1 National Institute on Drug Abuse (NIDA) Misuse of Prescription Drugs Last Updated January 2018 https://www.drugabuse.gov
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NationalInstituteonDrugAbuse(NIDA)
MisuseofPrescriptionDrugs
LastUpdatedJanuary2018
https://www.drugabuse.gov
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TableofContents
MisuseofPrescriptionDrugs
Summary
Whatisthescopeofprescriptiondrugmisuse?
Howmanypeoplesufferadversehealthconsequencesfrommisuseofprescriptiondrugs?
Isitsafetouseprescriptiondrugsincombinationwithothermedications?
Whichclassesofprescriptiondrugsarecommonlymisused?
Areprescriptiondrugssafetotakewhenpregnant?
Howcanprescriptiondrugmisusebeprevented?
Howcanprescriptiondrugaddictionbetreated?
WherecanIgetfurtherinformationaboutprescriptiondrugmisuse?
References
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Summary
Misuseofprescriptiondrugsmeanstakingamedicationinamannerordoseotherthanprescribed;takingsomeoneelse’sprescription,evenifforalegitimatemedicalcomplaintsuchaspain;ortakingamedicationtofeeleuphoria(i.e.,togethigh).*Thetermnonmedicaluseofprescriptiondrugsalsoreferstothesecategoriesofmisuse.Thethreeclassesofmedicationmostcommonlymisusedare :
opioids—usuallyprescribedtotreatpain
centralnervoussystem[CNS]depressants(thiscategoryincludestranquilizers,sedatives,andhypnotics)—usedtotreatanxietyandsleepdisorders
stimulants—mostoftenprescribedtotreatattention-deficithyperactivitydisorder(ADHD)
Prescriptiondrugmisusecanhaveseriousmedicalconsequences.Increasesinprescriptiondrugmisuse overthelast15yearsarereflectedinincreasedemergencyroomvisits,overdosedeathsassociatedwithprescriptiondrugs ,andtreatmentadmissionsforprescriptiondrugusedisorders,themostsevereformofwhichisaddiction.Amongthosewhoreportedpast-yearnonmedicaluseofaprescriptiondrug,nearly12percentmetcriteriaforprescriptiondrugusedisorder. Unintentionaloverdosedeathsinvolvingopioidpainrelievers
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havemorethanquadrupledsince1999andhaveoutnumberedthoseinvolvingheroinandcocainesince2002.
*Takingprescriptiondrugstogethighissometimescalled"prescriptiondrugabuse."
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Whatisthescopeofprescriptiondrugmisuse?
Misuseofprescriptionopioids,centralnervoussystem(CNS)depressants,andstimulantsisaseriouspublichealthproblemintheUnitedStates.Althoughmostpeopletakeprescriptionmedicationsresponsibly,anestimated54millionpeople(morethan20percentofthoseaged12andolder)haveusedsuchmedicationsfornonmedicalreasonsatleastonceintheirlifetime. Accordingtoresultsfromthe2014NationalSurveyonDrugUseandHealth,anestimated2.1millionAmericansusedprescriptiondrugsnonmedicallyforthefirsttimewithinthepastyear,whichaveragestoapproximately5,750initiatesperday.Fifty-fourpercentwerefemalesandabout30percentwereadolescents.
Thereasonsforthehighprevalenceofprescriptiondrugmisusevarybyage,gender,andotherfactors,butlikelyincludeeaseofaccess. Thenumberofprescriptionsforsomeofthesemedicationshasincreaseddramaticallysincetheearly1990s. Moreover,misinformationabouttheaddictivepropertiesofprescriptionopioidsandtheperceptionthatprescriptiondrugsarelessharmfulthanillicitdrugsareotherpossiblecontributorstotheproblem.
AlthoughmisuseofprescriptiondrugsaffectsmanyAmericans,certainpopulationssuchasyouth,olderadults,andwomenmaybeatparticularrisk.Inaddition,whilemorementhanwomencurrentlymisuseprescriptiondrugs,
theratesofmisuseandoverdoseamongwomenareincreasingfasterthanamongmen.
AdolescentsandYoungAdults
Nonmedicaluseofprescriptiondrugsishighestamongyoungadultsaged18to25,with4.6percentreportingnonmedicaluseinthepastmonth.Amongyouthaged12to17,1.6percentreportedpast-monthnonmedicaluseofprescriptionmedications.
Afteralcohol,marijuana,andtobacco,prescriptiondrugs(takennonmedically)
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areamongthemostcommonlyuseddrugsby12thgraders.TheNIDA’sMonitoringtheFuturesurveyofsubstanceuseandattitudesinteensfoundthatabout6percentofhighschoolseniorsreportedpast-yearnonmedicaluseoftheprescriptionstimulantAdderall in2017,and2percentreportedmisusingtheopioidpainrelieverVicodin .
