Ed complains to his brother Joe that stress has been keeping him awake. Joe sympathizes with his brother, offering him some sleep sedatives. ?I had the same problem, and my doctor prescribed these for me. They really work. Let me give you some.?
Joe and Ed unknowingly are engaging in a growing epidemic of substance abuse, albeit one that appears to be socially accepted?-prescription drug abuse (PDA).
PDA now surpasses illegal substance abuse: in 2003, the 15 million Americans abusing prescription drugs far outnumbered the 6 million abusing illicit street drugs.1 PDA is most common among young adults (aged 18-25),2 although the highest growth rate is seen in adolescents, increasing from 700,000 in 1992 to 3.2 million in 2003.1 Adolescent PDA can escalate rapidly to other abuses: young PDA abusers are twice as likely to abuse alcohol, 5 times more likely to use marijuana, and 15 times more likely to use Ectasy1 (see Table 13-6).
Historically, PDA was defined as prescription drug use for nonmedical purposes, with lifetime prevalence estimated at 20%.7 Today, PDA emerges in a different form?-practicing medicine without a license. A sizable number of people, especially those in their 20s and 30s, are skeptical of physicians, especially psychiatrists, and conduct their own research on conditions and treatments and act accordingly.8 Their goal is simply to feel better, either psychologically or physically, and not to get high or support an addiction. Those participating in PDA view self-medication as efficient and appropriate, consistent with self-empowerment.
One has to look only at Internet chatter to realize the level of sophistication underlying PDA; people discuss dosing, side effects, and treatment alternatives for a myriad of conditions. Some freely offer their physicians' recommendations and/or their own experience with the agent. Engaging in this behavior are especially those with psychiatric conditions, including anxiety and depression,8 and the medications discussed are not benign (eg, risperdone).8
Direct consumer advertising is partly to blame, often creating the impression that medication is the solution for life?s daily problems. Because agents are FDA-approved, people mistakenly believe that they are safe to use. The proliferation of illegal Internet pharmacies eases access; one survey found that 84% of online pharmacies did not require a prescription for selling controlled agents.6 Other factors fueling prescription abuse include lack of education among professionals, overprescribing, doctor shopping, ineffective prescription-monitoring programs, policies that are more reactive than proactive in nature, and society?s growing acceptance of pill sharing.4
Opioids, central nervous system depressants, and stimulants top the list of abused agents. Anabolic steroids, while not topping the list, are pursued by athletes and body builders. One study, for example, found that 2.6% of high school seniors used anabolic steroids in 20069 (see Table 210).
Several programs exist targeting prescription abuse. The Drug Enforcement Agency (DEA) is actively involved in prescription- monitoring programs. It has launched a toll-free international hotline (877-RxAbuse) for people to anonymously report illegal drug diversion, including suspicious Internet pharmacies.6
The National All Schedules Prescription Electronic Reporting Act of 2005 provides for the creation of a controlled substance monitoring program in each state. Some states now allow physician and pharmacist access to online utilization history, and data suggest reduced prescriptions per capita for pain relievers and stimulants.4 Although this monitoring is hailed by some as reducing prescription abuse via doctor shopping, some argue that the data also may indicate that clinicians might be reluctant to prescribe these agents even when they are appropriate, fearing public scrutiny.
The Synthetic Drug Control Strategy targets diversion at the individual level, including doctor shopping, prescription fraud, using illegal online pharmacies, and distributing or selling pills to others. This program seeks to reduce PDA by 15% from 2005 to 2008.4
Most national programs primarily support law-enforcement efforts, not those of health care professionals. Experts agree that increased education is needed at all levels of health care.4 Most physicians, for example, assess patients for alcohol abuse, but more than 40% fail to query patients about PDA.11 Consider the following statistics with regard to pharmacists:
Despite hectic workloads, screening of prescriptions and patients by pharmacists is crucial. A high risk for potential abuse exists even when patients legitimately receive opioids for pain management: their lifetime estimated prevalence for substance abuse disorders ranges from 36% to 56%.4
Counseling sessions should provide clear information and should emphasize that medications are prescribed based on individual needs and that patients must not share medications with others, even if those persons were previously prescribed the same agent and dose. Pharmacists must stay vigilant for suspicious or altered prescriptions?-a problem that diminishes with electronic prescribing. Pharmacists should review online utilization data, if available, for doctor or pharmacy shopping.
When pharmacists detect PDA, they should report it according to local regulations. They should warn patients not to stop an agent abruptly, emphasizing that medical guidance and supervision are required. If PDA has progressed to maintenance addiction to opioids, barbiturates, or benzodiazepines, abrupt withdrawal can be life-threatening. Addicted patients require supervised detoxification, followed by behavioral or cognitive?behavioral therapy.
Curbing prescription abuse requires multifaceted interventions. Increased vigilance at the pharmacy counter is a critical component of curbing PDA. Toward that objective, pharmacists should include prescription diversion and abuse in their annual continuing education selections.
1. Kirn T. Prescription medication abuse by teens soars. Fam Pract News. 2006;36:26.
2. Office of National Drug Control Policy, Executive Office of the President. Teens and prescription drugs: an analysis of recent trends on the emerging drug threat. February 2007. Available at: www.mediacampaign.org/teens/brochure.pdf.
3. National Institute on Drug Abuse. Trends in prescription drug abuse. Available at: www.drugabuse.gov/Researchreports/Prescription/prescription5.html. Accessed June 20, 2007.
4. Manchikanti L. National drug control policy and prescription drug abuse: facts and fallacies. Pain Physician. 2007;10:399-424.
5. Dunham W. Prescription drugs a problem on U.S. campuses. Reuters Health Information. March 2007. Available at: www.medscape.com/viewarticle/553688. Accessed June 6, 2007.
6. Office of National Drug Control Policy. Prescription drugs. Available at: www.whitehousedrugpolicy.gov/drugfact/prescrptn_drgs/index.html. Accessed June 20, 2007.
7. Medline Plus. Prescription drug abuse. Available at: www.nlm.nih.gov/medlineplus/prescriptiondrugabuse.html. Accessed June 20, 2007.
8. Harmon A. Young, assured, and playing pharmacist to friends. New York Times. November 16, 2005.
9. National Institute on Drug Abuse. NIDA InfoFacts: Steroids (Anabolic-Androgenic). Available at: www.drugabuse.gov/Infofacts/Steroids.html. Accessed July 17, 2007
10. National Institute on Drug Abuse. Selected prescription drugs with potential for abuse. Available at: www.drugabuse.gov/PDF/PrescriptionDrugs.pdf. Accessed July 15, 2007.
11. McCarthy M. Prescription drug abuse up sharply in the USA. Lancet. 2007;369:1505-1506.