Drug Abuse, Prescription


Controlled substances are prone to misuse and diversion. Cautious prescribing should be considered in all cases and monitoring all patients prescribed controlled substances to identify substance use disorder (SUD) is the key. Patients with SUD should be offered treatment (and/or referred as needed).


  • Prescription drug abuse behaviors exist on a continuum and can include:
    • 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 it was intended for
  • Commonly abused prescription medications include opioid analgesics, stimulants, central nervous system depressants, and barbiturates.
  • 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.


  • From 2013 to 2018, substance use–related emergency department (ED) visits increased from 2.926 million to 4.132 million.
  • The number of drug overdose deaths quadrupled from 1999 to 2019 and >932,000 deaths have been attributed to drug overdose.
  • In 2020, >91,000 drug overdose deaths occurred in the United States in which opioids were responsible for 78.4% of those deaths.


  • Predominant sex: males > females
  • 1 in 4 patients on long-term opioid therapy in primary care settings struggles with opioid addiction.
  • Predominant age: highest among adults aged 18 to 25 years (mean 22 years), then adolescents and teens aged 12 to 17 years, followed by adults aged ≥26 years

In 2017, 191 million opioid prescriptions were issued, and 11.5 million Americans were reported misusing opioid medications.

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, drug-related factors, genetics, sex, environment, and family history
  • Ongoing opioid prescription (≥3 months) greatly increases risk of opioid-related overdose at 1 year (4-fold) and 5 years (30-fold).

General Prevention

  • Try all available nonopioid treatments for pain before prescribing opioids for chronic pain.
  • Limit/avoid prescribing controlled medications on the first visit and limit 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).
  • Conduct thorough history, review records (prescription monitoring programs [PMPs]), and perform urine drug screens (UDSs) before deciding if a controlled substance is indicated.
  • Avoid prescribing benzodiazepines in the treatment of anxiety. Try cognitive-behavioral therapy, mindfulness, selective serotonin reuptake inhibitors, PRN antihistamines (anti-H1), or buspirone.
  • Support the use of CDC guidelines for prescribing controlled substances for chronic pain while integrating quality improvement measures, making these standard practice.
  • Wean/stop prescription of analgesics for chronic pain if ineffective for improving pain and function, if aberrant behaviors suggesting opioid use are present, or if patient overdoses.
  • Dose reduction of chronic opioids can decrease risk while improving pain, function, and quality of life.
  • Prescribe intranasal naloxone to all patients prescribed chronic opioids, provide education to patient and family members on proper use in case of overdose, and increase access to SUD services.
  • Identify and treat underlying SUD.

Commonly Associated Conditions

  • Opioids: tolerance, opioid-induced hyperalgesia, dependence, 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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