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Drug Abuse, Prescription

Drug Abuse, Prescription is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Prescription drug abuse behaviors exist on a continuum and may include:
    • 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, lorazepam), 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, 1.4 million drug-related ED visits (56%) were due to abused or misused pharmaceuticals.
  • Almost half of opioid overdose deaths involve a prescription opioid. In 2015, there were >15,000 overdose deaths involving prescription opioids in the United States.
  • Prescription opioids are the second most common gateway to illicit drug use.

Incidence
  • Predominant sex: males > females
  • Predominant age: highest among adults 18 to 25 years, then adolescents and teens 12 to 17 years, followed by adults ≥26 years
  • In 2011, >20% of the 3.1 million persons who were first-time substance abusers used prescription medications nonmedically.
  • 22 years is the average age for those with a first reported instance of nonmedical prescription drug use.
Prevalence
  • The number of persons with nonmedical opioid dependence increased from 936,000 in 2002 to 1.4 million in 2011.
  • Lifetime prevalence of prescription drug abuse is highest for opioids, benzodiazepines, and stimulants.

Etiology and Pathophysiology

  • Young adults perceive prescription medications to be more socially acceptable than other illicit drugs.
  • Pharmacokinetics, compound purity, government approval, extensive media advertising, and personal or family experiences with prescription medications all contribute to prescription drug misuse and dependence.

Genetics
Variant alleles affect the expression and function of opioid, dopamine, acetylcholine, serotonin, and GABA helping to explain susceptibility to different forms of prescription and nonprescription drugs.

Risk Factors

  • Sociodemographic, psychosocial, pain-, and drug-related factors
  • Genetics and environment; family history

General Prevention

  • Try all available nonopioid treatments for pain before prescribing opioids for chronic pain.
  • Dose reduction of chronic opioids can decrease risks to patients and may improve pain, function and quality of life in some patients (1)[A].
  • Educate and raise awareness about the dangers of misuse and abuse of prescription drugs. Focus on individuals, families, and communities.
  • Educate and reinforce safe practices for prescribing medications. Office-based, peer-to-peer education and follow-up with pharmacies help identify suspected abuse behaviors.
  • Develop or adopt a standard practice agreement for prescribing and monitoring controlled substances with abuse potential (2,3).
  • Limit or avoid prescribing controlled medications on the first visit (until a relationship can be established).
  • Take a thorough history, contact family members and past prescribers, and perform periodic urine drug screens (UDS). Stop prescription analgesics for chronic pain if they are ineffective in improving pain and function.
  • Prescription monitoring programs (PMP) reduce doctor shopping but not ED visits for drug overdose and prescription drug abuse–related deaths (2).
  • Avoid benzodiazepines and hypnotics in elderly patients.
  • Avoid using benzodiazepines for more than 2 to 4 weeks.
  • Use controlled substances cautiously if patients have a personal or family history of substance abuse or psychiatric disorders.
  • Identify and treat underlying substance abuse; involve behavioral health providers when possible.
  • Intranasal naloxone programs in communities with >1 enrollment/100,000 people and 5 or more opioid-related overdose fatalities reduce new opioid-related overdose deaths (4)[B].
  • Provide education to family members/caretakers on intranasal naloxone use in the event of a suspected opioid overdose (4)[B].

Commonly Associated Conditions

  • Opioids: respiratory depression and death with overdose, constipation, low testosterone, and sexual dysfunction with chronic use. Methadone is associated with QT prolongation, which increases risk for torsades de pointes.
  • Benzodiazepines: withdrawal syndromes/delirium, psychosis, anxiety, sleep driving, blackout states, cognitive impairment, impaired driving while awake; increased fall risk and mortality in elderly patients
  • Stimulants: hypertension, tachyarrhythmias, myocardial ischemia, seizures, hypothermia, psychosis, hallucinations, paranoia, anxiety

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Citation

Stephens, Mark B., et al., editors. "Drug Abuse, Prescription." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117612/all/Drug_Abuse__Prescription.
Drug Abuse, Prescription. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117612/all/Drug_Abuse__Prescription. Accessed March 19, 2019.
Drug Abuse, Prescription. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117612/all/Drug_Abuse__Prescription
Drug Abuse, Prescription [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117612/all/Drug_Abuse__Prescription.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Drug Abuse, Prescription ID - 117612 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117612/all/Drug_Abuse__Prescription PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -