Many clinicians equate drug abuse with cocaine, marijuana or heroin. Yet, a national survey reveals that some 3.9 million people in the United States currently use prescription-type psychotherapeutic drugs (most often pain relievers, tranquilizers or stimulants) for nonmedical reasons, far surpassing the 2.1 million people who use heroin, cocaine and/or crack cocaine (Substance Abuse and Mental Health Services Administration [SAMHSA], 2000).
Most addicts who prefer prescription drugs come to them through medical doors, warned Sheila Blume, M.D., addiction psychiatrist and former New York State Commissioner on Alcohol(Drug information on alcohol)ism.
"Now, they may get it from more than one doctor, or they may supplement it by street drugs, but the ones that I have treated…started by having these drugs prescribed for some reason and then they began to abuse them," she said in an interview with Psychiatric Times.
Health care providers need to be reminded that the medications they prescribe may have potential for abuse, she said, "and the more they hear it, the better."
The prevalence and incidence of illicit drug and alcohol use in the U.S. civilian population aged 12 and older is reported annually by SAMHSA in the National Household Survey on Drug Abuse (NHSDA). The 1999 results showed that 9.3 million individuals abused psychotherapeutics in the last year. The incidence of nonmedical prescription pain-reliever use rose significantly from the 1980s statistics of fewer than 500,000 initiates per year to 1.6 million initiates in 1998.
Looking at demographic factors, more youths aged 12 to 17 years (2.9%) and young adults aged 18 to 25 years (3.7%) abused psychotherapeutics than older adults (1.3%). More than half of current users were 26 years or older, and the rate for people aged 35 to 44 years was above 3%. Although generally more males than females abuse drugs, the rates are nearly equal with regard to psychotherapeutics (1.9% male; 1.7% female), the report authors said.
The Community Epidemiology Work Group (CEWG) survey, sponsored by the National Institute on Drug Abuse (NIDA), publishes reports twice a year, said Nicholas Kozel, project officer with NIDA's Division of Epidemiology, Services and Prevention Research.
"This program was started 25 years ago to give us a running commentary on the major trends and emerging problems in fairly large metropolitan areas around the country. Originally it was geared to heroin…but shortly after that we found there was so much diversity from city to city that we really opened the focus to anything that might be appearing in the area of drug use and abuse that could help us maintain some sort of an ongoing surveillance," Kozel explained to PT.
The CEWG network of researchers from 21 major U.S. metropolitan areas provides timely information about what is happening at the local and state levels. It collects information from emergency room data, treatment facilities, death records, police data, school records, local surveys, drug-testing programs in prisons and workplace programs.
"We thought that this was one way of enhancing our knowledge, in a national way," Kozel said. "It also picks up data and populations that are often missed in surveys."
The network has helped identify early misuse of some prescription and over-the-counter drugs that were later reclassified as Schedule I by the U.S. Drug Enforcement Administration (DEA) or banned from importation, Kozel added. These include 3,4-methylenedioxymethamphetamine (MDMA) or ecstasy, flunitrazepam(Drug information on flunitrazepam) (Rohypnol), and g-hydroxybutyrate, known as GHB.
MDMA, which has both stimulant and mild hallucinogenic effects, was moved to Schedule I status (no currently accepted medical use and high potential for abuse) in 1985 by the DEA. The CEWG reports that MDMA use is spreading beyond the all-night "raves" or dance parties to high schools, colleges and other social settings frequented by adolescents and young adults. Additionally, it is being combined with other drugs, including diazepam(Drug information on diazepam) (Valium), alprazolam(Drug information on alprazolam) (Xanax) and sildenafil(Drug information on sildenafil) citrate (Viagra) (CEWG, 2000b).
Because it was legal to buy the benzodiazepine flunitrazepam in Mexico for personal use, that country became a major source of Rohypnol coming into the United States, Kozel said. After it got its reputation as a date rape drug (it produces sedative-hypnotic effects including muscle relaxation and amnesia), flunitrazepam was banned from importation. According to the CEWG, a drug very similar to flunitrazepam, clonazepam(Drug information on clonazepam) (Klonopin), is now being sold as "roofies" in Miami, Minnesota and Texas.
In March 2000, the central nervous system depressant GHB was placed in Schedule I of the Controlled Substances Act (CEWG, 2000a). Gamma butyrolactone (GBL), the precursor chemical for the manufacture of GHB, was marketed as a health supplement. After the report of more than 122 serious illnesses and three deaths, in 1999 the U.S. Food and Drug Administration issued a warning stating that it was illegal to manufacture and distribute GHB, GBL or 1,4 butanediol-containing products for human consumption.
GHB and its precursors are routinely used at rave parties and around college campuses. GBL was linked to 18 hospitalizations and two overdose deaths among Princeton University students. The Massachusetts Poison Control Center reported that GHB/GBL accounted for 32% of illicit drug-related calls (CEWG, 2000a).
Frequently Abused Drugs
Opiate Abuse. According to Kozel, "Methadone [Dolophine] has caused problems for a number of years." In San Francisco, for example, selling of "take-home doses" of methadone(Drug information on methadone) has been reported (CEWG, 2000b).
Another opiate mentioned fairly consistently over the years by the CEWG is hydrocodone(Drug information on hydrocodone), Kozel said. Hydrocodone, one of the top five U.S. prescription drugs dispensed in 1999 (RxList, 2000), is a semisynthetic narcotic analgesic and a cough suppressant. It is frequently combined with acetaminophen as an analgesic as Vicodin or Lortab. Hydrocodone with acetaminophen is a Schedule CIII drug.