Althoughpast-yearnonmedicaluseofCNSdepressantsandopioidpainrelieversdecreasedamong12thgradersbetween2011and2015,thisisnotthecaseforthenonmedicaluseofstimulants.NonmedicaluseofAdderallincreasedbetween2009and2013buthassinceappearedtodecline. Whenaskedhowtheyobtainedprescriptionstimulantsfornonmedicaluse,morethanhalfoftheadolescentsandyoungadultssurveyedsaidtheyeitherboughtorreceivedthedrugsfromafriendorrelative.Interestingly,thenumberwhopurchasedthesedrugsthroughtheinternetwasnegligible.
Youthwhomisuseprescriptionmedicationsarealsomorelikelytoreportuseofotherdrugs.Multiplestudieshaverevealedassociationsbetweenprescriptiondrugmisuseandhigherratesofcigarettesmoking;heavyepisodicdrinking;andmarijuana,cocaine,andotherillicitdruguseamongU.S.adolescents,youngadults,andcollegestudents. Inthecaseofprescriptionopioids,medicaluseisalsoassociatedwithagreaterriskoffutureopioidmisuse,particularlyinadolescentswhodisapproveofillegaldruguseandhavelittletonohistoryofdruguse.
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OlderAdults
Morethan80percentofolderpatients(aged57to85years)useatleastoneprescriptionmedicationonadailybasis,withmorethan50percenttakingmorethanfivemedicationsorsupplementsdaily. Thiscanpotentiallyleadtohealthissuesresultingfromunintentionallyusingaprescriptionmedicationinamannerotherthanhowitwasprescribed,orfromintentionalnonmedicaluse.Thehighratesofmultiple(comorbid)chronicillnessesinolderpopulations,age-relatedchangesindrugmetabolism,andthepotentialfordruginteractionsmakesmedication(andothersubstance)misusemoredangerousinolderpeoplethaninyoungerpopulations. Further,alargepercentageofolderadultsalsouseover-the-countermedicinesanddietarysupplements,which(inadditiontoalcohol)couldcompoundanyadversehealthconsequencesresultingfromnonmedicaluseofprescriptiondrugs.
Women
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Overall,moremalesthanfemalesmisuseprescriptiondrugsinallagegroupsexceptadolescence(12to17years);adolescentgirlsexceedboysinthenonmedicaluseofallprescriptiondrugs,includingpainrelievers,sedatives,andstimulants.Amongnonmedicalusersofprescriptiondrugs,females12to17yearsoldarealsomorelikelytomeetsubstanceusedisordercriteriaforprescriptiondrugs. Additionally,whilemorementhanwomendieofprescriptionopioidoverdose,therateofoverdoseisincreasingmoresharplyinwomenthaninmen.
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Howmanypeoplesufferadversehealthconsequencesfrommisuseofprescriptiondrugs?
TheDrugAbuseWarningNetwork(DAWN)monitoredemergencydepartment(ED)visitsinselectedareasacrosstheNationthrough2011.DAWNreportedthatmorethan1.2millionEDvisitsin2011couldbeattributedtononmedicaluseofprescriptiondrugs;thisrepresentsabouthalf(50.5percent)ofallEDvisitsrelatedtodrugmisuse.Roughly488,000,or39.2percent,oftheseEDvisitsinvolvedprescriptionopioidpainrelievers,aratenearlytriplethatof6yearsprior.EDvisitsalsomorethanquadrupledforcentralnervoussystem(CNS)stimulantstonearly41,000visitsin2011andincreased138percentforCNSdepressantsto422,000visits.Ofthelatter,85percentinvolvedbenzodiazepines(e.g.,Xanax ).EDvisitsrelatedtouseofzolpidem(Ambien ),apopularprescribednon-benzodiazepinesleepaid,rosefromroughly13,000in2004to30,000in2011.MorethanhalfofEDvisitsfornonmedicaluseofprescriptiondrugsinvolvedmultipledrugs. Analysisofhospitalinpatientdataalsorevealeda72percentincreaseinhospitalizationsrelatedtoopioiduseoverthedecadefrom2002to2012,includingincreasesinseriousinfectionassociatedwithintravenousdrugadministration.Inpatientcostsforthesehospitalizationsquadrupledoverthesametimeperiod.
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Isitsafetouseprescriptiondrugsincombinationwithothermedications?
