To our knowledge, this is one of the few large-scale studies aimed at illustrating the associations between NMUPD and EBPs within the Chinese adolescent population, while also evaluating the underlying role of social support in the aforementioned associations. Our study revealed a lifetime prevalence of 1.3% for opioid misuse, 0.4% for sedative misuse, and 1.5% for APDU, respectively. In comparison, 3.7% of US adolescents reported past-year opioid misuse, 2.1% reported sedative misuse, and 5.9% reported NMUPD, indicating an elevated prevalence rate of drug abuse among US teenagers [34]. Similarly, a lifetime prevalence of prescription drug misuse was 2.20% for opioids, 8.50% for sedatives, and 9.78% for APDU in Spanish adolescents [35]. An average of 9.2% for lifetime non-medical pharmaceutical use and 6.6% for sedative misuse in European youth [36]. In this study, the observed rates of NMUPD among Chinese youths were notably lower compared to their counterparts in other countries. Likewise, previous evidence has suggested that significant racial disparities existed in opioid use disorder, and Asian populations had the lowest rate of opioid use disorder-related deaths, at a rate of 4.6 per 100,000 in 2020 [37–39]. Consistent with previous studies, statistically significant difference has been observed in the distribution of living arrangement, HSS, father’s education level, parental marriage status, study pressure, relationships with classmates or teachers, smoking, drinking, and social support between adolescents with and without NMUPD [40, 41]. Therefore, considering the impact of these covariates may aid in identifying adolescents at elevated risk of substance abuse.
The prevalence of total difficulties in EBPs was 5.4%, and the proportion of adolescents experiencing one or more EBPs reached 29.6% in this study. Previous studies indicated that the incidence rate of EBPs among adolescents aged 6–16 years in China was 17.6% [42]. Notably, during the COVID-19 period, the prevalence of EBPs among Chinese adolescents rose to 31.6% concerning total difficulties [43]. These findings underscore the transformation of emotional and behavioral disorders in adolescents into primary chronic conditions impacting their psychosocial functioning [44].
After adjusting for control variables, opioids misuse, sedatives misuse and APDU exhibited positive association with four dimensions of EBPs and negatively associated with prosocial behavior. Similarly, research conducted by Bhatia et al. demonstrated that adolescents who acknowledged a history of misusing prescription opioids were at an increased likelihood of engaging in a diverse array of risky behaviors, involving risky driving behaviors, instances of violent conduct, engagement in risky sexual behaviors, and suicide attempts [45]. Grant et al. also demonstrated that young people who misused sedative/tranquilizers were significantly more likely to have mental health problems [46]. Moreover, following adjustments for socio-demographic factors, our study observed that despite a slight reduction in effect sizes across all the adjusted models, sedative misuse, opioid misuse and APDU were still positively associated with total difficulties. Notably, this study failed to uncover a significant link between NMUPD and prosocial behavior. There are some possible explanations for the above situation. First, existing evidence suggests that oxytocin (OXT) plays a role in the neuroadaptive processes linked to addiction development [47]. Oxytocin, a polypeptide hormone, is produced in magnocellular neurons located within the supraoptic (SON) and paraventricular (PVN). It exhibits widespread distribution across brain circuits associated with process such as reward, learning, memory, stress, and addiction [48]. Second, Huang et al. found that dysregulation of oxytocin could manifest following repeated exposure to drug abuse. Patients with ketamine dependence (KD) demonstrated notably lower baseline levels of oxytocin compared to the control group [49]. Third, OXT has a central role in modulating prosocial behavior, including trusting behavior, generosity and cooperation and so on [50, 51]. Therefore, adolescents with substance abuse may have lower oxytocin levels, leading to a loss of prosocial behavior.
Further analyses of the current study illustrated that among all the participants, social support was a mediator in the association of NMUPD with total difficulties and total indirect effect was between 14.8% and 27.5%. Although few studies have reported the role of social support in the association between NMUPD and EBPs, there were some possible explanations for the mediating effect. First, prevalent stigmatizing attitudes towards substance abuse exist in the general public [18]. The public tends to distance themselves from individuals dealing with drug abuse issues in both professional and personal settings [19]. However, social support has been linked to a reduction in internalized stigma among those undergoing drug abuse treatment, subsequently contributing to improved mental health and overall well-being [52]. Second, Hameed et al. (2018) found an adverse link between social support and EBPs among adolescents [53]. Agyemang et al. (2022) found youth with low social support had the highest prevalence of suicide attempt [54]. Conversely, high social support contributed to increasing resilience and thus protecting adolescents from EBPs in Chinese adolescents [55, 56]. Likewise, a study in China using strengths perspectives helped adolescents within high-risk families to rebuild the social support networks, thus facilitated the decrease of EBPs [57]. We can infer that adolescent with NMUPD have lower levels of social support, which leads to a higher risk of EBPs.
Overall, the mediating role of social support contributes to our current comprehension of the mechanism underlying the association between NMUPD and EBPs. Relevant government departments are highly recommended to enhance the supervision of prescription drugs, raise teenagers' awareness of the harm of drug abuse, and offer psychological assistance and social support to those exhibiting drug abuse behaviors, so as to reduce the occurrence of adolescent’s EBPs. Besides, the main monitoring system of drug abuse in China was still aimed at drug rehabilitation institutions, with insufficient monitoring among adolescents using medical drugs [58]. What’s more, stigma and marginalization of drug abusers are still prevalent and there was insufficient support for drug abusers [59]. Therefore, there are some deficiencies in the drug abuse monitoring system. It is suggested that active monitoring could be carried out in medical institutions, schools and other places to strengthen its monitoring mode [58]. An exemplary model for consideration is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) demonstration program, which has shown effectiveness in reducing prescription drug misuse in several studies [60, 61].
This study has several outstanding strengths. Its school-based research design secured a high response rate and good participant cooperation, thereby elevating the overall data quality. The inclusion of a substantial sample size and one of few studies to explore the mediating effect of social support in the link between NMUPD and EBPs further strengthen the study. Regardless of these strengths, several limitations should be acknowledged. First, this study focused exclusively on participants in Guangdong province and students absent from school were excluded from this study, while students absent from school may have higher prevalence of NMUPD [62]. Second, a self-reported questionnaire was utilized to collect data, which was subject to recall bias and measurement errors. Third, the study's cross-sectional design limits our capacity to establish causal association between NMUPD and EBPs. Therefore, caution is advised when interpreting the mediating effects of social support in this association.