The non-medical use or abuse of prescription drugs is a serious and
growing public health problem in this country. The elderly
are among those most vulnerable to prescription drug abuse or misuse
because they are prescribed more medications than their
younger counterparts. Most people take prescription medications
responsibly; however, an estimated 48 million people (ages 12
and older) have used prescription drugs for non-medical reasons in
their lifetimes. This represents approximately 20 percent
of the U.S. population.
Also alarming is the fact that the 2004 National Institute on Drug
Abuse's (NIDA's) Monitoring the Future survey of 8th,
10th, and 12th-graders found that 9.3 percent of 12th-graders
reported using Vicodin without a prescription in the past year,
and 5.0 percent reported using OxyContin-making these medications
among the most commonly abused prescription drugs by
adolescents.
The abuse of certain prescription drugs-opioids, central nervous
system (CNS) depressants, and stimulants- can alter the
brain's activity and lead to addiction. While we do not yet
understand all of the reasons for the increasing abuse of
prescription drugs, we do know that accessibility is likely a
contributing factor. In addition to the increasing number of
medicines being prescribed for a variety of health problems, some
medications can be obtained easily from online pharmacies.
Most of these are legitimate businesses that provide an important
service; however, some online pharmacies dispense
medications without a prescription and without appropriate identity
verification, allowing minors to order the medications
easily over the Internet.
NIDA hopes to decrease the prevalence of this problem by increasing
awareness and promoting additional research on
prescription drug abuse. Prescription drug abuse is not a new
problem, but one that deserves renewed attention. It is
imperative that as a Nation we make ourselves aware of the
consequences associated with the misuse and abuse of these
medications.
Nora D. Volkow, M.D.
Director
National Institute on Drug Abuse
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Although most people take prescription medications
responsibly, there has been an increase in the nonmedical use of or,
as
NIDA refers to it in this report, abuse1 of prescription drugs in
the United States.
Opioids are commonly prescribed because of their
effective analgesic, or pain-relieving, properties. Medications that
fall
within this class-referred to as prescription narcotics-include
morphine (e.g., Kadian, Avinza), codeine, oxycodone (e.g.,
OxyContin, Percodan, Percocet), and related drugs. Morphine, for
example, is often used before and after surgical procedures
to alleviate severe pain. Codeine, on the other hand, is often
prescribed for mild pain. In addition to their pain-relieving
properties, some of these drugs-codeine and diphenoxylate (Lomotil)
for example-can be used to relieve coughs and diarrhea.
Opioids act on the brain and body by attaching to
specific proteins called opioid receptors, which are found in the
brain,
spinal cord, and gastrointestinal tract. When these drugs attach to
certain opioid receptors, they can block the perception
of pain. Opioids can produce drowsiness, nausea, constipation, and,
depending upon the amount of drug taken, depress
respiration. Opioid drugs also can induce euphoria by affecting the
brain regions that mediate what we perceive as pleasure.
This feeling is often intensified for those who abuse opioids when
administered by routes other than those recommended. For
example, OxyContin often is snorted or injected to enhance its
euphoric effects, while at the same time increasing the risk
for serious medical consequences, such as opioid overdose.
Taken as directed, opioids can be used to manage pain
effectively. Many studies have shown that the properly managed,
short-
term medical use of opioid analgesic drugs is safe and rarely causes
addiction-efined as the compulsive and uncontrollable
use of drugs despite adverse consequences-or dependence, which
occurs when the body adapts to the presence of a drug, and
often results in withdrawal symptoms when that drug is reduced or
stopped. Withdrawal symptoms include restlessness, muscle
and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose
bumps ("cold turkey"), and involuntary leg movements.
Long-term use of opioids can lead to physical dependence and
addiction. Taking a large single dose of an opioid could cause
severe respiratory depression that can lead to death.
Only under a physician's supervision can opioids be
used safely with other drugs. Typically, they should not be used
with
other substances that depress the CNS, such as alcohol,
antihistamines, barbiturates, benzodiazepines, or general
anesthetics, because these combinations increase the risk of
life-threatening respiratory depression.
