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Prescription Drug Abuse
Source: National Institute on Drug Addiction
Most people who take prescription medications take them responsibly;
however, the abuse of prescription drugs remains a
serious public health concern. Certain prescription drugs - opioids,
central nervous system (CNS) depressants, and stimulants - when abused,
can alter the brain's activity and lead to dependence and possibly addiction.
An estimated 9 million people used prescription drugs
for nonmedical reasons in 1999; more than a quarter of that number reported
using prescription drugs nonmedically for the first time in the previous
year.
The National Institute on Drug Abuse (NIDA) provides information
to answer questions about the consequences of abusing commonly prescribed
medications. In addition to offering information on what research has
taught us about how certain medications affect the brain and body, they also cover treatment options.
This publication was developed to help health care providers discuss
the consequences of prescription drug abuse with their patients. According
to a recent national survey of primary care physicians and patients regarding
substance abuse, 46.6 percent of physicians find it difficult to discuss
prescription drug abuse with their patients.
Prescription drug abuse is not a new problem, but one that deserves
renewed attention. We hope this scientific report is useful to the public,
particularly to individuals working with the elderly, who because of
the number of medications they may take for various medical conditions,
may be more vulnerable to misuse or abuse of prescribed medications.
In addition to opiates and stimulants, which are described in more detail on their own pages, here are details on some of the most often abused prescription medications:
CNS depressants
CNS depressants
are substances that can slow normal brain function.
Some CNS depressants are
useful in the treatment of anxiety and sleep disorders.
Among the medications that are commonly prescribed
for these purposes are the following:
- Barbiturates, such as mephobarbital (Mebaral) and
pentobarbital sodium (Nembutal), which are used to
treat anxiety, tension, and sleep disorders.
- Benzodiazepines, such as diazepam (Valium), chlordiazepoxide
HCl (Librium), and alprazolam (Xanax), which can
be prescribed to treat anxiety, acute stress reactions,
and panic attacks; the more sedating benzodiazepines,
such as triazolam (Halcion) and estazolam (ProSom)
can be prescribed for short-term treatment of sleep
disorders.
In higher doses, some CNS depressants can be used
as general anesthetics.
How do CNS depressants affect the brain and body?
Most act on the brain by affecting
the neurotransmitter gamma-aminobutyric acid (GABA).
Neurotransmitters are brain chemicals that facilitate
communication between brain cells. GABA works by decreasing
brain activity. Although the different kinds of CNS
depressants work in unique ways, ultimately it is through
their ability to increase GABA activity that they produce
a calming effect that is beneficial to those
suffering from anxiety or sleep disorders.
What are the possible consequences of CNS depressant use and abuse?
Despite their many
beneficial effects, barbiturates and benzodiazepines
have the potential for abuse and should be used only
as prescribed. During the first few days of taking
a prescribed CNS depressant, a person usually feels
sleepy and uncoordinated, but as the body becomes accustomed
to the effects of the drug, these feelings begin to
disappear. If one uses these drugs long term, the body
will develop tolerance for the drugs, and larger doses
will be needed to achieve the same initial effects.
In addition, continued use can lead to physical dependence
and - when use is reduced or stopped - withdrawal.
Because all CNS depressants work by slowing the brain's
activity, when an individual stops taking them, the
brain's activity can rebound and race out of control,
possibly leading to seizures and other harmful consequences.
Although withdrawal from benzodiazepines can be problematic,
it is rarely life threatening, whereas withdrawal from
prolonged use of other CNS depressants can have life-threatening
complications. Therefore, someone who is thinking about
discontinuing CNS depressant therapy or who is suffering
withdrawal from a CNS depressant should speak with
a physician or seek medical treatment.
Is it safe to use CNS depressants with other medications?
CNS depressants
should be used with other medications under a
physician's supervision. Typically, they should not
be combined with other medication or substances
that causes CNS depression, including prescription
pain medicines, some over-the-counter cold and allergy
medications, or alcohol. Using CNS depressants with
these other substances - particularly alcohol - can
slow breathing, or slow both the heart and respiration,
and possibly lead to death.
Trends in prescription drug abuse
Several indicators
suggest that prescription drug abuse is on the rise
in the United States. According to the 1999 National
Household Survey on Drug Abuse, in 1998, an estimated
1.6 million Americans used prescription pain relievers
nonmedically for the first time. This represents
a significant increase since the 1980s, when there
were generally fewer than 500,000 first-time users
per year. From 1990 to 1998, the number of new users
of pain relievers increased by 181 percent; the number
of individuals who initiated tranquilizer use increased
by 132 percent; the number of new sedative users
increased by 90 percent; and the number of people
initiating stimulant use increased by 165 percent.
