Prescription
drugs make complex surgery possible, relieve pain for millions of
people, and enable many individuals with chronic medical conditions
to control their symptoms and lead productive lives. Most people who
take prescription medications use them responsibly. However, the non-medical
use of prescription drugs is a serious public health concern. Nonmedical
use of prescription drugs like opioids, central nervous system (CNS)
depressants, and stimulants can lead to abuse and addiction, characterized
by compulsive drug seeking and use.
Addiction rarely occurs among people who use a pain reliever, CNS
depressant, or stimulant as prescribed; however, inappropriate use
of prescription drugs can lead to addiction in some cases. Patients,
healthcare professionals, and pharmacists all have roles in preventing
misuse and addiction. For example, if a doctor prescribes a pain medication,
CNS depressant, or stimulant, the patient should follow the directions
for use carefully, and also learn what effects the drug could have
and potential interactions with other drugs by reading all information
provided by the pharmacist. Physicians and other health care providers
should screen for any type of substance abuse during routine history-taking
with questions about what prescriptions and over-the-counter medicines
the patient is taking and why.
Trends in Prescription Drug Abuse
In 1999, an estimated 4 million people, about 2 percent
of the population age 12 and older, were currently (use in past month)
using prescription drugs non-medically. Of these, 2.6 million misused
pain relievers, 1.3 million misused sedatives and tranquilizers, and
0.9 million misused stimulants.1 While prescription drug
abuse affects many Americans, some trends of particular concern can
be seen among older adults, adolescents, and women.
The misuse of prescribed medications may be the most common form of drug abuse
among the elderly. Older people are prescribed medications about three times
more frequently than the general population, and have poorer compliance with
directions for use.
The National Household Survey on Drug Abuse1 numbers indicate that the sharpest
increases in new users of prescription drugs for non-medical purposes occur
in 12 to 17 and 18 to 25 year-olds. Among 12 to 14 year-olds, psychotherapeutics
(e.g., pain killers, tranquilizers, sedatives, and stimulants) were reported
to be one of two primary drugs used.
The 1999 Monitoring the Future Survey2 of 8th, 10th, and 12th graders
nationwide, showed that for barbiturates, tranquilizers, and narcotics other
than heroin, general long-term declines in use in the 1980s leveled-off in
the early 1990s, with modest increases again in the mid-1990s.
Overall, men and women have roughly similar rates of nonmedical use of prescription
drugs, with the exception of 12 to 17 year olds. In this age group, young women
are more likely than young men to use psychotherapeutic drugs nonmedically.
Also, among women and men who use either a sedative, anti-anxiety drug, or
hypnotic, women are almost twice as likely to become addicted.3
The Drug Abuse Warning Network,4 which collects data on drug-related
hospital emergency room episodes, reported that mentions of hydrocodone as
a cause for visiting an emergency room increased 37 percent among all age groups
from 1997 to 1999. Also, mentions of clonazepam increased 102 percent since
1992.
Commonly Abused Prescription Drugs
While many prescription drugs can be abused or misused, these three classes are
most commonly abused:
Opioids - often prescribed to treat pain.
CNS Depressants - used to treat anxiety and sleep disorders.
Stimulants - prescribed to treat narcolepsy and attention
deficit/hyperactivity disorder.
Opioids
Opioids are commonly prescribed because of their effective analgesic or pain
relieving properties. Many studies have shown that properly managed medical use
of opioid analgesic drugs is safe and rarely causes clinical addiction, which
is defined as compulsive, often uncontrollable use. Taken exactly as prescribed,
opioids can be used to manage pain effectively.