1 A common vocabulary has not been established in the field of
prescription drug abuse. Because much of the data collected in
this area focuses on nonmedical use of prescription drugs, the
definition of abuse used in this report does not correspond to
the definition of abuse/dependence listed in the Diagnostic and
Statistical Manual of Mental Disorders (DSM).
2 This does not apply only to opioids. Changes in routes of
administration also contribute to the abuse of other prescription
medications, and this practice can lead to serious medical
consequences.
CNS depressants, sometimes referred to as sedatives
and tranquilizers, are substances that can slow normal brain
function.
Because of this property, 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), are used to treat anxiety, tension, and
sleep disorders.
Benzodiazepines, such as diazepam (Valium), chlordiazepoxide HCl
(Librium), and alprazolam (Xanax), are prescribed to treat
anxiety, acute stress reactions, and panic attacks. The more
sedating benzodiazepines, such as triazolam (Halcion) and
estazolam (ProSom) are prescribed for short-term treatment of sleep
disorders. Usually, benzodiazepines are not prescribed
for long-term use.
There are numerous CNS depressants; most act on the
brain by affecting the neurotransmitter gammaaminobutyric acid (GABA).
Neurotransmitters are brain chemicals that facilitate communication
between brain cells. GABA works by decreasing brain
activity. Although the different classes of CNS depressants work in
unique ways, it is through their ability to increase GABA
activity that they produce a drowsy or calming effect that is
beneficial to those suffering from anxiety or sleep disorders.
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. 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, potentially 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.
CNS depressants should be used in combination with
other medications only under a physician's close supervision.
Typically,
they should not be combined with any other medication or substance
that causes CNS depression, including prescription pain
medicines, some OTC cold and allergy medications, and alcohol. Using
CNS depressants with these other substances -
particularly alcohol - can slow both the heart and respiration and
may lead to death.
As the name suggests, stimulants increase alertness,
attention, and energy, as well as elevate blood pressure and
increase
heart rate and respiration. Stimulants historically were used to
treat asthma and other respiratory problems, obesity,
neurological disorders, and a variety of other ailments. But as
their potential for abuse and addiction became apparent, the
medical use of stimulants began to wane. Now, stimulants are
prescribed for the treatment of only a few health conditions,
including narcolepsy, ADHD, and depression that has not responded to
other treatments.
Stimulants, such as dextroamphetamine (Dexedrine and
Adderall) and methylphenidate (Ritalin and Concerta), have chemical
structures similar to a family of key brain neurotransmitters called
monoamines, which include norepinephrine and dopamine.
Stimulants enhance the effects of these chemicals in the brain.
Stimulants also increase blood pressure and heart rate,
constrict blood vessels, increase blood glucose, and open up the
pathways of the respiratory system. The increase in dopamine
is associated with a sense of euphoria that can accompany the use of
these drugs.
As with other drugs of abuse, it is possible for
individuals to become dependent upon or addicted to many stimulants.
Withdrawal symptoms associated with discontinuing stimulant use
include fatigue, depression, and disturbance of sleep
patterns. Repeated use of some stimulants over a short period can
lead to feelings of hostility or paranoia. Further, taking
high doses of a stimulant may result in dangerously high body
temperature and an irregular heartbeat. There is also the
potential for cardiovascular failure or lethal seizures.
Stimulants should be used in combination with other
medications only under a physician's supervision. Patients also
should be
aware of the dangers associated with mixing stimulants and OTC cold
medicines that contain decongestants; combining these
substances may cause blood pressure to become dangerously high or
lead to irregular heart rhythms.
Although prescription drug abuse affects many
Americans, some concerning trends can be seen among older adults,
adolescents,
and women. Several indicators suggest that prescription drug abuse
is on the rise in the United States. According to the 2003
National Survey on Drug Use and Health (NSDUH), an estimated 4.7
million Americans used prescription drugs nonmedically for
the first time in 2002 -
2.5 million used pain relievers
1.2 million used tranquilizers
761,000 used stimulants
225,000 used sedatives
Pain reliever incidence increased-from 573,000 initiates in 1990 to
2.5 million initiates in 2000-and has remained stable
through 2003. In 2002, more than half (55 percent) of the new users
were females, and more than half (56 percent) were ages
18 or older.
