Download Misuse of Prescription Drugs

NationalInstituteonDrugAbuse(NIDA)
MisuseofPrescriptionDrugs
LastUpdatedAugust2016
https://www.drugabuse.gov
1
TableofContents
MisuseofPrescriptionDrugs
Summary
Whatisthescopeofprescriptiondrugmisuse?
Howmanypeoplesufferadversehealthconsequencesfrommisuseofprescription
drugs?
Isitsafetouseprescriptiondrugsincombinationwithothermedications?
Whichclassesofprescriptiondrugsarecommonlymisused?
Areprescriptiondrugssafetotakewhenpregnant?
Howcanprescriptiondrugmisusebeprevented?
Howcanprescriptiondrugaddictionbetreated?
WherecanIgetfurtherinformationaboutprescriptiondrugmisuse?
References
2
Summary
©iStock.com/ognianm
Misuseofprescriptiondrugsmeanstakingamedicationinamannerordose
otherthanprescribed;takingsomeoneelse’sprescription,eveniffora
legitimatemedicalcomplaintsuchaspain;ortakingamedicationtofeel
euphoria(i.e.,togethigh).*Thetermnonmedicaluseofprescriptiondrugsalso
referstothesecategoriesofmisuse.Thethreeclassesofmedicationmost
commonlymisusedare 1:
opioids—usuallyprescribedtotreatpain
centralnervoussystem[CNS]depressants(thiscategoryincludes
tranquilizers,sedatives,andhypnotics)—usedtotreatanxietyandsleep
disorders
stimulants—mostoftenprescribedtotreatattention-deficithyperactivity
disorder(ADHD)
Prescriptiondrugmisusecanhaveseriousmedicalconsequences.Increasesin
prescriptiondrugmisuse 2overthelast15yearsarereflectedinincreased
emergencyroomvisits,overdosedeathsassociatedwithprescriptiondrugs3–6,
andtreatmentadmissionsforprescriptiondrugusedisorders,themostsevere
formofwhichisaddiction.Amongthosewhoreportedpast-yearnonmedical
useofaprescriptiondrug,nearly12percentmetcriteriaforprescriptiondrug
usedisorder.1Unintentionaloverdosedeathsinvolvingopioidpainrelievers
3
havemorethanquadrupledsince1999andhaveoutnumberedthoseinvolving
heroinandcocainesince2002.7
*Takingprescriptiondrugstogethighissometimescalled"prescriptiondrug
abuse."
4
Whatisthescopeofprescription
drugmisuse?
Misuseofprescriptionopioids,centralnervoussystem(CNS)depressants,and
stimulantsisaseriouspublichealthproblemintheUnitedStates.Although
mostpeopletakeprescriptionmedicationsresponsibly,anestimated54million
people(morethan20percentofthoseaged12andolder)haveusedsuch
medicationsfornonmedicalreasonsatleastonceintheirlifetime.1Accordingto
resultsfromthe2014NationalSurveyonDrugUseandHealth,anestimated
2.1millionAmericansusedprescriptiondrugsnonmedicallyforthefirsttime
withinthepastyear,whichaveragestoapproximately5,750initiatesperday.
Fifty-fourpercentwerefemalesandabout30percentwereadolescents.1
Thereasonsforthehighprevalenceofprescriptiondrugmisusevarybyage,
gender,andotherfactors,butlikelyincludeeaseofaccess.8Thenumberof
prescriptionsforsomeofthesemedicationshasincreaseddramaticallysince
theearly1990s.9Moreover,misinformationabouttheaddictivepropertiesof
prescriptionopioidsandtheperceptionthatprescriptiondrugsarelessharmful
thanillicitdrugsareotherpossiblecontributorstotheproblem.10,11
AlthoughmisuseofprescriptiondrugsaffectsmanyAmericans,certain
populationssuchasyouth,olderadults,andwomenmaybeatparticularrisk.12–
14Inaddition,whilemorementhanwomencurrentlymisuseprescriptiondrugs,
theratesofmisuseandoverdoseamongwomenareincreasingfasterthan
amongmen.
AdolescentsandYoungAdults
Nonmedicaluseofprescriptiondrugsishighestamongyoungadultsaged18
to25,with4.4percentreportingnonmedicaluseinthepastmonth.Among
youthaged12to17,2.6percentreportedpast-monthnonmedicaluseof
prescriptionmedications.1
Afteralcohol,marijuana,andtobacco,prescriptiondrugs(takennonmedically)
5
areamongthemostcommonlyuseddrugsby12thgraders.TheNIDA’s
MonitoringtheFuturesurveyofsubstanceuseandattitudesinteensfoundthat
about1in13highschoolseniorsreportedpast-yearnonmedicaluseofthe
prescriptionstimulantAdderall ® in2015,andnearly1in23reportedmisusing
theopioidpainrelieverVicodin ® .15
Althoughpast-yearnonmedicaluseofCNSdepressantsandopioidpain
relieversdecreasedamong12thgradersbetween2011and2015,thisisnot
thecaseforthenonmedicaluseofstimulants.NonmedicaluseofAdderall ®
increasedbetween2009and2013andhasremainedelevated.15Whenasked
howtheyobtainedprescriptionstimulantsfornonmedicaluse,morethanhalfof
theadolescentsandyoungadultssurveyedsaidtheyeitherboughtorreceived
thedrugsfromafriendorrelative.Interestingly,thenumberwhopurchased
thesedrugsthroughtheinternetwasnegligible.1
Youthwhomisuseprescriptionmedicationsarealsomorelikelytoreportuseof
otherdrugs.Multiplestudieshaverevealedassociationsbetweenprescription
drugmisuseandhigherratesofcigarettesmoking;heavyepisodicdrinking;
andmarijuana,cocaine,andotherillicitdruguseamongU.S.adolescents,
youngadults,andcollegestudents.16–19Inthecaseofprescriptionopioids,
medicaluseisalsoassociatedwithagreaterriskoffutureopioidmisuse,
particularlyinadolescentswhodisapproveofillegaldruguseandhavelittleto
nohistoryofdruguse.14
6
Source:McCabeetal.,2012
OlderAdults
Morethan80percentofolderpatients(aged57to85years)useatleastone
prescriptionmedicationonadailybasis,withmorethan50percenttakingmore
thanfivemedicationsorsupplementsdaily.12Thiscanpotentiallyleadtohealth
issuesresultingfromunintentionallyusingaprescriptionmedicationina
mannerotherthanhowitwasprescribed,orfromintentionalnonmedicaluse.
Thehighratesofmultiple(comorbid)chronicillnessesinolderpopulations,
age-relatedchangesindrugmetabolism,andthepotentialfordruginteractions
makesmedication(andothersubstance)misusemoredangerousinolder
peoplethaninyoungerpopulations.20Further,alargepercentageofolder
adultsalsouseover-the-countermedicinesanddietarysupplements,which(in
additiontoalcohol)couldcompoundanyadversehealthconsequences
resultingfromnonmedicaluseofprescriptiondrugs.12
Women
7
Overall,moremalesthanfemalesmisuseprescriptiondrugsinallagegroups
exceptadolescence(12to17years);adolescentgirlsexceedboysinthe
nonmedicaluseofallprescriptiondrugs,includingpainrelievers,sedatives,
andstimulants.Amongnonmedicalusersofprescriptiondrugs,females12to
17yearsoldarealsomorelikelytomeetsubstanceusedisordercriteriafor
prescriptiondrugs.21Additionally,whilemorementhanwomendieof
prescriptionopioidoverdose,therateofoverdoseisincreasingmoresharplyin
womenthaninmen.22
8
Howmanypeoplesufferadverse
healthconsequencesfrommisuseof
prescriptiondrugs?
TheDrugAbuseWarningNetwork(DAWN)monitoredemergencydepartment
(ED)visitsinselectedareasacrosstheNationthrough2011.DAWNreported
thatmorethan1.2millionEDvisitsin2011couldbeattributedtononmedical
useofprescriptiondrugs;thisrepresentsabouthalf(50.5percent)ofallED
visitsrelatedtodrugmisuse.Roughly488,000,or39.2percent,oftheseED
visitsinvolvedprescriptionopioidpainrelievers,aratenearlytriplethatof6
yearsprior.EDvisitsalsomorethanquadrupledforcentralnervoussystem
(CNS)stimulantstonearly41,000visitsin2011andincreased138percentfor
CNSdepressantsto422,000visits.Ofthelatter,85percentinvolved
benzodiazepines(e.g.,Xanax® ).EDvisitsrelatedtouseofzolpidem(Ambien ® ),
apopularprescribednon-benzodiazepinesleepaid,rosefromroughly13,000
in2004to30,000in2011.MorethanhalfofEDvisitsfornonmedicaluseof
prescriptiondrugsinvolvedmultipledrugs.4Analysisofhospitalinpatientdata
alsorevealeda72percentincreaseinhospitalizationsrelatedtoopioiduse
overthedecadefrom2002to2012,includingincreasesinseriousinfection
associatedwithintravenousdrugadministration.Inpatientcostsforthese
hospitalizationsquadrupledoverthesametimeperiod.23
9
Isitsafetouseprescriptiondrugsin
combinationwithothermedications?
©Shutterstock/DavidSmart
Thesafetyofusingprescriptiondrugsincombinationwithothersubstances
dependsonanumberoffactorsincludingthetypesofmedications,dosages,
othersubstanceuse(e.g.,alcohol),andindividualpatienthealthfactors.
Patientsshouldtalkwiththeirhealthcareprovideraboutwhethertheycan
safelyusetheirprescriptiondrugswithothersubstances,includingprescription
andover-the-counter(OTC)medicationsaswellasalcohol,tobacco,andillicit
drugs.Specifically,drugsthatslowdownbreathingrate,suchasopioids,
alcohol,antihistamines,prescriptioncentralnervoussystemdepressants
(includingbarbituratesandbenzodiazepines),orgeneralanesthetics,should
notbetakentogetherbecausethesecombinationsincreasetheriskoflifethreateningrespiratorydepression.5,24Stimulantsshouldalsonotbeusedwith
othermedicationsunlessrecommendedbyaphysician.Patientsshouldbe
awareofthedangersassociatedwithmixingstimulantsandOTCcold
medicinesthatcontaindecongestants,ascombiningthesesubstancesmay
causebloodpressuretobecomedangerouslyhighorleadtoirregularheart
rhythms.25
10
Whichclassesofprescriptiondrugs
arecommonlymisused?
Opioids
Whatareopioids?
Opioidsaremedicationsthatactonopioidreceptorsinboththespinalcord
andbraintoreducetheintensityofpain-signalperception.Theyalsoaffect
brainareasthatcontrolemotion,whichcanfurtherdiminishtheeffectsof
painfulstimuli.Theyhavebeenusedforcenturiestotreatpain,cough,and
diarrhea.26Themostcommonmodernuseofopioidsistotreatacutepain.