Among the drugs that fall within this class - sometimes referred to as narcotics
- are morphine, codeine, and related drugs. Morphine is often used before or
after surgery to alleviate severe pain. Codeine is used for milder pain. Other
examples of opioids that can be prescribed to alleviate pain include oxycodone
(OxyContin-an oral, controlled release form of the drug); propoxyphene (Darvon);
hydrocodone (Vicodin); hydromorphone (Dilaudid); and meperidine (Demerol),
which is used less often because of its side effects. In addition to their
effective pain relieving properties, some of these drugs can be used to relieve
severe diarrhea (Lomotil, for example, which is diphenoxylate) or severe coughs
(codeine).
Opioids act 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 in the brain and spinal cord they
can effectively block the transmission of pain messages to the brain.
In addition to relieving pain, opioid drugs can affect regions of the brain
that mediate what we perceive as pleasure, resulting in the initial euphoria
that many opioids produce. They can also produce drowsiness, cause constipation,
and, depending upon the amount of drug taken, depress breathing. Taking a large
single dose could cause severe respiratory depression or be fatal.
Opioids may interact with other drugs and are only safe to use with other
drugs under a physician's supervision. Typically, they should not be used with
substances such as alcohol, antihistamines, barbiturates, or benzodiazepines.
These drugs slow down breathing, and their combined effects could risk life-threatening
respiratory depression.
Chronic use of opioids can result in tolerance to the drugs so that higher
doses must be taken to obtain the same initial effects. Long-term use also
can lead to physical dependence - the body adapts to the presence of the drug
and withdrawal symptoms occur if use is reduced abruptly.
Symptoms of withdrawal can include restlessness, muscle and bone pain, insomnia,
diarrhea, vomiting, cold flashes with goose bumps ("cold turkey"), and involuntary
leg movements.
Options for effectively treating addiction to prescription opioids are drawn
from experience and research on treating heroin addiction. Some examples follow.
Methadone, a synthetic opioid that blocks the effects of heroin and other
opioids, eliminates withdrawal symptoms, and relieves drug craving. It has
been used for over 30 years to successfully treat people addicted to opioids.
Other medications include LAAM (levo-alpha-acetyl-methadol), an alternative
to methadone that blocks the effects of opioids for up to 72 hours. Naltrexone
is a long acting opioid blocker often used with highly motivated individuals
in treatment programs promoting complete abstinence, and also to prevent relapse.
Buprenorphine, another synthetic opioid, will soon be available. Also, naloxone
counteracts the effects of opioids and is used to treat overdoses.
CNS Depressants
CNS depressants slow down normal brain function. In higher doses, some CNS depressants
can become general anesthetics.
CNS depressants can be divided into two groups, based on their chemistry and
pharmacology:
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. Benzodiazepines that have a more
sedating effect, such as triazolam (Halcion) and estazolam (ProSom) can be
prescriped for short-term treatment of sleep disorders.
There are many CNS depressants, and most act on the brain similarly - they
affect the neurotransmitter gamma-aminobutyric acid (GABA). Neurotransmitters
are brain chemicals that facilitate communication between brain cells. GABA
works by decreasing brain activity. Although different classes of CNS depressants
work in unique ways, ultimately it is their ability to increase GABA activity
that produces a drowsy or calming effect. Despite these beneficial effects
for people suffering from anxiety or sleeping disorders, barbiturates and benzodiazepines
can be addictive and should be used only as prescribed.
CNS depressants should not be combined with any medication or substance that
causes sleepiness, including prescription pain medicines, certain over-the-counter
cold and allergy medications, or alcohol. The effects of the drugs can combine
to slow breathing, or slow both the heart and respiration, which can be fatal.
Discontinuing prolonged use of high doses of CNS depressants can lead to withdrawal.
Because they work by slowing the brain's activity, a potential consequence
of abuse is that when one stops taking a CNS depressant the brain's activity
can rebound to the point that seizures can occur. Someone thinking about ending
their use of a CNS depressant, or who has stopped and is suffering withdrawal,
should speak with a physician and seek medical treatment.
