Abuse of Prescription Drugs Close Behind Alcohol, Marijuana

A tractor-trailer filled with more than 16 million doses of hydrocodone combination products was stolen from a truck stop in Troy, Ill, on June 17, while en route to a pharmaceuticals distributor in Gurnee, Ill. Although street drug dealers are now the likely distributors of the stolen products, their "customers" are fewer than the number of people who obtain prescription drugs illegally from friends and family.

In fact, about 60% of users of illegal prescription drugs receive them free from friends or relatives, H. Westley Clark, MD, JD, director, Center for Substance Abuse Treatment (CSAT), of the federal Substance Abuse and Mental Health Services Administration (SAMHSA), told attendees at the American Society of Addiction Medicine 38th Annual Medical-Scientific Conference, held in Miami, April 26-29. According to a 2005 household survey by SAMHSA, 17% of those acknowledging illegal use of prescription products obtain them by presenting pain complaints to multiple physicians, or "doctor shopping"; 0.8% obtain the medications from sources on the Internet; and 4.3% procure them from dealers.

"We have this cultural permissiveness to exchange what's in peoples' medicine cabinets," Clark lamented.

Although recognizing this principal source of illegal prescription drugs, Clark emphasized his support for continued access to these medications for therapeutic indications, and he also empathized with those who store the medications for later use.

"How many of you are willing to suffer from excruciating acute or chronic pain in the service of a public policy that prohibits the use of prescription opioids?" he asked. While SAMHSA encourages destroying leftover prescription products, Clark also questioned that notion, asking, "How many of you are willing to throw out something that still might have good use, for which you've already paid?"

The number of people abusing prescription drugs in the United States-particularly opioid analgesics but including benzodiazepine anxiolytics and CNS stimulants indicated for attention- deficit/hyperactivity disorder-is exceeded only by those abusing alcohol and by those using marijuana, according to Clark. The problem is not unique to the United States; the United Nations-affiliated International Narcotics Control Board estimates that the number of people abusing prescription drugs worldwide is closing in on the number of people using illegal substances.¹ An additional hazard principally encountered outside the United States is posed by adulterated or counterfeit prescription products, which the World Health Organization estimates to involve up to half of all prescription products in developing countries.²

In his address, Clark related data from the Drug Abuse Warning Network review of hospital emergency department visits in 2005, which indicate that more than 1.4 million visits were associated with substance use and abuse and about 600,000 were attributable to nonmedical use of prescription products. One third of the visits associated with prescription products involved opioid analgesics, representing a 24% increase from the previous year. In addition, Clark noted that reports to SAMHSA from about 13,500 licensed substance use treatment programs from 2002 to 2005 indicate a 45% increase in admissions for opioid use from the previous reporting period.

Delving further into data on use, Jane Maxwell, PhD, director of the Center for Excellence in Epidemiol-ogy, Gulf Coast Addiction Technology Transfer Center, Austin, Tex, said that hydrocodone/acetaminophen products appear more popular in the western United States, while oxycodone (OxyContin) is the predominant opioid analgesic abused in the East. She also noted the increasing trend among young adults of combining prescription drugs such as alprazolam (Xanax) and carisoprodol (Soma) with other medications or alcohol.

A much publicized example of this was the arrest in July of former Vice President Al Gore's son for driving at excessive speed; according to the Associated Press (AP), he was in possession of "campus favorites" marijuana, alprazolam, diazepam (Valium), and hydrocodone/acetaminophen (Vicodin). The AP report described students commonly exchanging information on prescription drug use on Internet social Web sites such as Facebook.

Maxwell said that prescription drugs are often combined with alcohol to produce intoxication without blood alcohol levels above the "driving under the influence" threshold. In addition, she noted, young adults who use prescription drugs recognize that the drugs are less likely to be adulterated than street substances and increasingly consider them safer.

Men aged 18 to 25 are the largest demographic group to abuse opioid analgesics, followed by girls aged 12 to 17, according to Maxwell. "It's a young population," she declared, "and if they're using as teenagers and young adults, we're going to see them continue to use-just like we saw the kids who started on marijuana 30 years ago continuing, a lot of them, as older adults."

Prescribing with less diversion

"Our policy dilemma," declared Anton C. Bizzell, MD, CSAT Division of Pharmacologic Therapies, who chaired a symposium at the meeting, "is how do we ensure that such medications continue to be readily available for therapeutic use while limiting the access to nontherapeutic misuse or abuse."

Nathaniel Katz, MD, adjunct assistant professor of anesthesiology at Tufts University, Boston, discussed how physicians can help reduce illegal drug diversion. "As the prescriber, our obligation extends beyond the patient who is sitting in front of you that you're handing the prescription to . . . ; it extends also to [persons] collateral to that patient, people in that household," Katz said. "If we take a public health perspective on this problem, [it extends] to . . . the community that you're dispensing medications into."

Katz recommended several measures to increase the safety of prescribing, including using tamper- and copy-proof prescription blanks, securing and limiting access to the blanks, posting controlled substance prescribing policies in patient waiting areas, and flagging charts of long-term opioid therapy patients for particular monitoring. Patients who are found to misuse the prescribed medications should not be treated in primary care, according to Katz, but should be referred to or co-treated by pain or addiction specialists.

Katz noted that several studies, typically those using urine drug screening, have ascertained that about 20% to 40% of patients who receive long-term opioid treatment will ultimately abuse the drugs and/or other substances. Their urine screens may indicate the presence of other opioids from another prescriber or other source; other, nonprescribed substances; or absence of the prescribed analgesic despite continued refills, because these are diverted to other users. There may also be a pattern of early prescription refilling or repeated requests to replace lost prescriptions.

Katz recommended the use of screening tools to help detect active drug abuse or susceptibility to abuse. (The Substance Use Screening & Assessment Instruments Database compiled by the University of Washington Alcohol and Drug Abuse Institute is available at http://lib.adai.washington.edu/instruments.) Katz noted the high predictive value of one question in particular: "Do you need to smoke a cigarette within an hour of awakening in the morning?"

Theodore Parran, Jr, MD, MPH, of Case Western Reserve University, Cleveland, presented information from his risk management courses on prescribing and other medicolegal issues for physicians referred by medical boards for lapses in judgment or procedure.

Parran emphasized the importance of maintaining good documentation of addiction screening, functional assessments, monitoring for treatment benefit, and efforts to titrate or switch treatments to achieve greater benefit than adverse effect. The medical record should include the history and physical and neurological examination results, and it should show a good faith effort to obtain previous medical records, Parran said.

Treatment plans should be individualized, he said, and should avoid, when possible, polypharmacy with multiple controlled schedule prescriptions. He cautioned against adding short-acting opioid medications to long-acting dosages for breakthrough pain, recommending alternatives, such as NSAIDs or nonpharmacotherapeutic approaches. Parran finds there is actually a tendency to underprescribe opioid analgesics for those for whom they are indicated, while prescribing excessively for those few who, he characterized, "should never be allowed within 50 yards of your Drug Enforcement Administration numbers." For the latter, he concurred with Katz regarding the need to obtain consultation or to refer the patient for nonopioid pain management and/or methadone (Dolophine, Methadose) or buprenorphine/naloxone (Suboxone) programs with appropriate monitoring and controls.

References:

References

1.

Abuse of prescription drugs surges across globe. MSNBC.com, February 28, 2007. Available at:

http://www.msnbc.msn.com/id/17388276

. Accessed July 18, 2007.

2.

National Institute on Drug Abuse.

Prescription Drugs: Abuse and Addiction.

Bethesda, Md: National Institutes of Health; revised August 2005. NIH publication 05-4881.