Abuse of prescription drugs has been a national problem for decades, but recently the number of young Americans using prescription drugs for nonmedical purposes has been increasing at an alarming rate. Between 1999 and 2006, the US Department of Health and Human Services reports, the number of surveyed 12- to 17-year-olds who reported nonmedical use of a psychotherapeutic medication within the previous year increased by more than 60%.1
High-profile cases have thrust the problem into public view. In July 2007, the son of former Vice President Al Gore was arrested on suspicion of illegal possession of Vicodin®, Xanax®, Valium®, and Adderall®.2 And in January 2008, the 28-year-old actor Heath Ledger was found dead of acute intoxication resulting from the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine.3
Recent public awareness campaigns have taken up the fight against prescription drug abuse, as demonstrated in television ads from the Partnership for a Drug-Free America (www.drugfree.org). Their clear message is that abuse of prescription drugs can be as dangerous as that of illicit drugs like cocaine or heroin.
In 2005, an estimated 1.4 million US emergency department (ED) visits were related to substance abuse—in 37% of cases, abuse of prescription drugs. Prescription drug overdose is common among 12- to 17-year-olds, with more than 13,000 ED visits per year attributed to overmedication.4 The prescription drugs that are most commonly abused have potentially serious adverse effects and can cause accidental disability or death. They are also frequently implicated in suicide attempts: 45% involve prescription pain medication and 56%, sedatives or stimulants.4
It is imperative for clinicians, especially emergency medicine providers (EMPs), to appreciate the magnitude of prescription drug abuse among adolescents so that overdoses or chronic abuse can be identified appropriately, and treatment and prevention strategies can be implemented. An understanding of the basic pharmacology and toxicology of commonly abused prescription medications is especially helpful.
Awareness of the current trends and demographics of prescription drug abuse will enable EMPs to reevaluate their prescribing practices. The challenge is to maximize safe and effective treatment while minimizing the diversion of prescription drugs and the development of substance abuse disorders.
Defining the Problem
Using the three behavioral variables of intent, practice, and consequences, this definition can be established: Prescription drug abuse is the use of a controlled substance for reasons other than that for which it was prescribed, often in dosages different from those prescribed, resulting in disability or dysfunction and often involving illegal activity and risk of harm to the abuser.5
The National Institute on Drug Abuse6 designates prescription drugs with potential for abuse as psychotherapeutics. Classes of psychotherapeutics, in descending order of prevalence of abuse, are pain relievers, tranquilizers, stimulants, and sedatives.1
The most recent National Survey on Drug Use and Health (NSDUH) showed use of illicit drugs and overall teen drug use at a five-year low. Since 2002, current illicit drug use among 12- to 17-year-olds has declined by 16%, including an 18% decrease in current marijuana use and a marked 25% decrease in marijuana use among teenage boys.1,7,8
Yet these promising findings are overshadowed by the alarming number of young people who report misusing prescription drugs. More youth now initiate drug use with prescription pain relievers than with marijuana.1 In two recent studies, 5.2 million respondents 12 or older had used prescription pain relievers nonmedically in the previous month—a 10% increase since 2005. Concurrently, overall nonmedical use of prescription drugs among 12- to 17-year-olds increased by 12%.1,7 (See figure.1)
Among adolescents, pain relievers are the most commonly abused prescription drugs. On an average day in 2006, 2,517 adolescents used pain relievers nonmedically for the first time.1 The wide availability of these drugs contributes significantly to the problem. A recent analysis of Drug Enforcement Administration (DEA) data shows that in 1996, Americans purchased more than 200,000 pounds of codeine, hydrocodone, meperidine, morphine, and oxycodone. Between 1997 and 2007, the volume of five major painkillers distributed in the US rose by 90%. Sales of oxycodone alone rose nearly 600% between 1997 and 20059,10 (see Table 19-11).
The simultaneous decline in use of illicit drugs and increase in prescription drug abuse may be explained in part by teenagers’ perception that abusing prescriptions is less harmful and less risky than using illicit street drugs. Widespread direct-to-consumer advertising for pain relievers, psychotropics, and sedatives may also lead teens to rationalize their use of prescriptions.