The Drug Abuse Warning Network (DAWN), which monitors medications
and illicit drugs reported in emergency departments (EDs)
across the Nation, recently found that two of the most frequently
reported prescription medications in drug abuse-related
cases are benzodiazepines (e.g., diazepam, alprazolam, clonazepam,
and lorazepam) and opioid pain relievers (e.g., oxycodone,
hydrocodone, morphine, methadone, and combinations that include
these drugs). In 2002, benzodiazepines accounted for 100,784
mentions that were classified as drug abuse cases, and opioid pain
relievers accounted for more than 119,000 ED mentions.
From 1994 to 2002, ED mentions of hydrocodone and oxycodone
increased by 170 percent and 450 percent, respectively. While ED
visits attributed to drug addiction and drug-taking for psychoactive
effects have been increasing, intentional overdose
visits have remained stable since 1995.
Older adults
Persons 65 years of age and above comprise only 13 percent of the
population, yet account for approximately one-third of all
medications prescribed in the United States. Older patients are more
likely to be prescribed long-term and multiple
prescriptions, which could lead to unintentional misuse.
The elderly also are at risk for prescription drug abuse, in which
they intentionally take medications that are not medically
necessary. In addition to prescription medications, a large
percentage of older adults also use OTC medicines and dietary
supplements. Because of their high rates of comorbid illnesses,
changes in drug metabolism with age, and the potential for
drug interactions, prescription and OTC drug abuse and misuse can
have more adverse health consequences among the elderly
than are likely to be seen in a younger population. Elderly persons
who take benzodiazepines are at increased risk for
cognitive impairment associated with benzodiazepine use, leading to
possible falls (causing hip and thigh fractures), as well
as vehicle accidents. However, cognitive impairment may be
reversible once the drug is discontinued.
Adolescents and young adults
Data from the 2003 NSDUH indicate that 4.0 percent of youth ages 12
to 17 reported nonmedical use of prescription medications
in the past month. Rates of abuse were highest among the 18-25 age
group (6.0 percent). Among the youngest group surveyed,
ages 12-13, a higher percentage reported using psychotherapeutics
(1.8 percent) than marijuana (1.0 percent).
The NIDA Monitoring the Future survey of 8th-, 10th-, and
12th-graders found that the nonmedical use of opioids,
tranquilizers, sedatives/barbiturates, and amphetamines was
unchanged between 2003 and 2004. Specifically, the survey found
that 5.0 percent of 12th-graders reported using OxyContin without a
prescription in the past year, and 9.3 percent reported
using Vicodin, making Vicodin one of the most commonly abused licit
drugs in this population. Past year, nonmedical use of
tranquilizers (e.g., Valium, Xanax) in 2004 was 2.5 percent for
8th-graders, 5.1 percent for 10th-graders, and 7.3 percent
for 12th-graders. Also within the past year, 6.5 percent of
12th-graders used sedatives/ barbiturates (e.g., Amytal,
Nembutal) nonmedically, and 10.0 percent used amphetamines (e.g.,
Ritalin, Benzedrine).
Youth who use other drugs are more likely to abuse prescription
medications. According to the 2001 National Household Survey
on Drug Abuse (now the NSDUH), 63 percent of youth who had used
prescription drugs nonmedically in the past year had also
used marijuana in the past year, compared with 17 percent of youth
who had not used prescription drugs nonmedically in the
past year.
Gender differences
Studies suggest that women are more likely than men
to be prescribed an abusable prescription drug, particularly
narcotics
and antianxiety drugs—in some cases, 55 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 are at increased risk for nonmedical use of narcotic analgesics and tranquilizers
(e.g., benzodiazepines).
The risks for addiction to prescription drugs
increase when the drugs are used in ways other than for those
prescribed.
Healthcare providers, primary care physicians, and pharmacists, as
well as patients themselves, all can play a role in
identifying and preventing prescription drug abuse.