According to the Drug Abuse Warning Network (DAWN), hydrocodone-related emergency-department episodes increased significantly (p<0.05) in Chicago, Detroit, Philadelphia, Phoenix and San Diego between the first half of 1998 and the first half of 1999.
Codeine, hydromorphone(Drug information on hydromorphone) (Dialaudid), propoxyphene (Darvon and Darvocet) and oxycodone(Drug information on oxycodone) (Percocet and Percodan) also appear frequently in DAWN and CEWG reports (CEWG, 2000b). The Maryland Drug Early Warning System (DEWS), a realtime substance-abuse monitoring program, has identified oxycodone as a leading emerging drug (CEWG, 2000b).
Benzodiazepines. Diazepam, clonazepam, alprazolam and other benzodiazepines are the most commonly abused pharmaceutical depressants in the CEWG areas. Clonazepam and alprazolam use seem to be increasing, and, according to focus groups in Philadelphia, alprazolam has overtaken diazepam as the most popular pill on the street (CEWG, 2000b).
Benzodiazepines are frequently combined with other drugs, but the combinations vary with geographical location. For example, in Texas, alprazolam is used to heighten and prolong the effects of heroin. In Atlanta, diazepam and alprazolam are often used with or following methamphetamine, MDMA or other stimulants (CEWG, 2000b).
Stimulants. A Schedule II stimulant, methamphetamine has long been a problem drug in San Diego. Now its use has become a problem in other sections of the west, southwest and Hawaii (NIDA, 2000). In 1999, methamphetamine accounted for 32% of treatment admissions (public programs) in San Diego. Hispanic admissions for methamphetamine abuse are increasing. In Honolulu, where abuse of crystal methamphetamine (ice) is high, treatment admissions for primary methamphetamine abuse increased 11% from the first half of 1999 (CEWG, 2000a).
Ritalin (methylphenidate) and Adderall (a combination of four amphetamines) also appear in the CEWG reports:
In 1999, 165 methylphenidate(Drug information on methylphenidate)-related poison calls were made in Detroit; and 419 were reported in Texas, with 114 of those involving intentional misuse or abuse…On Chicago's South Side, where it costs $3 to $4 per pill, some African Americans inject methylphenidate ('west coast'); some mix it with heroin as a speedball, or in combination with both cocaine and heroin for a more potent effect.
Adderall figures prominently in poison calls in Boston and Texas, according to the CEWG. In 1999, 278 confirmed exposures were reported in Texas, with 149 involving misuse or abuse.
Ephedrine(Drug information on ephedrine) and pseudoephedrine(Drug information on pseudoephedrine) are also causing problems. In Seattle, for example, youth workers report increases in the number of youth who are "megadosing" on pseudoephedrine cold tablets (CEWG, 2000b). According to 1999 poison data in Texas, of the 351 ephedrine calls reported, 111 involved misuse or abuse. More than half (55%) of the callers were women, and the average age of the callers was 25 years.
Actions Physicians Can Take
While more is becoming known about the abuse of prescription drugs, prescribers must still develop strategies to curb abuse.
What people get hooked on depends somewhat on the drugs most commonly used in a specific geographic area for pain, insomnia, premenstrual tension and the like, Blume said. Blume advised clinicians to take a good history and to get to know their patients.
"That seems so obvious, but when you have someone who has a prescription drug problem, they will go from psychiatrist to psychiatrist, and from primary care physician to primary care physician, with some story, such as 'I am visiting the area and I ran out.' If you don't take a good history, you will wind up supplying people with drugs that…are harming them," she said.
"It is really important to have a wide view of that person's life," according to Blume. "For example, is there a chronic pain problem? Are they getting other kinds of medications from a primary care physician? It is always good medical practice to have a consent from your patient and be in touch with their primary care physician, especially again when drugs are in question."
If physicians become suspicious that something might be wrong, Blume suggests holding a family conference.
Impaired health care professionals, such as physicians and pharmacists, are also at risk for abusing prescription drugs, especially since they have ready access to medications, Blume added.
Asked about available education on this topic, Blume said, "Until fairly recently-and it is nowhere perfect yet-there was very spotty education about prescription drug dependence, either in medical school or postgraduate work." Impaired health care professionals, aware of the problem, have advocated for increased discussion of prescription drug dependence in medical school curricula.
The federal government and some states have been very diligent about policing the use of drugs, Blume said, adding that in New York, for example, the health department investigates physicians if they are prescribing amounts of opiates unusual for their type of practice.
Some physician groups have issued policy statements and joined in nationwide awareness campaigns. In April 2000, the board of directors of the American Society of Addiction Medicine (ASAM) issued a policy statement strongly supporting measures to counteract prescription drug diversion that do not violate the confidentiality of the physician-patient relationship. Those measures include educating all health care professionals who are licensed to prescribe, dispense or administer prescription drugs; analyzing prescribing patterns of psychoactive drugs by individual practitioners; and improved monitoring of controlled drugs by federal and state governments. ASAM also maintains an Internet message board where health care professionals can ask their colleagues for help on such issues as GHB and schizophrenia and intravenous drug addiction.
The American Academy of Child and Adolescent Psychiatry has joined with NIDA and other national organizations to alert young adults, educators and others about the dangers of such club drugs as MDMA and GHB. Other resources include the Treatment Improvement Protocol (TIP) Series 26 (Substance Abuse Among Older Adults) and Series 33 (Treatment for Stimulant Use Disorders), both available from SAMHSA.