Longitudinal pathway from low academic performance in adolescence to prescription drug misuse in adulthood: The mediating role of substance use and the moderating role of sex

BACKGROUND AND OBJECTIVES: Prescription drug misuse (PDM) has serious health and social consequences, highlighting the importance of identifying early risk factors. This study examines longitudinal pathways linking low academic performance in adolescence, substance use in emerging adulthood, and PDM in young adulthood, with attention to sex differences. METHODS: Participants were 5114 individuals (54% female) from Waves 1, 3, and 4 of the National Longitudinal Study of Adolescent to Adult Health. A two-group structural equation model stratified by sex was performed to examine the pathways to PDM. Moderated mediation was also tested between males and females. RESULTS: Low academic performance in adolescence was associated with substance use in emerging adulthood for both males (p < .001) and females (p < .001), which in turn was associated with PDM in young adulthood (males: p < .001; females: p < .001). Only among females, low academic performance in adolescence was negatively associated with PDM in young adulthood (p < .001). The moderation effects of sex on the pathways from substance use to PDM (p < .05) and from low academic performance to PDM (p < .05) were significant at one-tailed test. DISCUSSION AND CONCLUSIONS: Adolescents with poor academic performance represent a high-risk group for later PDM, emphasizing the need for early preventions. Prevention strategies should consider sex-specific pathways, particularly targeting substance use in emerging adulthood. SCIENTIFIC SIGNIFICANCE: Identifying early academic and behavioral risk factors provides valuable insight for clinicians and prevention professionals aiming to reduce PDM across the life course.