However,sincethe1990s,theyhavebeenincreasinglyusedtotreat
chronicpain,despitesparseevidencefortheireffectivenesswhenused
longterm.27Indeed,somepatientsexperienceaworseningoftheirpainor
increasedsensitivitytopainasaresultoftreatmentwithopioids,a
phenomenonknownashyperalgesia.28Importantly,inadditiontorelieving
pain,opioidsalsoactivaterewardregionsinthebraincausingthe
euphoria—orhigh—thatunderliesthepotentialformisuseandaddiction.
Chemically,thesemedicationsareverysimilartoheroin,whichwas
originallysynthesizedfrommorphineasapharmaceuticalinthelate19th
century.29Thesepropertiesconferanincreasedriskofaddictionand
overdoseeveninpatientswhotaketheirmedicationasprescribed.27
Prescriptionopioidmedicationsincludehydrocodone(e.g.,Vicodin ® ),
oxycodone(e.g.,OxyContin ® ,Percocet® ),oxymorphone(e.g.,Opana ® ),
morphine(e.g.,Kadian ® ,Avinza ® ),codeine,fentanyl,andothers.
HydrocodoneproductsarethemostcommonlyprescribedintheUnited
Statesforavarietyofindications,includingdental-andinjury-related
pain.30Oxycodoneandoxymorphonearealsoprescribedformoderateto
severepainrelief.31,32Morphineisoftenusedbeforeandaftersurgical
procedurestoalleviateseverepain,andcodeineistypicallyprescribedfor
milderpain.26Inadditiontotheirpain-relievingproperties,someofthese
drugs—codeineanddiphenoxylate(Lomotil ® ),forexample—areusedto
11
26
relievecoughsandseverediarrhea.26
Howdoopioidsaffectthebrainandbody?
Opioidsactbyattachingtoandactivatingopioidreceptorproteins,which
arefoundonnervecellsinthebrain,spinalcord,gastrointestinaltract,and
otherorgansinthebody.26Whenthesedrugsattachtotheirreceptors,they
inhibitthetransmissionofpainsignals.Opioidscanalsoproduce
drowsiness,mentalconfusion,nausea,constipation,andrespiratory
depression,andsincethesedrugsalsoactonbrainregionsinvolvedin
reward,theycaninduceeuphoria,particularlywhentheyaretakenata
higher-than-prescribeddoseoradministeredinotherwaysthan
intended.26Forexample,OxyContin ® isanoralmedicationusedtotreat
moderatetoseverepainthroughaslow,steadyreleaseoftheopioid.
SomepeoplewhomisuseOxyContin ® intensifytheirexperienceby
snortingorinjectingit.†33Thisisaverydangerouspractice,greatly
increasingtheperson’sriskforseriousmedicalcomplications,including
overdose.
12
UnderstandingDependence,Addiction,andTolerance
Dependenceoccursasaresultofphysiologicaladaptationstochronic
exposuretoadrug.Itisoftenapartofaddiction,buttheyarenot
equivalent.Addictioninvolvesotherchangestobraincircuitryandis
distinguishedbycompulsivedrugseekingandusedespitenegative
consequences.34
Thosewhoaredependentonamedicationwillexperience
unpleasantphysicalwithdrawalsymptomswhentheyabruptlyreduce
orstopuseofthedrug.Thesesymptomscanbemildtosevere
(dependingonthedrug)andcanusuallybemanagedmedicallyor
avoidedbyslowlytaperingdownthedrugdosage.35
Tolerance,ortheneedtotakehigherdosesofamedicationtogetthe
sameeffect,oftenaccompaniesdependence.Whentoleranceoccurs,
itcanbedifficultforaphysiciantoevaluatewhetherapatientis
developingadrugproblemorhasamedicalneedforhigherdosesto
controlhisorhersymptoms.Forthisreason,physiciansshouldbe
vigilantandattentivetotheirpatients’symptomsandlevelof
functioningandshouldscreenforsubstancemisusewhentolerance
ordependenceispresent.27
Whatarethepossibleconsequencesofprescription
opioidmisuse?
13
©iStock.com/Sezeryadigar
Whentakenasprescribed,patientscanoftenuseopioidstomanagepain
safelyandeffectively.However,itispossibletodevelopasubstanceuse
disorderwhentakingopioidmedicationsasprescribed.Thisriskandthe
riskforoverdoseincreasewhenthesemedicationsaremisused.Evena
singlelargedoseofanopioidcancausesevererespiratorydepression
(slowingorstoppingofbreathing),whichcanbefatal;takingopioidswith
alcoholorsedativesincreasesthisrisk.5,24
Whenproperlymanaged,short-termmedicaluseofopioidpainrelievers—
takenforafewdaysfollowingoralsurgery,forinstance—rarelyleadstoan
opioidusedisorderoraddiction.Butregular(e.g.,severaltimesaday,for
severalweeksormore)orlonger-termuseofopioidscanleadto
dependence(physicaldiscomfortwhennottakingthedrug),tolerance
(diminishedeffectfromtheoriginaldose,leadingtoincreasingtheamount
taken),and,insomecases,addiction(compulsivedrugseekinganduse)
(see"UnderstandingDependence,Addiction,andTolerance").Withboth
dependenceandaddiction,withdrawalsymptomsmayoccurifdruguseis
suddenlyreducedorstopped.Thesesymptomsmayincluderestlessness,
muscleandbonepain,insomnia,diarrhea,vomiting,coldflasheswith
goosebumps,andinvoluntarylegmovements.29
Misuseofprescriptionopioidsisalsoariskfactorfortransitioningtoheroin
use.Readmoreabouttherelationshipbetweenprescriptionopioidsand
14
heroinintheNIDA'sPrescriptionOpioidsandHeroinResearchReport.
