Drug Abuse, Prescription


Controlled substances are prone to misuse and diversion. Universal precautions should be used for monitoring of all patients prescribed controlled substances to identify substance use disorder in affected patients. Patients with substance use disorder should be offered treatment (and/or referred as needed).


  • Prescription drug abuse behaviors exist on a continuum and may include the following:
    • Use of medication for medical reasons other than what the prescriber intended
    • Use of medication for nonmedical reasons such as to get high (dissociative effects) or to enhance performance
    • 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.


  • More than half of ED-related visits are related to abused or misused pharmaceuticals (opioid and nonopioid).
  • In the United States in 2016, there were 17,087 overdose deaths involving prescription opioids, which account for 27% of all drug overdose deaths that year.


  • Predominant sex: males > females
  • Predominant age: highest among adults 18 to 25 years (mean 22 years), then adolescents and teens 12 to 17 years, followed by adults ≥26 years


  • Lifetime prevalence of prescription drug abuse is highest for opioids, benzodiazepines, and stimulants.
  • In the United States in 2016, the CDC found that 4.3% reported misuse of prescription pain relievers, 2.1% for prescription stimulants, 2.2% for prescription tranquilizers, and 0.6% for prescription sedatives.

Etiology and Pathophysiology

Opioids, benzodiazepines, stimulants, and barbiturates produce euphoria, tolerance, and dependence leading to misuse and addiction.

Variant alleles affect the expression and function of opioid, dopamine, acetylcholine, serotonin, and γ-aminobutyric acid, helping to explain susceptibility to different forms.

Risk Factors

  • Sociodemographic, psychiatric, pain- and drug-related factors
  • Genetics, environment, family history
  • Ongoing opioid prescription (3+ months) greatly increases risk of opioid-related overdose at 1 (4-fold) and 5 years (30-fold).

General Prevention

  • Limit or avoid prescribing controlled medications on the first visit (until the relationship is established). Limit initial quantity of opioid pain medication prescribed to a few days (1)[A].
  • Screen by asking questions about unhealthy drug use (including prescription drugs, USPSTF-B recommendation).
  • Take a thorough history, review records, and perform periodic urine drug screens (UDSs) before deciding if a controlled substance is indicated.
  • Try all available nonopioid treatments for pain before prescribing opioids for chronic pain.
  • Avoid prescribing benzodiazepines. Use other treatments for anxiety (cognitive-behavioral therapy, mindfulness, selective serotonin reuptake inhibitors, PRN H1 blocker, buspirone).
  • Avoid benzodiazepines and hypnotics in elderly.
  • Patients should give good informed consent about risks of controlled medications before starting AND every 3 months while continuing treatment.
  • Develop/adopt standard practice agreements for prescribing and monitoring controlled substances.
  • Wean/stop prescription analgesics for chronic pain if ineffective for improving pain and function, if aberrant behaviors suggesting opioid use present, or if patient overdoses.
  • Dose reduction of chronic opioids can decrease risk while improving pain, function, and quality of life.
  • Prescription monitoring programs (PMPs) reduce doctor shopping but not ED visits for overdose and prescription drug abuse–related deaths (2)[A].
  • Identify and treat underlying substance use disorder.
  • Prescribe intranasal naloxone to all patients prescribed chronic opioids and provide education to patient and family members on proper use in case of overdose.

Commonly Associated Conditions

  • Opioids: tolerance (loss of effectiveness over time), opioid-induced hyperalgesia, dependence (uncomfortable withdrawal symptoms), addiction (which can lead to loss of savings, job, close relationships and incarceration, hepatitis C virus or HIV infection, etc.), overdose/death, depression, constipation, low testosterone, and sexual dysfunction
  • Benzodiazepines and barbiturates: dependence (withdrawal can cause seizures, delirium tremens, death), psychosis, anxiety, sleep driving, blackout states, cognitive impairment, impaired driving; increased fall risk and mortality in elderly patients
  • Stimulants: dependence, hypertension, tachyarrhythmias, myocardial ischemia, seizures, hypothermia, psychosis, hallucinations, paranoia, anxiety

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