What Demographics Tell Us
Prevalence of prescription drug abuse by adolescents varies by region, ethnicity, and gender. It is highest in small cities and the Western states and lowest in urban areas of the Northeast. Prevalence rates are highest among American Indians or Alaska Natives (17%) and lowest among adolescents of Asian descent (7%). In general, Caucasian youths are more likely to misuse prescription psychotherapeutics than are African-Americans or Asian-Americans.1
Notably, rates of nonmedical prescription use among 12- to 17-year-olds were higher in girls than in boys for pain relievers, stimulants, and tranquilizers.1 In all other age-groups, prescription drug abuse is more prevalent among males.
Several risk factors correlate significantly with adolescent nonmedical prescription use, including mental health treatment, use of illicit drugs, female gender, and binge drinking. Self-reported lack of religiosity, high rates of family conflict, and presence of sensation-seeking behaviors are also considered risk factors.11,12
Diversion of Prescription Psychotherapeutics
Diversion, the most common means of obtaining medications for unintended purposes, encompasses a number of inappropriate or illegal activities, including selling, trading, or sharing legitimately prescribed medications. Patients trying to obtain greater quantities than would ordinarily be prescribed (for primary or secondary purposes) may resort to doctor-shopping, falsely claiming a lost prescription, seeking escalating dosing from the provider, or forgery.
In addition to the long-established routes of diversion (eg, theft, doctor-shopping, malingering), prescription exchange among teenagers is a growing trend. Opioids and other agents are increasingly available to young patients through family members, because rising numbers of prescriptions are being written. These startling increases may reflect a fear of litigation for undertreating patients’ pain or a concern to score well in patient satisfaction surveys. Other possible factors are a paradigm shift in pain management, the ever-increasing use of EDs by patients with chronic pain, or influence from the pharmaceutical industry. Nevertheless, the result is a flood of available drugs complicating a system that is already fraught with abuse.
Despite the rise in prescriptions for opioids, only about 14% of those used by teenagers are prescribed for them. Most teens who abuse prescription medications obtain them from peers or family members with legitimate prescriptions. About one-third of those who use prescription opioids rely on Internet no-prescription Web sites (NPWs) or drug dealers.8
In a 2005 Web-based survey of 1,086 high school students, 49% had been prescribed a sleeping aid, sedative, stimulant, or pain medication at least once.10 Among these students, 24% (27.5% of girls; 17.4% of boys) reported having lent their prescriptions or given them to other students.10 Having their medications stolen or being forced to give them away were often cited as significant problems.
Internet NPWs offer teenagers nearly unlimited opportunities to buy psychotherapeutics privately. The Government Accountability Office estimates that some 400 Internet pharmacies (200 based overseas) were selling drugs illegally in 2003.13 Identification beyond a credit card is rarely required, and search engines facilitate purchasing: Using search terms like “no prescription vicodin,” Gordon et al14 reported a hit rate of 80% to 90% for NPWs but no links to addiction help–related sites. Buying psychotherapeutics from drug dealers is less discreet but often more expensive (see Table 215,16).
Identifying and Managing Abuse and Overdose
Three drug classes account for the majority of prescription medication abuse among teenagers: opioids, stimulants, and sedative-hypnotics (see Table 31,17). Dose-response curves suggest their anticipated effects, but individual responses vary; anyone willing to take a prescribed medication for nonmedical purposes is at risk for adverse effects. The following is a brief review of presenting signs and symptoms, appropriate intervention, and long-term complications of prescription drug abuse and overdose.18
Of the three psychotherapeutic classes mentioned, opioids are most commonly used for nonmedical purposes. This class comprises naturally derived opiates (eg, heroin, morphine, codeine), semisynthetic opioids (eg, hydrocodone, oxycodone), and synthetically made opioids (eg, fentanyl, methadone, meperidine).
After ingestion, the initial effect is relaxation and blunted response to pain. With increasing doses, drowsiness ensues, with a reduction in pulse rate and blood pressure. Other common findings include muscle flaccidity, pupillary miosis, bradypnea, and decreased bowel sounds. (NOTE: Among the opioids, meperidine does not cause miosis.) Significant overdose results in the classic presentation of central nervous system (CNS) and respiratory depression and miosis; the episode may culminate in coma, apnea, and even death.
Treatment of a patient who pre-sents with opioid overdose consists of airway and ventilatory support, with special consideration given to opioid antagonists (eg, naloxone) that competitively inhibit the binding of opioid agonists. The goal of naloxone therapy is to elicit appropriate spontaneous ventilation, not necessarily complete arousal. Precipitation of withdrawal symptoms should be avoided, and clinicians should be aware that the half-life of naloxone is relatively short (especially compared with methadone); resedation may follow initial improvement.
