> Table of Contents > Drug Abuse, Prescription
Drug Abuse, Prescription
Carolyn Cammarano, PharmD, RPh
Matthew A. Silva, PharmD, RPh, BCPS
Jeffrey Baxter, MD
image BASICS
DESCRIPTION
  • Prescription drug abuse behaviors exist on a continuum and may include the following:
    • 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), 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
  • In 2011, 56% of the 2.5 million drug-related ED visits attributed to drug misuse and abuse were due to pharmaceuticals (1.4 million) (1).
  • Prescription opioids are the second most commonly used class to initiate illicit drug use (1.9 million) (2).
Incidence
  • Predominant sex: males > females (2)
  • Predominant age: highest among adults 18 to 25 years, then adolescents and teens 12 to 17 years, followed by adults ≥26 years (2)
  • >20% of the 3.1 million persons who were first-time substance abusers in 2011 used prescription medications nonmedically (2).
  • The average age of persons with the first reported instance of nonmedical prescription drug use is 22.4 years (2).
Prevalence
  • The number of persons with nonmedical opioid dependence increased from 936,000 in 2002 to 1.4 million in 2011 (2).
  • Lifetime prevalence of prescription drug abuse is highest for opioids, benzodiazepines, and stimulants.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Prescription medications are now perceived by young adults to be more socially acceptable than other illicit drugs.
  • Pharmacokinetics, compound purity, government approval, and extensive media advertising, along with personal or family experiences with prescription medication, contribute to perceived advantages of prescription drug misuse over street drugs and other illicit substances.
Genetics
Variant alleles affecting the expression and function of opioid, dopamine, acetylcholine, serotonin, and GABA may explain susceptibility to all forms of prescription and nonprescription drug abuse behaviors.
RISK FACTORS
  • Sociodemographic, psychosocial, pain- and drug-related factors
  • Genetics and environment; family history
GENERAL PREVENTION
  • Educate and raise awareness about the dangers of misuse and abuse of prescription drugs. Focus on individuals, then families, then communities.
  • Educate and reinforce safe practices in evaluating patients and prescribing medications. Use office-based peer-to-peer education and follow-up with pharmacies when abuse behaviors are suspected.
  • Develop or adopt a standard practice agreement for prescribing and monitoring controlled substances with abuse potential (3,4,5)
  • Prescription monitoring programs (PMP) show fair evidence in reducing doctor shopping but have not reliably shown reductions in ED visits for drug overdose and prescription drug abuse-related deaths (3).
  • Avoid prescribing benzodiazepines and hypnotics to elderly (6).
  • Avoid using benzodiazepines >2 to 4 weeks.
  • Minimize controlled substances when patients have a personal or family history of substance abuse or psychiatric disorders (7).
  • Limit or avoid prescribing controlled medications on first visit and until a relationship can be established.
  • Take a thorough history, contact family members and past prescribers, and perform observed urine drug screens. Stop prescribing prescription analgesics for chronic pain when they are not working, if a patient is unable to take medications as prescribed or if there are problems related to opioid and nonopioid analgesics. Identify and treat underlying substance abuse problems, and involve behavioral health providers when possible.
  • Effective intranasal naloxone education and distribution to opioid users, family, friends, and social service agency staff contacts in communities with >1 enrollment/100,000 people and 5 or more opioid-related overdose fatalities reduce new opioid overdose deaths (8)[B].
  • Consider providing spouse/family members and/or caretakers access to and education on intranasal naloxone use in the event of a suspected opioid overdose (8)[B].
COMMONLY ASSOCIATED CONDITIONS
  • Benzodiazepines: withdrawal syndromes/delirium, psychosis, anxiety, sleep driving, blackout states, cognitive impairment, impaired driving while awake; increased fall risk and mortality in elderly patients
  • Amphetamines: hypertension, tachyarrhythmias, myocardial ischemia, seizures, hypothermia, psychosis, hallucinations, paranoia, anxiety
  • Opioids: respiratory depression and death with overdose, low testosterone, and sexual dysfunction with chronic abuse. Methadone is associated with QT prolongation, which increases risk for torsades de pointes.
image DIAGNOSIS
Screening: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”; primary care setting sensitivity of 100% and specificity of ˜75% (9)[C]
HISTORY
Consider aberrant behaviors found when taking a history. Patient may ask for dose escalations and early refills (“spilled the bottle …”, “pharmacist shorted me …”, etc.), has strong preference for one drug, targets appointments at end of day and after hours, and shows hostile/threatening behavior or overly flattering behavior.