In 1999, an estimated 4 million people - almost 2
percent of the population aged 12 and older - were
currently (use in past month) using certain prescription
drugs nonmedically: pain relievers (2.6 million users),
sedatives and tranquilizers (1.3 million users),
and stimulants (0.9 million users).
Although prescription drug abuse affects many Americans,
some trends of concern can be seen among older adults,
adolescents, and women. In addition, health care
professionals - including physicians, nurses, pharmacists,
dentists, anesthesiologists, and veterinarians -
may be at increased risk of prescription drug abuse
because of ease of access, as well as their ability
to self-prescribe drugs. In spite of this increased
risk, recent surveys and research in the early 1990s
indicate that health care providers probably suffer
from substance abuse, including alcohol and drugs,
at a rate similar to rates in society as a whole,
in the range of 8 to 12 percent.
Older adults
The misuse of
prescription drugs may be the most common form of
drug abuse among the elderly. Elderly persons use
prescription medications approximately three times
as frequently as the general population and have
been found to have the poorest rates of compliance
with directions for taking a medication. In addition,
data from the Veterans Affairs Hospital System suggest
that elderly patients may be prescribed inappropriately
high doses of medications such as benzodiazepines
and may be prescribed these medications for longer
periods than are younger adults. In general, older
people should be prescribed lower doses of medications,
because the body's ability to metabolize many medications
decreases with age.
An association between age-related morbidity and
abuse of prescription medications likely exists.
For example, elderly persons who take benzodiazepines
are at increased risk for falls that cause hip and
thigh fractures, as well as for vehicle accidents.
Cognitive impairment also is associated with benzodiazepine
use, although memory impairment may be reversible
when the drug is discontinued. Finally, use of benzodiazepines
for longer than 4 months is not recommended for elderly
patients because of the possibility of physical dependence.
Adolescents and young adults
Data from the
National Household Survey on Drug Abuse indicate
that the most dramatic increase in new users of prescription
drugs for nonmedical purposes occurs in 12- to 17-year-olds
and 18- to 25-year-olds. In addition, 12- to 14-year-olds
reported psychotherapeutics (for example, painkillers
or stimulants) as one of two primary drugs used.
The 1999 Monitoring the Future survey showed that
for barbiturates, tranquilizers, and narcotics other
than heroin, the general, long-term declines in use
among young adults in the 1980s leveled off in the
early 1990s, with modest increases again in the mid-
to late 1990s. For example, the use of methylphenidate
(Ritalin) among high school seniors increased from
an annual prevalence (use of the drug within the
preceding year) of 0.1 percent in 1992 to an annual
prevalence of 2.8 percent in 1997 before reaching
a plateau.
It also appears that college students' nonmedical
use of pain relievers such as oxycodone with aspirin
(Percodan) and hydrocodone (Vicodin) is on the rise.
The 1999 Drug Abuse Warning Network, which collects
data on drug-related episodes in hospital emergency
departments, reported that mentions of hydrocodone
as a cause for visiting an emergency room increased
by 37 percent among all age groups from 1997 to 1999.
Mentions of the benzodiazepine clonazepam (Klonopin)
increased by 102 percent since 1992.
Gender
Studies suggest
that women are more likely than men to be prescribed
abusable prescription drugs, particularly narcotics
and anti-anxiety drugs - in some cases 48 percent
more likely.
Overall, men and women have roughly similar rates
of nonmedical use of prescription drugs. An exception
is found among 12- to 17-year-olds: In this age group,
young women are more likely than young men to use
psychotherapeutic drugs nonmedically.
In addition, research has shown that women and men
who use prescription opioids are equally likely to
become addicted. However, among women and men who
use either a sedative, anti-anxiety drug, or hypnotic,
women are almost two times more likely to become
addicted.
Preventing and detecting prescription drug abuse
Although most
patients use medications as directed, abuse of and
addiction to prescription drugs are public health
problems for many Americans. However, addiction rarely
occurs among those who use pain relievers, CNS depressants,
or stimulants as prescribed; the risk for addiction
exists when these medications are used in ways other
than as prescribed. Health care providers such as
primary care physicians, nurse practitioners, and
pharmacists as well as patients can all play a role
in preventing and detecting prescription drug abuse.