Oxycodone (OxyContin®) is of particular concern, in part due to its potency—and its subsequent prevalence. According to Monitoring the Future,19 a remarkable 5.3% prevalence of oxycodone use was reported in 12th graders in 2007.
Ordinarily, an 80-mg dose of oxycodone is slowly released over 12 hours, but numerous methods are used to circumvent the pill’s time-release matrix; these uses are associated with high morbidity and mortality rates. Crushed oxycodone—hillbilly heroin—is immediately available for systemic absorption. Insufflation, too, results in relatively immediate effects. Slower absorption can be achieved by parachuting—a method of rolling or folding powdered or crushed drugs in toilet paper or other thin paper and ingesting it.18
Oxycodone injection requires more preparation. After the wax coating is removed, the pill is crushed into a fine powder, mixed with water, and liquefied over heat; any remaining wax is extracted, and the liquid is filtered through cotton and injected. Residual impurities can cause significant intravascular complications.
These agents include amphetamines and amphetamine-like drugs, such as phendimetrazine and benzphetamine, which are marketed as weight-loss medications. Methamphetamine is the most commonly abused drug in this class, with a lifetime use rate, throughout the US population, of 4.9%.7 However, only a small proportion is derived from the prescription forms used to treat attention-deficit/hyperactivity disorder or narcolepsy.
The two most commonly abused individual stimulants are methylphenidate (Ritalin®) and dextroamphetamine (Dexedrine®), with US lifetime use rates of 1.7% and 1.1%, respectively.7 As a class, prescription diet pills have a higher rate of nonmedical US lifetime use, 3.4%.
Despite amphetamines’ low therapeutic index, persons who use them are known to develop high tolerance with ongoing use.18 Clinical response to amphetamines can be described as sympathomimetic effects, with CNS signs and symptoms ranging from anxiety and euphoria to severe agitation, hyperthermia, and seizures. Tachycardia, hypertension, diaphoresis, and tremors are classic symptoms. Potentially lethal complications include tachyarrhythmias, myocardial infarction, rhabdomyolysis, status epilepticus, and intracranial hemorrhage. Chronic use can lead to cardiomyopathy, dental decay, paranoia, and pulmonary hypertension.
The mainstays of treatment include blunting the sympathomimetic response with benzodiazepines and addressing the secondary complications of stimulant use. Managing agitation, hyperthermia, rhabdomyolysis, seizures, and tachydysrhythmias are critical following severe toxicity.18
Under the umbrella of sedative-hypnotic agents fall benzodiazepines, barbiturates, skeletal muscle relaxants, antidepressants, and antihistamines. Certainly, benzodiazepines dominate this assortment, but several other medications pose serious risk when used nonmedically. Despite their preponderance, benzodiazepines cause relatively few deaths (compared with barbiturates), especially when they are used alone.
Although the clinical presentation of a patient with benzodiazepine overdose varies according to the specific agent ingested, common features include drowsiness, CNS depression, stupor, nystagmus, hypothermia, respiratory depression, and coma.18 Occasionally, ataxia is the only presenting sign of accidental benzodiazepine ingestion in the pediatric patient, but CNS depression is usually present. Cardiovascular instability can result directly, from depression of myocardial contractility, medullary depression, and vasodilation; or indirectly, from respiratory compromise. Ancillary signs, such as barbiturate blisters, may facilitate the diagnosis.
Primary treatment remains airway support with symptomatic and supportive care. Though rarely indicated following benzodiazepine poisoning, flumazenil is a competitive inhibitor of benzodiazepine receptors. It should be considered only in patients previously naive to benzodiazepines (as in the case of accidental pediatric ingestion) or following iatrogenic sedation. Use of flumazenil after long-term benzodiazepine therapy or in patients with a lowered seizure threshold may precipitate an acute withdrawal state, arrhythmias, and seizures. With proper airway support and monitoring, most patients improve clinically as the drugs are metabolized.18
Preventive Strategies for Emergency Medicine Clinicians
Although data involving emergency PAs and NPs are not readily available, fewer than 40% of physicians receive formal medical school training in recognizing prescription drug abuse or diversion.4 According to the Center on Addiction and Substance Abuse (CASA) survey, 43% of physicians neglect to ask about prescription drug abuse during the patient history.20
Because continuity of care is inherently lacking in emergency medicine, certain active interventions are recommended during the patient encounter to limit nonmedical use of prescription drugs. Three particularly important techniques are recognizing cardinal features of patients who seek to obtain psychotherapeutic medications for nonmedical purposes; adapting prescription writing habits to provide safe, appropriate interventions; and educating patients.