Howisprescriptionopioidmisuserelatedtochronic
pain?
Healthcareprovidershavelongwrestledwithhowbesttotreatthemore
than100millionAmericanswhosufferfromchronicpain.36Opioidshave
beenthemostcommontreatmentforchronicpainsincethelate1990s,but
recentresearchhascastdoubtbothontheirsafetyandtheirefficacyinthe
treatmentofchronicpainwhenitisnotrelatedtocancerorpalliative
care.27Thepotentialrisksinvolvedwithlong-termopioidtreatment,such
asthedevelopmentofdrugtolerance,hyperalgesia,andaddiction,present
doctorswithadilemma,asthereislimitedresearchonalternative
treatmentsforchronicpain.Patientsthemselvesmayevenbereluctantto
takeanopioidmedicationprescribedtothemforfearofbecoming
addicted.
Estimatesoftherateofopioidaddictionamongchronicpainpatientsvary
fromabout3percentupto26percent.Thisvariabilityistheresultof
differencesintreatmentduration,insufficientresearchonlong-term
outcomes,anddisparatestudypopulationsandmeasuresusedtoassess
nonmedicaluseoraddiction.37
Tomitigateaddictionrisk,physiciansshouldadheretotheCDCGuideline
forPrescribingOpioidsforChronicPain.Beforeprescribing,physicians
shouldassesspainandfunctioning,considerifnon-opioidtreatment
optionsareappropriate,discussatreatmentplanwiththepatient,evaluate
thepatient’sriskofharmormisuse,andcoprescribenaloxonetomitigate
theriskforoverdose(seetheNIDA'swebpageonnaloxone).Whenfirst
prescribingopioids,physiciansshouldgivethelowesteffectivedosefor
theshortesttherapeuticduration.Astreatmentcontinues,thepatient
shouldbemonitoredatregularintervals,andopioidtreatmentshouldbe
continuedonlyifmeaningfulclinicalimprovementsinpainandfunctioning
areseenwithoutharm.27
†Changingtherouteofadministrationcanalsobeafeatureofthemisuse
15
ofotherprescriptionmedications,includingstimulants,apracticethatcan
leadtoseriousmedicalconsequences.
CNSDepressants
WhatareCNSdepressants?
Centralnervoussystem(CNS)depressants,acategorythatincludes
tranquilizers,sedatives,andhypnotics,aresubstancesthatcanslowbrain
activity.Thispropertymakesthemusefulfortreatinganxietyandsleep
disorders.Thefollowingareamongthemedicationscommonlyprescribed
forthesepurposes38:
Benzodiazepines,suchasdiazepam(Valium® ),clonazepam
(Klonopin ® ),andalprazolam(Xanax® ),aresometimesprescribedto
treatanxiety,acutestressreactions,andpanicattacks.Clonazepam
mayalsobeprescribedtotreatseizuredisorders.Themoresedating
benzodiazepines,suchastriazolam(Halcion ® )andestazolam
(Prosom® )areprescribedforshort-termtreatmentofsleepdisorders.
Usually,benzodiazepinesarenotprescribedforlong-termuse
becauseofthehighriskfordevelopingtolerance,dependence,or
addiction.
Non-benzodiazepinesleepmedications,suchaszolpidem(Ambien ® ),
eszopiclone(Lunesta ® ),andzaleplon(Sonata ® ),knownasz-drugs,
haveadifferentchemicalstructurebutactonthesameGABAtypeA
receptorsinthebrainasbenzodiazepines.Theyarethoughttohave
fewersideeffectsandlessriskofdependencethanbenzodiazepines.
Barbiturates,suchasmephobarbital(Mebaral ® ),phenobarbital
(Luminal ® ),andpentobarbitalsodium(Nembutal ® ),areusedless
frequentlytoreduceanxietyortohelpwithsleepproblemsbecauseof
theirhigherriskofoverdosecomparedtobenzodiazepines.However,
theyarestillusedinsurgicalproceduresandtotreatseizuredisorders.
HowdoCNSdepressantsaffectthebrainandbody?
16
MostCNSdepressantsactonthebrainbyincreasingactivityatreceptors
fortheinhibitoryneurotransmittergamma-aminobutyricacid(GABA).
Althoughthedifferentclassesofdepressantsworkinuniqueways,itis
throughtheirabilitytoincreaseGABAsignaling—therebyincreasing
inhibitionofbrainactivity—thattheyproduceadrowsyorcalmingeffect
thatismedicallybeneficialtothosesufferingfromanxietyorsleep
disorders.38
WhatarethepossibleconsequencesofCNS
depressantmisuse?