Role of health care providers
About 70 percent
of Americans - approximately 191 million people -
visit a health care provider at least once every 2 years. Thus, health
care providers are in a unique position not only
to prescribe needed medications appropriately, but
also to identify prescription drug abuse and help the patient recognize the problem,
set goals for recovery, and seek appropriate treatment
when necessary. Screening for any type of substance
abuse can be incorporated into routine history taking
with questions about what prescriptions and over-the-counter
medicines the patient is taking and why. Screening
also can be performed if a patient presents with
specific symptoms associated with problem use of
a substance.
Over time, providers should note any rapid increases
in the amount of a medication needed - which may indicate
the development of tolerance - or frequent requests
for refills before the quantity prescribed should have
been used. They should also be alert to the fact that
those addicted to prescription medications may engage
in "doctor shopping," moving from provider to provider
in an effort to get multiple prescriptions for the
drug they abuse.
Preventing or stopping prescription drug abuse is an important part of patient
care. However, health care providers should not avoid prescribing or administering
strong CNS depressants and painkillers, if they are needed. (See box on pain
and opiophobia.)
Role of pharmacists
Pharmacists can play a key role in preventing
prescription drug misuse and abuse by providing clear information and advice
about how to take a medication appropriately, about the effects the medication
may have, and about any possible drug interactions. Pharmacists can help prevent
prescription fraud or diversion by looking for false or altered prescription
forms. Many pharmacies have developed "hotlines" to alert other pharmacies
in the region when a fraud is detected.
Role of patients
There are several ways that patients can
prevent prescription drug abuse. When visiting the doctor, provide a complete
medical history and a description of the reason for the visit to ensure that
the doctor understands the complaint and can prescribe appropriate medication.
If a doctor prescribes a pain medication, stimulant, or CNS depressant, follow
the directions for use carefully and learn about the effects that the drug
could have, especially during the first few days during which the body is adapting
to the medication. Also be aware of potential interactions with other drugs
by reading all information provided by the pharmacist. Do not increase or decrease
doses or abruptly stop taking a prescription without consulting a health care
provider first. For example, if you are taking a pain reliever for chronic
pain and the medication no longer seems to be effectively controlling the pain,
speak with your physician; do not increase the dose on your own. Finally, never
use another person's prescription.
Treating prescription drug addiction
Years of research have shown us that addiction
to any drug, illicit or prescribed, is a brain disease that can, like other
chronic diseases, be effectively treated. But no single type of treatment is
appropriate for all individuals addicted to prescription drugs. Treatment must
take into account the type of drug used and the needs of the individual. To
be successful, treatment may need to incorporate several components, such as
counseling in conjunction with a prescribed medication, and multiple courses
of treatment may be needed for the patient to make a full recovery.
The two main categories of drug addiction treatment are behavioral and pharmacological.
Behavioral treatments teach people how to function without drugs, how to handle
cravings, how to avoid drugs and situations that could lead to drug use, how
to prevent relapse, and how to handle relapse should it occur. When delivered
effectively, behavioral treatments - such as individual counseling, group or
family counseling, contingency management, and cognitive-behavioral therapies
- also can help patients improve their personal relationships and ability to
function at work and in the community.
Some addictions, such as opioid addiction, can also be treated with medications.
These pharmacological treatments counter the effects of the drug on the brain
and behavior. Medications also can be used to relieve the symptoms of withdrawal,
to treat an overdose, or to help overcome drug cravings. Although a behavioral
or pharmacological approach alone may be effective for treating drug addiction,
research shows that a combination of both, when available, is most effective.
Treating addiction to CNS depressants
Patients addicted to barbiturates and benzodiazepines
should not attempt to stop taking them on their own, as withdrawal from these
drugs can be problematic, and in the case of certain CNS depressants, potentially
life-threatening. Patients addicted to these
medications should undergo medically supervised detoxification because the
dose must be gradually tapered off. Inpatient or outpatient counseling can
help the individual during this process. Cognitive-behavioral therapy also
has been used successfully to help individuals adapt to the removal from benzodiazepines.
Often the abuse of barbiturates and benzodiazepines occurs in conjunction
with the abuse of another substance or drug, such as alcohol or cocaine. In
these cases, the treatment approach must address the multiple
addictions.
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