DIAGNOSTIC TESTS & INTERPRETATION
  • Urine drug screens are recommended to identify patients who are noncompliant or abusing prescription drugs despite limited evidence of reliability and accuracy (3,10)[C].
  • Urine drug screen (UDS): Order an expanded panel to detect commonly used opioids (ask specifically for semisynthetics [hydrocodone, hydromorphone, oxycodone] and synthetics [methadone, fentanyl, propoxyphene, meperidine]) along with tramadol and buprenorphine.
  • Clonazepam and lorazepam rarely show up as benzodiazepines in routine UDS and should be ordered specifically.
Initial Tests (lab, imaging)
  • Interpretation: Results are positive if drugs that are not prescribed are present; positive in presence of illicit drugs (marijuana, cocaine); suspect diversion if negative for prescribed drug.
  • Be suspicious if patient refuses test.
  • OxyContin will only be positive for oxycodone.
  • Hydrocodone will be positive for hydrocodone and hydromorphone.
  • Codeine will be positive for codeine plus morphine.
  • Heroin will be positive for morphine.
  • Thus, if UDS is positive for morphine, it could mean that a patient took morphine, codeine, heroin, or hydrocodone.
Diagnostic Procedures/Other
Cut down, Anger at being questioned about use, Guilt about prior use, Eye-opener use early in day (CAGE) or Alcohol use disorders identification test (AUDIT) to assess current alcohol use. Drug abuse screening test (DAST) helps determine patient's involvement with drugs over the past year. Details: http://counsellingresource.com/lib/quizzes/drug-testing/drug-abuse/. Screener and Opioid Assessment for Patients with Pain (SOAPP); Opioid Risk Tool (ORT); and Diagnosis, Intractability, Risk, Efficacy (DIRE) are tools used to assess risk of opioid misuse (11)[C].
Test Interpretation
See “History.”
image TREATMENT
  • Whenever there is evidence of prescription opioid abuse, the controlled substance should be tapered to begin discontinuing drug therapy (3)[C].
  • Benzodiazepines cannot be stopped abruptly for risk of seizures and death. A Cochrane Review supported a gradual benzodiazepine withdrawal over 10 weeks (12)[A].
  • Amphetamines can be stopped abruptly without risk of severe withdrawal or death.
  • The general approach to treatment includes inpatient, residential, or outpatient detoxification as required; counseling and intensive counseling as needed; and ongoing medication-assisted treatment.
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GENERAL MEASURES
Alcoholics Anonymous/Narcotics Anonymous is helpful, as are Al-Anon/Alateen for family members. Nonjudgmental interactions and cognitive-behavioral therapy focused on motivational interviewing, goal-setting, and brief interventions help manage anxiety, insomnia, and denial and improve willingness to change.
MEDICATION
  • Opioid detoxification programs use clonidine (13)[A], buprenorphine (13,14)[A], or methadone (15)[A] under the direction of an addiction specialist. Buprenorphine is as effective as methadone but safer (16)[A]. Both buprenorphine and methadone are more effective than clonidine for detoxification.
  • Buprenorphine and methadone have been found to be similarly effective when used in long-term opioid maintenance therapy. Long-term therapy supervised by an addiction specialist is preferable to short-term detoxification.
  • Subutex (buprenorphine) lacks naloxone and is prone to diversion and abuse because patients can crush, snort, or shoot to get high. Suboxone (buprenorphine and naloxone) discourages abuse and diversion because naloxone displaces buprenorphine binding to opioid receptors. Newer Suboxone sublingual film is preferred as the dosage form is difficult to adulterate.