Physicians. Because about 70 percent of Americans (approximately 191
million people) visit their primary care physician at
least once every 2 years, these doctors are in a unique position-not
only to prescribe medications, but also to identify
prescription drug abuse when it exists, help the patient recognize
the problem, set recovery goals, and seek appropriate
treatment. Screening for prescription drug abuse can be incorporated
into routine medical visits by asking about substance
abuse history, current prescription and OTC use, and reasons for
use. Doctors should take note of rapid increases in the
amount of medication needed, or frequent, unscheduled refill
requests. Doctors also should be alert to the fact that those
addicted to prescription drugs may engage in "doctor shopping"-
moving from provider to providerÑin an effort to obtain
multiple prescriptions for the drug(s) they abuse.
Preventing or stopping prescription drug abuse is an important part
of patient care. However, healthcare providers should not
avoid prescribing or administering stimulants, CNS depressants, or
opioid pain relievers if needed. (See text box on "Pain
Treatment and Addiction.")
Pharmacists. By providing clear information on how to take a
medication appropriately and describing possible side effects or
drug interactions, pharmacists also can play a key role in
preventing prescription drug abuse. Moreover, by monitoring
prescriptions for falsification or alterations and being aware of
potential "doctor shopping," pharmacists can be the first
line of defense in recognizing prescription drug abuse. Some
pharmacies have developed hotlines to alert other pharmacies in
the region when a fraudulent prescription is detected.
Patients. There are also steps a patient can take to ensure that
they use prescription medications appropriately. Patients
should always follow the prescribed directions, be aware of
potential interactions with other drugs, never stop or change a
dosing regimen without first discussing it with their healthcare
provider, and never use another person's prescription.
Patients should inform their healthcare professionals about all the
prescription and OTC medicines and dietary and herbal
supplements they are taking, in addition to a full description of
their presenting complaint, before they obtain any other
medications.
About 70 percent of Americans - approximately 191
million people - visit a health care provider, such as a primary
care
physician, 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 when it exists 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.)
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.
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.
Years of research have shown us that addiction to any
drug (illicit or prescribed) is a brain disease that, like other
chronic diseases, can be treated effectively. 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. Successful
treatment may need to incorporate several components, including
detoxification, counseling, and in some cases, the use of
pharmacological therapies. 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 encourage
patients to stop drug use and teach them how to function without
drugs, handle cravings, avoid drugs and situations that
could lead to drug use, and handle a relapse should it occur. When
delivered effectively, behavioral treatments-such as
individual counseling, group or family counseling, contingency
management, and cognitiveÐ behavioral therapiesÑalso can help
patients improve their personal relationships and their ability to
function at work and in the community.
Some addictions, such as opioid addiction, can be treated with
medications. These pharmacological treatments counter the
effects of the drug on the brain and behavior, and can be used to
relieve withdrawal symptoms, treat an overdose, or help
overcome drug cravings. Although a behavioral or pharmacological
approach alone may be effective for treating drug addiction,
research shows that, at least in the case of opioid addiction, a
combination of both is most effective.
Several options are available for effectively
treating prescription opioid addiction. These options are drawn from
research
regarding the treatment of heroin addiction, and include medications
such as naltrexone, methadone, and buprenorphine, as
well as behavioral counseling approaches.
Naltrexone is a medication that blocks the effects of opioids and is
used to treat opioid overdose and addiction. Methadone
is a synthetic opioid that blocks the effects of heroin and other
opioids, eliminates withdrawal symptoms, and relieves drug
craving. It has been used successfully for more than 30 years to
treat heroin addiction. The Food and Drug Administration
(FDA) approved buprenorphine in October 2002, after more than a
decade of research supported by NIDA. Buprenorphine, which
can be prescribed by certified physicians in an office setting, is
long lasting, less likely to cause respiratory depression
than other drugs, and is well tolerated. However, more research is
needed to determine the effectiveness of these medications
for the treatment of prescription drug abuse.
A useful precursor to longterm treatment of opioid addiction is
detoxification. Detoxification in itself is not a treatment.
