any person, which means that it does not matter what the quick fix is to fix, but quick fix works for anyone with different trauma, well-being or reasons which must mean that everyone can be addictive to some extent.

Own Medication Misused

In all cases where participants were able to mark the onset of the misuse, it was due to drugs prescribed by a physician, rather than being caused by the purchase of black-market prescription drugs. In most cases, it was a medicine that the person in question was prescribed himself. Stimulants that were prescribed for attention deficit hyperactivity disorder (ADHD) were the most commonly misused prescribed drug. Leo described when he started to misuse his ADHD medication:

Then I started taking a little more than I should have taken, when my parents started to pay a little less attention to the fact that I was taking it right. . .I started reading about it online and found out if I took a lot of it at once, I would get intoxicated.

Axel as well described his experience of the onset of prescription stimulant misuse:

You did not associate it [prescription drug misuse] with anything bad, because you got it from a doctor, it was just the drugs I took anyway and [were the same drugs that] my mom told me to take . . . maybe I did not take them for 10 days and then took many at the same time or something.

George described how he started misusing opioids that he originally got prescribed by a doctor when he ended up in hospital due to a sports injury:

This has such a depressant and encouraging effect. . . if this helps you something . . . you found the ease of being able to do something that you should not be able to do or has been taken for some reason, this is just like a scam. I had tried everything, every way but then I just found this [effects from drug misuse], then just yes, why the hell should one exercise disgustingly much and try to fix something if this [drug misuse] works. But of course, this is not something that gave long-term results, it just numbs you.

Medication From Others Misused

The onset of misuse of prescription drugs among participants in some cases involved prescription drugs that participants borrowed from a friend or were taken from family members without their knowledge, like Mark stated, “I started stealing from him [dad] and he did not notice anything.” Stuart also mentioned his experience and said that there were many possibilities of where to get a hold of prescription drugs without a prescription:

You can get this, for example, if someone was on this drug [got prescription for a drug] but has stopped and he has it in his closet or a little brother or sister of someone or something is taking these drugs, mother, grandmother or whatever, it is everywhere [prescription drugs].

Continued Prescription Drug Misuse

With the continued misuse of prescription drugs, participants described their experience to a greater extent as a vicious cycle, by then the drugs were also obtained on the black market and from medical visits on false pretenses. The participants experienced that as time went on, the side effects and both physical and mental symptoms of dependence and addiction became more prominent.

A Vicious Cycle

Many participants described their experience with the misuse of benzodiazepine as a vicious cycle. Leo said: “. . . I remember that I experienced little or no anxiety until I started taking Xanax then I started to feel anxiety. . . a vicious cycle.” George described his experience of addiction as a vicious cycle:

I was using this at work, because I was sweating in the morning, I just needed it, then I just became normal and better after taking it. It was all under control but of course it was not really under control.

There was also a vicious cycle of expectations; the idea of misusing the drugs was usually better than the act itself, Leo described it: “then it never fills, it will never be as good as you think.” George also mentioned his experience of a vicious cycle when misusing opioids and success in sports:

. . .at that time everyone was so proud of me because I was so quick to recover, [people said:] wow how efficient you have been, lucky how well you are doing and then of course I could not stop taking the drugs, and the pain got worse again, you just keep going, just my physiotherapist saying it was a great improvement and the doctor saying it’s amazing how well it was going—but then I was just misusing the drugs from them.

Participants also described a rapid change in their boundaries with continued misuse, in terms of the substances they were willing to misuse, as they always set the mark higher and higher. That is, they were willing to take more substances that they initially would not have, they described this as a kind of vicious cycle. David said,

Look, you always have a principle but then you break them, you understand me, let’s say you are starting to smoke weed, then your principle is that you are just going to smoke weed and not do anything more, then your principles rise, yes okay speed maybe ok and cocaine, then the principle always rises more and more.

Black Market

The main ways the participants in this study accessed prescription drugs in their continued misuse was through online sales sites. The technology was widely mentioned when the black market was discussed, and participants in this context mentioned “. . . apps, Facebook groups and through friends and something, there is a lot of distribution,” said Axel. Leo also mentioned in that context: “technology has also developed so fast and it is as if many people forget that with it, everything in society develops, including the black market.” John mentioned the rapid changes on the black market that he thought the police would have a hard time keeping up with:

It’s so easy access [to access drugs] and pills [prescription drugs intended to misuse] are fairly new, the police do not know anything about this, my friends were arrested [by the police and a urine sample taken to screen for drugs] and nothing was detected because they do not know what they are looking for.

Easy access was frequently mentioned “it’s no problem to get stuff [prescription drugs and other substances]in Iceland, in one [second],” like David said. Mark also stated that it is “as little problem as possible[to access drugs in Iceland].”

Medical Visits on False Pretenses

Frequent medical visits on false pretenses were mentioned among the participants when talking about continued misuse of prescription drugs. Mark stated: “I have gone to the doctor and lied to get a certain medicine and then misused it.” The participants believed that it was easy to get a prescription by presenting with an invented symptom that they had read about online that was treated with a particular drug. They also mentioned that they had described made up drug tolerance to their doctor to get a higher dose prescribed. Participants stated that they had taken advantage of a situation where a doctor was working as a substitute at their health care clinic, as they considered it more likely that they would get prescribed medication. George mentioned:

I have never had a problem getting [prescriptions] from doctors, it was so easy that it is actually ridiculous . . . It was easy, I just called and checked again and again, if it did not work, I thought there must be a new [doctor] coming and if it did not work, I just tried the next one and the next one. This was no problem, I never got into trouble and never had to go through the back door [black market]. Twice I had to go to the health center, to see some 25-year-old [doctor], newly graduated or something, he examined me, and I described it. I just knew exactly what I needed to say. . .I was always going to say what he wanted to hear. It always went the same way, I was always going to get these drugs [prescription], I met all the criteria, but if he [doctor],

had thought about the fact that I had been given 700 pills before, then why on earth do I need more.