Despitetheirbeneficialtherapeuticeffects,benzodiazepinesand
barbiturateshavethepotentialformisuseandshouldbeusedonlyas
prescribed.38Theuseofnon-benzodiazepinesleepaids,orz-drugs,is
lesswell-studied,butcertainindicatorshaveraisedconcernabouttheir
psychoactivepropertiesaswell.39
Duringthefirstfewdaysoftakingadepressant,apersonusuallyfeels
sleepyanduncoordinated,butasthebodybecomesaccustomedtothe
effectsofthedrugandtolerancedevelops,thesesideeffectsbeginto
disappear.Ifoneusesthesedrugslongterm,heorshemayneedlarger
dosestoachievethetherapeuticeffects.Continuedusecanalsoleadto
dependenceandwithdrawalwhenuseisabruptlyreducedorstopped(see
"UnderstandingDependence,Addiction,andTolerance").Becauseall
sedativesworkbyslowingthebrain’sactivity,whenanindividualstops
takingthem,therecanbeareboundeffect,resultinginseizuresorother
harmfulconsequences.38
Althoughwithdrawalfrombenzodiazepinescanbeproblematic,itisrarely
lifethreatening,whereaswithdrawalfromprolongeduseofbarbiturates
canhavelife-threateningcomplications.40Therefore,someonewhois
thinkingaboutdiscontinuingasedativeorwhoissufferingwithdrawalfrom
CNSdepressantsshouldspeakwithaphysicianorseekimmediate
medicaltreatment.
17
Stimulants
Whatarestimulants?
Stimulantsincreasealertness,attention,andenergy,aswellaselevate
bloodpressure,heartrate,andrespiration.Historically,stimulantswere
usedtotreatasthmaandotherrespiratoryproblems,obesity,neurological
disorders,andavarietyofotherailments.Butastheirpotentialformisuse
andaddictionbecameapparent,thenumberofconditionstreatedwith
stimulantshasdecreased.41Now,stimulantsareprescribedforthe
treatmentofonlyafewhealthconditions,includingattention-deficit
hyperactivitydisorder(ADHD),narcolepsy,andoccasionallytreatmentresistantdepression.42–44
Howdostimulantsaffectthebrainandbody?
Stimulants,suchasdextroamphetamine(Dexedrine ® ,Adderall ® )and
methylphenidate(Ritalin ® ,Concerta ® ),actinthebrainonthefamilyof
monoamineneurotransmittersystems,whichincludenorepinephrineand
dopamine.Stimulantsenhancetheeffectsofthesechemicals.Anincrease
indopaminesignalingfromnonmedicaluseofstimulantscaninducea
feelingofeuphoria,andthesemedications’effectsonnorepinephrine
increasebloodpressureandheartrate,constrictbloodvessels,increase
bloodglucose,andopenupbreathingpassages.45
Whatarethepossibleconsequencesofstimulant
misuse?
Aswithotherdrugsinthestimulantcategory,suchascocaine,itispossible
forpeopletobecomedependentonoraddictedtoprescriptionstimulants.
Withdrawalsymptomsassociatedwithdiscontinuingstimulantuseinclude
fatigue,depression,anddisturbedsleeppatterns.Repeatedmisuseof
somestimulants(sometimeswithinashortperiod)canleadtofeelingsof
hostilityorparanoia,orevenpsychosis.29Further,takinghighdosesofa
stimulantmayresultindangerouslyhighbodytemperatureandan
irregularheartbeat.Thereisalsothepotentialforcardiovascularfailureor
18
45
seizures.45
CognitiveEnhancers
Thedramaticincreasesinstimulantprescriptionsoverthelast2decades
haveledtotheirgreateravailabilityandtoincreasedriskfordiversionand
nonmedicaluse.46Whentakentoimproveproperlydiagnosedconditions,
thesemedicationscangreatlyenhanceapatient’squalityoflife.However,
becausemanyperceivethemtobegenerallysafeandeffective,
prescriptionstimulantssuchasAdderall ® andModafinil ® arebeing
misusedmorefrequently.
Stimulantsincreasewakefulness,motivation,andaspectsofcognition,
learning,andmemory.Somepeopletakethesedrugsintheabsenceof
medicalneedinanefforttoenhancementalperformance.47Militarieshave
longusedstimulantstoincreaseperformanceinthefaceoffatigue,andthe
UnitedStatesArmedForcesallowfortheiruseinlimitedoperational
settings.48Thepracticeisnowreportedbysomeprofessionalstoincrease
theirproductivity,byolderpeopletooffsetdecliningcognition,andbyboth
highschoolandcollegestudentstoimprovetheiracademicperformance.
Nonmedicaluseofstimulantsforcognitiveenhancementposespotential
healthrisks,includingaddiction,cardiovascularevents,andpsychosis.
Theuseofpharmaceuticalsforcognitiveenhancementhasalsosparked
debateovertheethicalimplicationsofthepractice.Issuesoffairnessarise
ifthosewithaccessandwillingnesstotakethesedrugshavea
performanceedgeoverothers,andimplicitcoerciontakesplaceifaculture
ofcognitiveenhancementgivestheimpressionthatapersonmusttake
drugsinordertobecompetitive.47,49
19
Areprescriptiondrugssafetotake
whenpregnant?
©iStock.com/Photobac
Prescriptionmedicationstakenbyapregnantwomancancauseherbabyto
developdependence,whichcanresultinwithdrawalsymptomsafterbirth,
knownasneonatalabstinencesyndrome(NAS).Thiscanrequireaprolonged
stayinneonatalintensivecareand,inthecaseofopioids,treatmentwith
medication(see"SexandGenderDifferencesinSubstanceUseDisorder
Treatment"intheNIDA'sSubstanceUseinWomenResearchReport).Women
shouldconsultwiththeirdoctorstodeterminewhichmedicationstheycan
continuetakingduringpregnancy.