Rather, its primary objective is to relieve withdrawal symptoms
while the patient adjusts to being drug free. To be
effective, detoxification must precede long-term treatment that
either requires complete abstinence or incorporates a
medication, such as methadone or buprenorphine, into the treatment
program.
Patients addicted to barbiturates and benzodiazepines
should not attempt to stop taking them on their own. Withdrawal
symptoms from these drugs can be problematic, andÑin the case of
certain CNS depressants- potentially life-threatening.
Although no research regarding the treatment of barbiturate and
benzodiazepine addiction exists, addicted patients should
undergo medically supervised detoxification because the treatment
dose must be gradually tapered. Inpatient or outpatient
counseling can help the individual during this process.
Cognitivebehavioral therapy, which focuses on modifying the
patient's
thinking, expectations, and behaviors, while at the same time
increasing skills for coping with various life stressors, also
has been used successfully to help individuals adapt to the
discontinuation of benzodiazepines.
Often barbiturate and benzodiazepine abuse occurs in conjunction
with the abuse of another substance or drug, such as alcohol
or cocaine. In these cases of polydrug abuse, the treatment approach
must address the multiple addictions.
Treatment of addiction to prescription stimulants,
such as Ritalin, is often based on behavioral therapies that have
proven
effective in treating cocaine and methamphetamine addiction. At this
time, there are no proven medications for the treatment
of stimulant addiction. However, NIDA is supporting a number of
studies on potential medications for treating stimulant
addiction.
Depending on the patient's situation, the first steps in treating
prescription stimulant addiction may be tapering the drug
dosage and attempting to ease withdrawal symptoms. The
detoxification process could then be followed by one of many
behavioral therapies. Contingency management, for example, uses a
system that enables patients to earn vouchers for drug-free
urine tests. (These vouchers can be exchanged for items that promote
healthy living.) Cognitive-behavioral therapy also may
be an effective treatment for addressing stimulant addiction.
Finally, recovery support groups may be helpful in conjunction
with behavioral therapy.
Generally prescribed for Postsurgical pain relief Management of
acute or chronic pain
Relief of cough and diarrhea
In the body
Opioids attach to opioid receptors in the brain and spinal cord,
blocking the perception of pain.
Effects of short-term use
Alleviates pain
Drowsiness
Constipation
Depressed respiration (depending on dose)
Effects of long-term use
Potential for physical dependence and addiction
Possible negative effects
Severe respiratory depression or death following a large single dose
Should not be used with Other substances that cause CNS depression,
including Alcohol, Antihistamines, Barbiturates,
Benzodiazepines, General anesthetics
Generally prescribed for Anxiety, Tension, Panic attacks, Acute
stress reactions, Sleep disorders, Anesthesia (at high doses)
In the body
CNS depressants slow brain activity through actions on the GABA
system, producing a calming effect.
Effects of short-term use
A "sleepy" and uncoordinated feeling during the first few days; as
the body becomes accustomed (tolerant) to the effects,
these feelings diminish.
Effects of long-term use
Potential for physical dependence and addiction
Possible negative effects
Seizures following a rebound in brain activity after reducing or
discontinuing use
Should not be used with
Other substances that cause CNS depression, including Alcohol,
Prescription opioid pain medicines, Some OTC cold and allergy
medications
-------------
Stimulants
Dextroamphetamine (Dexedrine and Adderall)
Methylphenidate (Ritalin and Concerta)
Generally prescribed for Narcolepsy Attention-deficit hyperactivity
disorder (ADHD)
Depression that does not respond to other treatment
In the body
Stimulants enhance brain activity, causing an increase in alertness,
attention, and energy.
Effects of short-term use Elevated blood pressure Increased heart
rate Increased espiration Suppressed appetite Sleep
deprivation
Effects of long-term use
Potential for physical dependence and addiction
Effects of long-term use
Potential for physical dependence and addiction
Possible negative effects
Dangerously high body temperature or an irregular heartbeat after
taking high doses
Cardiovascular failure or lethal seizures
For some stimulants, hostility or feelings of paranoia after taking
high doses repeatedly over a short period of time
Should not be used with
OTC decongestant medications, Antidepressants unless supervised by a
physician,
Some asthma medications
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