Dependence and Addiction

With continued prescription drug misuse, participants expressed a desire for a particular condition and described their experiences of physical and mental dependance, withdrawal symptoms, and other side effects. George described his experience:

If I stopped, there were withdrawal symptoms, sweating and such . . . There was no one who told me that this was addictive [refers to healthcare professionals]. I went to the health center a few times because of the side effects because I had taken so much . . .but then they just said it was just a side effect and no one doubts about all the medication that I have gotten from the doctor . . . then I just kept going.

Some participants felt that their physical and mental habits due to the misuse of prescription drugs were much more severe compared to their experience with the use of other substances. Axel described it,

I was terribly addicted to cocaine and used it daily and smoked [weed] every day, although I do not remember it. I also drank [alcohol] every other day and it was just such a soup [polydrug use] but the prescription drugs were a priority because they are so terribly addictive and they are just like, they just take over. I had once overdosed because of cocaine but I do not know how many times I have overdosed because of prescription drug misuse.

Participants especially talked about benzodiazepine in context with dependence, Axel said “. . . so terribly addictive. . .as soon as I started using Xanax it was game over.” Leo also stated: “. . . then [started misusing benzodiazepine] I completely lost control of myself.” David also described his experience: “I began to use Xanax and it took me worse than anything, really. . . since then the ball rolled.”

Discussion

This specific topic has been under-researched in Iceland and no previous qualitative studies on young Icelandic men’s experiences of misuse of prescription drugs are known by the authors. The results of the study therefore shed new light on our knowledge of the misuse of prescription drugs in Icelandic society.

The participants in the study described their experience of the misuse of prescription drugs as a quick fix, especially in the beginning, and this applied to all the drug classes that were discussed. Defining a quick fix is something that seems to be a quick and easy solution to a problem, but really the solution is not good and will not last long (Quick fix, n.d.).

Most of the results of the study were consistent with previous studies. For example, that was the case when it came to influencing factors for prescription drug misuse (Conn & Marks, 2017; Cragg et al., 2019; Nargiso et al., 2015). In this study, it was clear that the manifestation of drug misuse in musical texts and television material, in which it was considered trivial, had affected the onset of drug misuse among participants, that was also identified in a study by Conn and Marks (2017). Findings in this study were also comparable to previous findings in that the reasons for drug misuse are to some extent limited to different drug classes and that the reasons behind misuse are many (Abraham et al., 2019; Blevins et al., 2017; Compton et al., 2018; Sales et al., 2019; Votaw et al., 2019). This gives an indication that it is important to look at the misuse of prescription drugs as a multifaceted problem driven by various motivations.

Description of the distribution of prescription drugs in this study was similar to the findings in the Novak et al. (2016) meta-analysis. However, the onset of drug misuse among the participants in this study could mainly be traced to the misuse of medicines that the person in question had originally been prescribed by a physician. How participants described easy access to drugs in this study is similar to the findings in the Nordic comparative study by Demant et al. (2019).

The common thread of the participants’ experience of misusing prescription drugs—”where there are stars, there is also darkness”—which refers to their experience not only being characterized as a negative one but one that had been positive in the beginning should be worth paying attention to. In the results of this study, the experience of the participant was that the darkness was quick to take over, but without the stars shining so brightly in the beginning, perhaps the beginning would never have taken place. But why do the stars shine so brightly? Why do these young Icelandic men experience a sense of bliss and relief when misusing drugs? Why do they feel the need to “zone out”? That brings us to what the knowledge in the results of this study provides us: the influencing factors, and reasons behind the misuse of prescription drugs could provide clues as to how they could be addressed with the aim of preventing drug misuse in Icelandic society. For example, it could be effective to implement increased mental health study materials in Icelandic schools so that young people learn healthy ways of coping and become less likely to misuse drugs to increase their well-being. In addition, subsidies for psychological and psychiatric services in Iceland, in addition to shorter waiting lists, could prove useful in increasing the likelihood that individuals will seek professional help in dealing with mental challenges, rather than turning to drug misuse for self-treatment. Also, such subsidies could strengthen knowledge of both responsible prescription drug use and the misuse of prescription drugs and thereby respond to the lack of knowledge on this topic that the individuals in this study described as an influencing factor for drug misuse. According to the results of this study these factors and others could have considerable practical value in the field of prevention and could be used in development of a prevention policy in Iceland, regarding this issue. The strengths and novelty of this study lie therefore in the sample and the location as very little is known about prescription drug misuse in Iceland as this research topic has not been extensively studied in Iceland.

Limitations in this study could lie in the small number of individuals in the sample and care should be taken not to generalize from the results from the specific to the general. It should also be considered that this is a retrospective study and the time elapsed since they misused prescription drugs could potentially distort their experience and narrative.

The results of this study are not intended to underestimate the help that prescription drugs can provide to individuals who need them, but only refer to the misuse of such drugs. Further research is needed on the issue, and it may be interesting to carry out a quantitative study with a larger sample and all genders, to get clearer answers about the nature and extent of misuse of prescription drugs among young people in Iceland.