Opioidpainmedicationsrequireparticularattention;risingratesofNAShave
beenassociatedwithincreasesintheprescriptionofopioidsforpainin
pregnantwomen.NASassociatedwithopioiduse(heroinorprescription
opioids)increasedfivefoldfrom2000to2012,withahigherrateofincreasein
morerecentyears.50,51
20
Howcanprescriptiondrugmisusebe
prevented?
Clinicians,Patients,andPharmacists
Physicians,theirpatients,andpharmacistsallcanplayaroleinidentifyingand
preventingnonmedicaluseofprescriptiondrugs.
Clinicians.Morethan80percentofAmericanshadcontactwithahealth
careprofessionalinthepastyear52,placingdoctorsinauniquepositionto
identifynonmedicaluseofprescriptiondrugsandtakemeasurestoprevent
theescalationofapatient’smisusetoasubstanceusedisorder.Byasking
aboutalldrugs,physicianscanhelptheirpatientsrecognizethataproblem
exists,provideorreferthemtoappropriatetreatment,andsetrecovery
goals.Evidence-basedscreeningtoolsfornonmedicaluseofprescription
drugscanbeincorporatedintoroutinemedicalvisits(seetheNIDAMED
webpageforresourcesformedicalandhealthprofessionals).Doctors
shouldalsotakenoteofrapidincreasesintheamountofmedication
neededorfrequent,unscheduledrefillrequests.Doctorsshouldbealertto
thefactthatthosemisusingprescriptiondrugsmayengagein"doctor
shopping"—movingfromprovidertoprovider—inanefforttoobtainmultiple
prescriptionsfortheirdrug(s)ofchoice.
Prescriptiondrugmonitoringprograms(PDMPs),state-runelectronic
databasesusedtotracktheprescribinganddispensingofcontrolled
prescriptiondrugstopatients,arealsoimportanttoolsforpreventingand
identifyingprescriptiondrugmisuse.Whileresearchregardingtheimpactof
theseprogramsiscurrentlymixed,theuseofPDMPsinsomestateshas
beenassociatedwithlowerratesofopioidprescribingandoverdose 53–56,
thoughissuesofbestpractices,easeofuse,andinteroperabilityremainto
beresolved.
In2015,thefederalgovernmentlaunchedaninitiativedirectedtoward
reducingopioidmisuseandoverdose,inpartbypromotingmorecautious
andresponsibleprescribingofopioidmedications.Inlinewiththeseefforts,
21
in2016theCentersforDiseaseControlandPrevention(CDC)publishedits
CDCGuidelineforPrescribingOpioidsforChronicPaintoestablishclinical
standardsforbalancingthebenefitsandrisksofchronicopioidtreatment.27
Preventingorstoppingnonmedicaluseofprescriptiondrugsisanimportant
partofpatientcare.However,certainpatientscanbenefitfromprescription
stimulants,sedatives,oropioidpainrelievers.Therefore,physiciansshould
balancethelegitimatemedicalneedsofpatientswiththepotentialriskfor
misuseandrelatedharms.
Patients.Patientscantakestepstoensurethattheyuseprescription
medicationsappropriatelyby:
followingthedirectionsasexplainedonthelabelorbythepharmacist
beingawareofpotentialinteractionswithotherdrugsaswellasalcohol
neverstoppingorchangingadosingregimenwithoutfirstdiscussingit
withthedoctor
neverusinganotherperson’sprescription,andnevergivingtheir
prescriptionmedicationstoothers
storingprescriptionstimulants,sedatives,andopioidssafely
Additionally,patientsshouldproperlydiscardunusedorexpired
medicationsbyfollowingU.S.FoodandDrugAdministration(FDA)
guidelinesorvisitingU.S.DrugEnforcementAdministrationcollection
sites.57Inadditiontodescribingtheirmedicalproblem,patientsshould
alwaysinformtheirhealthcareprofessionalsaboutalltheprescriptions,
over-the-countermedicines,anddietaryandherbalsupplementstheyare
takingbeforetheyobtainanyothermedications.
22
©iStock.com/HconQ
Pharmacists.Pharmacistscanhelppatientsunderstandinstructionsfor
takingtheirmedications.Inaddition,bybeingwatchfulforprescription
falsificationsoralterations,pharmacistscanserveasthefirstlineofdefense
inrecognizingproblematicpatternsinprescriptiondruguse.Some
pharmacieshavedevelopedhotlinestoalertotherpharmaciesintheregion
whentheydetectafraudulentprescription.Alongwithphysicians,
pharmacistscanusePDMPstohelptrackopioid-prescribingpatternsin
patients.
MedicationFormulationandRegulation
Manufacturersofprescriptiondrugscontinuetoworkonnewformulationsof
opioidmedications,knownasabuse-deterrentformulations(ADF),which
includetechnologiesdesignedtopreventpeoplefrommisusingthemby
snortingorinjection.Approachescurrentlybeingusedorstudiedforuse
include:
23
physicalorchemicalbarriersthatpreventthecrushing,grinding,or
dissolvingofdrugproducts
agonist/antagonistcombinationsthatcauseanantagonist(whichwill
counteractthedrugeffect)tobereleasediftheproductismanipulated
aversivesubstancesthatareaddedtocreateunpleasantsensationsifthe
drugistakeninawayotherthandirected
deliverysystemssuchaslong-actinginjectionsorimplantsthatslowly
releasethedrugovertime
newmolecularentitiesorprodrugsthatattachachemicalextensiontoa
drugthatrendersitinactiveunlessitistakenorally
SeveralADFopioidsareonthemarket,andtheFDAhasalsocalledforthe
developmentofADFstimulants.58WhileADFopioidshavebeenshownto
decreasetheillicitvalueofadrug,intheabsenceofreduceddemand,theycan
shiftusetootherformulations.58Medicationregulationhasbeenshowntobe
effectiveindecreasingtheprescribingofopioidmedications.In2014,theDrug
EnforcementAdministrationmovedhydrocodoneproductsfromscheduleIIIto
themorerestrictivescheduleII,whichresultedinadecreaseinhydrocodone
prescribingthatdidnotresultinanyattendantincreasesintheprescribingof
otheropioids.30
DevelopmentofSaferMedications
Thedevelopmentofeffective,nonaddictingpainmedicationsisapublichealth
priority.Agrowingnumberofolderadultsandanincreasingnumberofinjured
militaryservicemembersaddtotheurgencyoffindingnewtreatments.