In addition to medical supervision, counseling in an in-patient or out-patient
setting can help people who are overcoming addiction to CNS depressants. For
example, cognitive-behavioral therapy has been used successfully to help individuals
in treatment for abuse of benzodiazepines. This type of therapy focuses on
modifying a patient's thinking, expectations, and behaviors while simultaneously
increasing their skills for coping with various life stressors.
Often the abuse of CNS depressants 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 needs to address the multiple addictions.
Stimulants
Stimulants are a class of drugs that enhance brain activity - they cause an increase
in alertness, attention, and energy that is accompanied by increases in blood
pressure, heart rate, and respiration.
Historically, stimulants were used to treat asthma and other respiratory problems,
obesity, neurological disorders, and a variety of other ailments. As their
potential for abuse and addiction became apparent, the use of stimulants began
to wane. Now, stimulants are prescribed for treating only a few health conditions,
including narcolepsy, attention-deficit hyperactivity disorder (ADHD), and
depression that has not responded to other treatments. Stimulants may also
be used for short-term treatment of obesity, and for patients with asthma.
Stimulants such as dextroamphetamine (Dexedrine) and methylphenidate (Ritalin)
have chemical structures that are similar to key brain neurotransmitters called
monoamines, which include norepinephrine and dopamine. Stimulants increase
the levels of these chemicals in the brain and body. This, in turn, increases
blood pressure and heart rate, constricts blood vessels, increases blood glucose,
and opens up the pathways of the respiratory system. In addition, the increase
in dopamine is associated with a sense of euphoria that can accompany the use
of these drugs.
Research indicates that people with ADHD do not become addicted to stimulant
medications, such as Ritalin, when taken in the form prescribed and at treatment
dosages.5 However, when misused, stimulants can be addictive.
The consequences of stimulant abuse can be extremely dangerous. Taking high
doses of a stimulant can result in an irregular heartbeat, dangerously high
body temperatures, and/or the potential for cardiovascular failure or lethal
seizures. Taking high doses of some stimulants repeatedly over a short period
of time can lead to hostility or feelings of paranoia in some individuals.
Stimulants should not be mixed with antidepressants or over-the-counter cold
medicines containing decongestants. Anti-depressants may enhance the effects
of a stimulant, and stimulants in combination with decongestants may cause
blood pressure to become dangerously high or lead to irregular heart rhythms.
Treatment of addiction to prescription stimulants, such as methylphenidate
and amphetamines, is based on behavioral therapies proven effective for treating
cocaine or methamphetamine addiction. At this time, there are no proven medications
for the treatment of stimulant addiction. Antidepressants, however, may be
used to manage the symptoms of depression that can accompany early abstinence
from stimulants.
Depending on the patient's situation, the first step in treating prescription
stimulant addiction may be to slowly decrease the drug's dose and attempting
to treat withdrawal symptoms. This process of detoxification could then be
followed with one of many behavioral therapies. Contingency management, for
example, uses a system that enables patients to earn vouchers for drug-free
urine tests; the vouchers can be exchanged for items that promote healthy living.
Cognitive-behavioral therapies are proving beneficial, and recovery support
groups may also be effective in conjunction with a behavioral therapy.
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The number of drug-abuse related visits to hospital emergency rooms (ERs) involving benzodiazepine medications exceeded 100,000 in 2002, a 41 percent increase since 1995, according to the Substance Abuse and Mental Health Administration's Drug Abuse Warning Network (DAWN). Nearly half of the emergency department (ED) visits involving benzodiazapines -- which include such psychotherapeutic sedatives as Valium, Xanax, Klonopin, and Ativan -- were connected with suicidal ideation, gestures or attempts.
Today, some of the most pressing substance-abuse concerns in the U.S. military involve prescription and over-the-counter (OTC) medications. Some health officials contend that too many troops are being authorized to take antidepressants and sleeping pills, while others are worried about the illicit sharing of prescription drugs and the overuse of OTC meds by men and women in uniform.
Some of the Basic Facts
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