Drug Abuse, Prescription

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Basics

Description

  • Prescription drug abuse behaviors exist on a continuum and may include:
    • Use of medication for nonmedical reasons such as to get high or enhance performance
    • Use of medication for medical reasons other than what the prescriber intended
    • Use of medication for any reason by someone other than the person for whom the medication was originally prescribed
  • Commonly abused prescription medications include opioid analgesics (morphine, oxycodone, hydrocodone, oxymorphone, hydromorphone, fentanyl, methadone, buprenorphine), stimulants (amphetamine, methylphenidate), benzodiazepines (alprazolam, clonazepam, lorazepam), and barbiturates (secobarbital, amobarbital).
  • Diversion is a term used to describe the rerouting of medications from prescriptions or other legitimate supplies for recreational use or criminal activity, such as selling prescription medication for personal profit.

Epidemiology

  • More than half of ED related visits are related to abused or misused pharmaceuticals (opioid and nonopioid).
  • Almost half of opioid overdose deaths involve a prescription opioid. In 2015, there were >15,000 overdose deaths involving prescription opioids in the United States.
  • Prescription opioid abuse is the strongest predictor of heroin initiation and use.

Incidence
  • Predominant sex: males > females
  • Predominant age: highest among adults 18 to 25 years (mean 22 years), then adolescents and teens 12 to 17 years, followed by adults ≥26 years
Prevalence
  • Lifetime prevalence of prescription drug abuse is highest for opioids, benzodiazepines, and stimulants.
  • 18.7 million (6.9%) of U.S. population misuse prescription drugs (opioid and nonopioids combined) and 7.5 million (2.8%) persons age 12 years or older report prescription drug misuse in the past month.
  • 11.8 million (4.4%) with some form of opioid misuse
  • 11.5 million used prescription opioids and analgesics
  • 6.9 million (59%) used hydrocodone.
  • 3.9 million (33%) used oxycodone.
  • Only 1 in 5 receives specialty treatment.

Etiology and Pathophysiology

  • Opioids, benzodiazepines, stimulants, and barbiturates produce euphoria, tolerance, and dependence leading to misuse and addiction.
  • Many adults perceive prescription medications to be more socially acceptable than other illicit drugs.

Genetics
Variant alleles affect the expression and function of opioid, dopamine, acetylcholine, serotonin, and GABA helping to explain susceptibility to different forms of prescription and nonprescription drugs.

Risk Factors

  • Sociodemographic, psychiatric, pain-, and drug-related factors
  • Genetics, environment, family history
  • Ongoing opioid prescription (3+ months) greatly increases risk of opioid-related overdose at 1 year (4-fold) and 5 years (30-fold).

General Prevention

  • Limit or avoid prescribing controlled medications on the first visit (until the relationship is established).
  • Take a thorough history, review records, and perform periodic urine drug screens (UDSs) before deciding if controlled substance is indicated.
  • Try all available nonopioid treatments for pain before prescribing opioids for chronic pain.
  • Avoid prescribing benzodiazepines. Use other treatments for anxiety (CBT, mindfulness, SSRIs, PRN H1 blocker, buspirone).
  • Avoid benzodiazepines and hypnotics in elderly patients.
  • Patients should give good informed consent about risks of controlled medications (see “Commonly Associated Conditions” below) before starting AND at least every 3 months while continuing treatment.
  • Develop/adopt standard practice agreements for prescribing and monitoring controlled substances with abuse potential.
  • Wean/stop prescription analgesics for chronic pain if ineffective for improving pain and function, if aberrant behaviors suggesting opioid use present, or if patient overdoses.
  • Dose reduction of chronic opioids can decrease risk while improving pain, function, and quality of life.
  • Educate and reinforce safe practices for prescribing medications. Office-based, peer-to-peer education and follow-up with pharmacies help identify abuse behaviors.
  • Prescription monitoring programs (PMPs) reduce doctor shopping but not ED visits for overdose and prescription drug abuse–related deaths.
  • Identify and treat underlying substance abuse; involve behavioral health providers when possible.
  • Prescribe intranasal naloxone to all patients prescribed chronic opioids and provide education to patient and family members on proper use in case of overdose. Intranasal naloxone programs in communities with >1 enrollment/100,000 people and 5 or more opioid-related overdose fatalities reduce new opioid-related overdose deaths.

Commonly Associated Conditions

  • Opioids: tolerance (loss of effectiveness over time), opioid-induced hyperalgesia, dependence (uncomfortable withdrawal if loss of access), addiction (which can lead to loss of savings, job, close relationships and incarceration, HCV or HIV infection, etc.), overdose/death, depression, constipation, low testosterone, and sexual dysfunction with chronic use. Methadone is associated with QT prolongation, which increases risk for torsades de pointes.
  • Benzodiazepines and barbiturates: dependence (withdrawal can cause seizures, delirium tremens, death), psychosis, anxiety, sleep driving, blackout states, cognitive impairment, impaired driving while awake; increased fall risk and mortality in elderly patients
  • Stimulants: dependence, hypertension, tachyarrhythmias, myocardial ischemia, seizures, hypothermia, psychosis, hallucinations, paranoia, anxiety

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