Researchersareexploringalternativetreatmentapproachesthattargetother
signalingsystemsinthebodysuchastheendocannabinoidsystem,whichis
alsoinvolvedinpain.59Moreresearchisalsoneededtobetterunderstand
effectivechronicpainmanagement,includingidentifyingfactorsthatpredispose
somepatientstosubstanceusedisordersanddevelopingmeasurestoprevent
thenonmedicaluseofprescriptionmedications.
24
Howcanprescriptiondrugaddiction
betreated?
Yearsofresearchhaveshownthatsubstanceusedisordersarebraindisorders
thatcanbetreatedeffectively.Treatmentmusttakeintoaccountthetypeofdrug
usedandtheneedsoftheindividual.Successfultreatmentmayneedto
incorporateseveralcomponents,includingdetoxification,counseling,and
medications,whenavailable.Multiplecoursesoftreatmentmaybeneededfor
thepatienttomakeafullrecovery.60
Thetwomaincategoriesofdrugaddictiontreatmentarebehavioraltreatments
(suchascontingencymanagementandcognitive-behavioraltherapy)and
medications.Behavioraltreatmentshelppatientsstopdrugusebychanging
unhealthypatternsofthinkingandbehavior;teachingstrategiestomanage
cravingsandavoidcuesandsituationsthatcouldleadtorelapse;or,insome
cases,providingincentivesforabstinence.Behavioraltreatments,whichmay
taketheformofindividual,family,orgroupcounseling,alsocanhelppatients
improvetheirpersonalrelationshipsandtheirabilitytofunctionatworkandin
thecommunity.60
Addictiontoprescriptionopioidscanadditionallybetreatedwithmedications
includingbuprenorphine,methadone,andnaltrexone[see"MedicationAssistedTreatment(MAT)"below].Thesedrugscancountertheeffectsof
opioidsonthebrainorrelievewithdrawalsymptomsandcravings,helpingthe
patientavoidrelapse.Medicationsforthetreatmentofaddictionare
administeredincombinationwithpsychosocialsupportsorbehavioral
treatments,knownasmedication-assistedtreatment(MAT).61
Medication-AssistedTreatment(MAT)
Naltrexoneisanantagonistmedicationthatpreventsotheropioidsfrom
bindingtoandactivatingopioidreceptors.Itisusedtotreatoverdoseand
addiction.Aninjectable,long-actingformofnaltrexone(Vivitrol ® )canbea
usefultreatmentchoiceforpatientswhodonothavereadyaccessto
25
healthcareorwhostrugglewithtakingtheirmedicationsregularly.
Methadoneisasyntheticopioidagonistthatpreventswithdrawal
symptomsandrelievesdrugcravingsbyactingonthesamebraintargets
asotheropioidssuchasheroin,morphine,andopioidpainmedications.It
hasbeenusedsuccessfullyformorethan40yearstotreatheroinaddiction
butisgenerallyonlyavailablethroughspeciallylicensedopioidtreatment
programs.
Buprenorphineisapartialopioidagonist—itbindstotheopioidreceptor
butonlypartiallyactivatesit—thatcanbeprescribedbycertifiedphysicians
inanofficesetting.Likemethadone,itcanreducecravingsandiswell
toleratedbypatients.InMay2016,theU.S.FoodandDrugAdministration
(FDA)approvedtheNIDA-supporteddevelopmentofanimplantable
formulationofbuprenorphine.Itprovides6monthsofsustainedtreatment,
whichwillgivebuprenorphine-stabilizedpatientsgreatereaseintreatment
adherence.
Therehasbeenapopularmisconceptionthatmedicationswithagonist
activity,suchasmethadoneorbuprenorphine,replaceoneaddictionwith
another.Thisisnotthecase.Opioidusedisorderisassociatedwith
imbalancesinbraincircuitsthatmediatereward,decision-making,impulse
control,learning,andotherfunctions.Thesemedicationsrestorebalance
tothesebraincircuits,preventingopioidwithdrawalandrestoringthe
patienttoanormalaffectivestatetoallowforeffectivepsychosocial
treatmentandsocialfunctioning.