  • There is neither support for using or converting to long half-life benzodiazepines before beginning a slow, gradual 10-week benzodiazepine taper, although diazepam is often preferred, nor are there any benefits shown using propranolol, buspirone, progesterone, hydroxyzine, or dothiepin to manage withdrawal symptoms. Carbamazepine may be useful in patients who were dependent on ≥20 mg diazepam equivalents daily, and antidepressants may be helpful for depression and anxiety linked to benzodiazepine withdrawal.
  • Atomoxetine and bupropion SR can also be helpful in managing ADHD symptoms in select patients.
ISSUES FOR REFERRAL
Refer to chemical dependency groups/addiction specialists/pain management and psychiatry/psychology when patients have polysubstance abuse and to treat underlying mood and anxiety disorders, PTSD, and ADHD.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Acupuncture, yoga, meditation, or martial arts may aid in anxiety management and stress reduction.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Indications for inpatient detoxification are concomitant alcohol and benzodiazepine dependence (increased risk of seizures), mental confusion/delirium, history of seizures, psychosis, active suicidal ideation, serious comorbid medical issues, and absence of social support.
image ONGOING CARE
PATIENT EDUCATION
  • Advise patients receiving controlled medication to keep them hidden and inaccessible to others. Inform patients that giving their medication to others may result in legal charges. Warn about potential addiction when starting controlled substances and about withdrawal symptoms when a medication is stopped abruptly. Warn of the dangers of respiratory depression and death when opioids are mixed with benzodiazepines. Advise patients on controlled substances; avoid all alcohol and any illicit drugs.
  • Tell patient to come to you if he or she begins to need medication in increasing amounts, uses it to feel high or overcome stress, or spends a lot of time craving it and thinking about the next dose. Emphasize that you will create a mutual plan to stop the medication and try something new. Inform spouse/family members when family dynamics are an important behavioral component.
REFERENCES
1. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD: Center for Behavioral Health Statistics and Quality, 2013.
2. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. HHS Publication No. (SMA) 12-4713.
3. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part I-evidence assessment. Pain Physician. 2012;15(3 Suppl):S1-S65.
4. Hariharan J, Lamb GC, Neuner JM. Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. J Gen Intern Med. 2007;22(4):485-490.
5. Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152(11):712-720.
6. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.
7. Miotto K, Kaufman A, Kong A, et al. Managing co-occurring substance use and pain disorders. Psychiatr Clin North Am. 2012;35(2):393-409.
8. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174.
9. Smith PC, Schmidt SM, Allensworth-Davies D, et al. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155-1160.
10. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2-guidance. Pain Physician. 2012;15(3 Suppl):S67-S116.
11. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2): 113-130.
12. Denis C, Fatséas M, Lavie E, et al. Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings. Cochrane Database Syst Rev. 2006;(3):CD005194.
13. Gowing L, Ali R, White JM. Buprenorphine for the management of opioid withdrawal. Cochrane Database Syst Rev. 2009;(3):CD002025.
14. Maremmani I, Gerra G. Buprenorphine-based regimens and methadone for the medical management of opioid dependence: selecting the appropriate drug for treatment. Am J Addict. 2010;19(6):557-568.
15. Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;(3):CD002209.
16. Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.
Codes
&NA;
ICD10
  • F19.10 Other psychoactive substance abuse, uncomplicated
  • F11.10 Opioid abuse, uncomplicated
  • F15.10 Other stimulant abuse, uncomplicated
Clinical Pearls
&NA;
  • Education and prescription monitoring programs are important for preventing prescription drug abuse.
  • Use a standardized office practice agreement when prescribing controlled substances.
  • Screening: “How many times in the past year have you used an illegal drug or prescription medication for nonmedical reasons?”
  • Avoid prescribing controlled substances and nonbenzodiazepine hypnotics to patients at risk for substance abuse or with an Axis 1 or Axis 2 diagnosis.
  • Discontinue prescription opioid analgesics if pain or functionality does not improve and if there's evidence of prescription or illicit drug abuse (i.e., positive UDS, driving while intoxicated [DWI], accidental or intentional overdose, early refills).
  • Limit benzodiazepine use to 2 to 4 weeks.
  • Conduct frequent, observed Urine screen.
  • Addiction is a potentially fatal disease.