In a limited time, EMPs must obtain as much information as possible about a patient’s illness and personal situation without appearing to be suspicious or judgmental; confrontations may prompt some patients to resort to verbal aggression. Many EMPs pride themselves on their aptitude for “reading” patients and gaining their trust during the initial encounter.
Patterns in the medical records may indicate a history of prescription drug abuse. A more detailed history might elicit other relevant risk factors: a history of chronic pain, psychiatric disorders—even smoking within one hour of waking in the morning.4,20 In the presence of two or more risk factors, strong consideration should be given to nonnarcotic treatment of pain and referral to a primary care clinician for multidisciplinary intervention.
Several available screening tools can increase sensitivity while standardizing the process; examples are the Screener and Opioid Assessment for Patients in Pain (see www.painedu.org) and the Screening Instrument for Substance Abuse Potential.21 These may be more useful in the primary care or outpatient setting than in the ED with its time constraints.
The manner in which EMPs write prescriptions can have direct impact on medication diversion. In the ED, prescriptions are more commonly written for opioid pain medications than for sedatives or stimulants. While addressing pain adequately is important, it is often appropriate to prescribe lower-potency opioids or even nonnarcotic pain relievers. EMPs should limit the total number of pills specified in proportion to the immediate diagnosis, and refills should not be provided—if for no other reason than to encourage timely follow-up.
Delayed-release opioids, because they lack the protective measures built into delayed-release stimulants, should be avoided in the ED for treatment of acute pain; research is under way to develop oxycodone in viscous gel form that is immune to injection.22 In other efforts, opioids are being combined with the antagonist naloxone to blunt the opioids’ immediate euphoric effects.20 Writing out the number of pills on hand-written prescriptions and using watermark paper for computer-generated prescriptions can also diminish forgery and diversion.
Educating patients—especially teenagers—about the potential for drug tolerance, dependence, and abuse plays an integral role in combating this problem. With most diverted prescription psychotherapeutic medications coming from family or friends, convincing parents to safeguard prescriptions in the household is critical. A huge discrepancy exists between what parents perceive about their children’s prescription drug use and what actually occurs. Although 21% of teenagers admit to using prescription pain medications for their psychotherapeutic effects, only 1% of parents consider it “extremely likely” or “very likely” that their child has done so.23
When parents actively address this important issue—teaching their children about the dangers of drug and prescription drug abuse—these practices can be reduced by nearly half.23 Impressing on parents the importance of their role in preventing prescription drug abuse may be the single most important way for EMPs to further the cause.
Resources for Concerned Clinicians
The DEA and the FDA rely on a complex set of databases to monitor prescription drug abuse. The Drug Abuse Warning Network (DAWN)24 and the NSDUH,8 administered by the Department of Health and Human Services, are two examples. DAWN is a public health surveillance system that monitors drug-related visits to hospital EDs through chart review and drug-related deaths investigated by medical examiners and coroners. By joining DAWN, EDs can gain access to real-time data and receive payments to participate in data collection.24 NSDUH gathers data by administering in-home, face-to-face questionnaires to a representative sample of the population. Both programs publish reports on the Internet and make findings available to the general public.8,24
Also in the arena of prescription drug abuse monitoring is an industry-initiated database known as RADARS (Researched Abuse, Diversion and Addiction-Related Surveillance), developed by Purdue Pharma to address diversion and abuse of OxyContin®. RADARS’ goal is to develop proactive, timely, geographically sensitive methods to detect abuse and diversion of OxyContin and other scheduled prescription medications.25 This program acquires high-quality data from drug abuse experts, law enforcement agencies, and regional Poison Control Centers, covering more than 80% of the nation’s zip codes. Regionally specific risk-minimization strategies are RADARS’ next goal.
Clinicians who provide emergency care are in a position to slow, or even reverse, the escalating misuse of prescription medications by teenage patients. Primary care providers, too, are called on to keep abreast of emerging reports on this trend, to reconsider how they write prescriptions for psychotherapeutic agents, and to be vigilant to the signs of abuse in their adolescent patients.
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20. Wilson JF. Strategies to stop abuse of prescribed opioid drugs. Ann Intern Med. 2007;146(12):897-900.
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