WhileMATisthestandardofcarefortreatingopioidusedisorder,farfewer
peoplereceiveMATthancouldpotentiallybenefitfromit.Notallpeople
withopioidusedisorderseektreatment.Evenwhentheyseektreatment,
theywillnotnecessarilyreceiveMAT.Themostrecenttreatment
admissionsdataavailableshowthatonly18percentofpeopleadmittedfor
prescriptionopioidusedisorderhaveatreatmentplanthatincludesMAT.62
However,evenifthenationwideinfrastructurewereoperatingatcapacity,
between1.3and1.4millionmorepeoplehaveopioidusedisorderthan
couldcurrentlybetreatedwithMATduetolimitedavailabilityofopioid
26
treatmentprogramsthatcandispensemethadoneandtheregulatorylimit
onthenumberofpatientsthatphysicianscantreatwithbuprenorphine.63
CoordinatedeffortsareunderwaynationwidetoexpandaccesstoMAT,
includingarecentincreaseinthebuprenorphinepatientlimitfrom100
patientsto275forqualifiedphysicianswhorequestthehigherlimit.64
TheNIDAissupportingresearchneededtodeterminethemosteffective
waystoimplementMAT.Forexample,recentworkhasshownthat
buprenorphinemaintenancetreatmentismoreeffectivethantapering
patientsoffofbuprenorphine.65Also,startingbuprenorphinetreatment
whenapatientisadmittedtotheemergencydepartment,suchasforan
overdose,isamoreeffectivewaytoengageapatientintreatmentthan
referralorbriefintervention.66Finally,datahaveshownthattreatmentwith
methadone,buprenorphine,ornaltrexoneforincarceratedindividuals
improvespost-releaseoutcomes.67–69
ReversinganOpioidOverdosewithNaloxone
Theopioidoverdose-reversaldrugnaloxoneisanopioidantagonistthat
canrapidlyrestorenormalrespirationtoapersonwhohasstopped
breathingasaresultofoverdoseonprescriptionopioidsorheroin.
Naloxonecanbeusedbyemergencymedicalpersonnel,firstresponders,
andbystanders.Formoreinformation,visittheNIDA'swebpageon
naloxone.
27
TreatingAddictiontoCNSDepressants
Patientsaddictedtocentralnervoussystem(CNS)depressantssuchas
tranquilizers,sedatives,andhypnoticsshouldnotattempttostoptaking
themontheirown.Withdrawalsymptomsfromthesedrugscanbesevere
and—inthecaseofcertainmedications—potentiallylife-threatening.29
ResearchontreatingaddictiontoCNSdepressantsissparse;however,
patientswhoaredependentonthesemedicationsshouldundergo
medicallysuperviseddetoxificationbecausethedosagetheytakeshould
betaperedgradually.Inpatientoroutpatientcounselingcanhelp
individualsthroughthisprocess.Cognitive-behavioraltherapy,which
focusesonmodifyingthepatient’sthinking,expectations,andbehaviors
whileincreasingskillsforcopingwithvariouslifestressors,hasalsobeen
usedsuccessfullytohelpindividualsadapttodiscontinuing
benzodiazepines.70
OftenCNSdepressantmisuseoccursinconjunctionwiththeuseofother
drugs(polydruguse),suchasalcoholoropioids.71Insuchcases,the
treatmentapproachshouldaddressthemultipleaddictions.
Atthistime,therearenoFDA-approvedmedicationsfortreatingaddiction
toCNSdepressants,thoughresearchisongoinginthisarea.
28
TreatingAddictiontoPrescriptionStimulants
TreatmentofaddictiontoprescriptionstimulantssuchasAdderall ® and
Concerta ® isbasedonbehavioraltherapiesthatareeffectivefortreating
cocaineandmethamphetamineaddiction.Atthistime,therearenoFDAapprovedmedicationsfortreatingstimulantaddiction.TheNIDAis
supportingresearchinthisarea.41
Dependingonthepatient,thefirststepsintreatingprescriptionstimulant
addictionmaybetotaperthedrugdosageandattempttoeasewithdrawal
symptoms.Behavioraltreatmentmaythenfollowthedetoxificationprocess
(see"BehavioralTherapies"intheNIDA'sPrinciplesofDrugAddiction
Treatment:AResearch-BasedGuide).
29
WherecanIgetfurtherinformation
aboutprescriptiondrugmisuse?
Tolearnmoreaboutprescriptiondrugsandotherdrugs,visittheNIDAwebsite
atdrugabuse.govorcontacttheDrugPubsResearchDisseminationCenterat
877-NIDA-NIH(877-643-2644;TTY/TDD:240-645-0228).
TheNIDA'swebsiteincludes:
informationondrugsandrelatedhealthconsequences
NIDApublications,news,andevents
resourcesforhealthcareprofessionals
fundinginformation(includingprogramannouncementsanddeadlines)
internationalactivities
linkstorelatedwebsites(accesstowebsitesofmanyotherorganizationsin
thefield)
informationinSpanish(enespañol)
NIDAwebsitesandwebpages
drugabuse.gov
teens.drugabuse.gov
easyread.drugabuse.gov
drugabuse.gov/drugs-abuse/prescription-drugs-cold-medicines
researchstudies.drugabuse.gov
irp.drugabuse.gov
Forphysicianinformation
30
NIDAMED:drugabuse.gov/nidamed
Otherwebsites
Informationaboutprescriptiondrugmisuseisalsoavailablethroughthe
followingwebsites:
SubstanceAbuseandMentalHealthServicesAdministration:samhsa.gov
U.S.DrugEnforcementAdministration:dea.gov
MonitoringtheFuture:monitoringthefuture.org
PartnershipforDrug-FreeKids:drugfree.org/drug-guide
Thispublicationisavailableforyouruseandmaybereproducedinits
entiretywithoutpermissionfromtheNIDA.Citationofthesourceis
appreciated,usingthefollowinglanguage:Source:NationalInstituteon
DrugAbuse;NationalInstitutesofHealth;U.S.DepartmentofHealthand
HumanServices.
31
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