Thesafetyofusingprescriptiondrugsincombinationwithothersubstancesdependsonanumberoffactorsincludingthetypesofmedications,dosages,othersubstanceuse(e.g.,alcohol),andindividualpatienthealthfactors.Patientsshouldtalkwiththeirhealthcareprovideraboutwhethertheycansafelyusetheirprescriptiondrugswithothersubstances,includingprescriptionandover-the-counter(OTC)medicationsaswellasalcohol,tobacco,andillicitdrugs.Specifically,drugsthatslowdownbreathingrate,suchasopioids,alcohol,antihistamines,prescriptioncentralnervoussystemdepressants(includingbarbituratesandbenzodiazepines),orgeneralanesthetics,shouldnotbetakentogetherbecausethesecombinationsincreasetheriskoflife-threateningrespiratorydepression. Stimulantsshouldalsonotbeusedwithothermedicationsunlessrecommendedbyaphysician.PatientsshouldbeawareofthedangersassociatedwithmixingstimulantsandOTCcoldmedicinesthatcontaindecongestants,ascombiningthesesubstancesmaycausebloodpressuretobecomedangerouslyhighorleadtoirregularheartrhythms.
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Whichclassesofprescriptiondrugsarecommonlymisused?
Opioids
Whatareopioids?
Opioidsaremedicationsthatactonopioidreceptorsinboththespinalcordandbraintoreducetheintensityofpain-signalperception.Theyalsoaffectbrainareasthatcontrolemotion,whichcanfurtherdiminishtheeffectsofpainfulstimuli.Theyhavebeenusedforcenturiestotreatpain,cough,anddiarrhea. Themostcommonmodernuseofopioidsistotreatacutepain.However,sincethe1990s,theyhavebeenincreasinglyusedtotreatchronicpain,despitesparseevidencefortheireffectivenesswhenusedlongterm. Indeed,somepatientsexperienceaworseningoftheirpainorincreasedsensitivitytopainasaresultoftreatmentwithopioids,aphenomenonknownashyperalgesia. Importantly,inadditiontorelievingpain,opioidsalsoactivaterewardregionsinthebraincausingtheeuphoria—orhigh—thatunderliesthepotentialformisuseandaddiction.Chemically,thesemedicationsareverysimilartoheroin,whichwasoriginallysynthesizedfrommorphineasapharmaceuticalinthelate19thcentury. Thesepropertiesconferanincreasedriskofaddictionandoverdoseeveninpatientswhotaketheirmedicationasprescribed.
Prescriptionopioidmedicationsincludehydrocodone(e.g.,Vicodin ),oxycodone(e.g.,OxyContin ,Percocet ),oxymorphone(e.g.,Opana ),morphine(e.g.,Kadian ,Avinza ),codeine,fentanyl,andothers.HydrocodoneproductsarethemostcommonlyprescribedintheUnitedStatesforavarietyofindications,includingdental-andinjury-relatedpain. Oxycodoneandoxymorphonearealsoprescribedformoderatetoseverepainrelief. Morphineisoftenusedbeforeandaftersurgicalprocedurestoalleviateseverepain,andcodeineistypicallyprescribedformilderpain. Inadditiontotheirpain-relievingproperties,someofthesedrugs—codeineanddiphenoxylate(Lomotil ),forexample—areusedto
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Howdoopioidsaffectthebrainandbody?
Opioidsactbyattachingtoandactivatingopioidreceptorproteins,whicharefoundonnervecellsinthebrain,spinalcord,gastrointestinaltract,andotherorgansinthebody. Whenthesedrugsattachtotheirreceptors,theyinhibitthetransmissionofpainsignals.Opioidscanalsoproducedrowsiness,mentalconfusion,nausea,constipation,andrespiratorydepression,andsincethesedrugsalsoactonbrainregionsinvolvedinreward,theycaninduceeuphoria,particularlywhentheyaretakenatahigher-than-prescribeddoseoradministeredinotherwaysthanintended. Forexample,OxyContin isanoralmedicationusedtotreatmoderatetoseverepainthroughaslow,steadyreleaseoftheopioid.SomepeoplewhomisuseOxyContin intensifytheirexperiencebysnortingorinjectingit. Thisisaverydangerouspractice,greatlyincreasingtheperson’sriskforseriousmedicalcomplications,includingoverdose.
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UnderstandingDependence,Addiction,andTolerance
Dependenceoccursasaresultofphysiologicaladaptationstochronicexposuretoadrug.Itisoftenapartofaddiction,buttheyarenotequivalent.Addictioninvolvesotherchangestobraincircuitryandisdistinguishedbycompulsivedrugseekingandusedespitenegativeconsequences.
Thosewhoaredependentonamedicationwillexperienceunpleasantphysicalwithdrawalsymptomswhentheyabruptlyreduceorstopuseofthedrug.Thesesymptomscanbemildtosevere(dependingonthedrug)andcanusuallybemanagedmedicallyoravoidedbyslowlytaperingdownthedrugdosage.
Tolerance,ortheneedtotakehigherdosesofamedicationtogetthesameeffect,oftenaccompaniesdependence.Whentoleranceoccurs,itcanbedifficultforaphysiciantoevaluatewhetherapatientisdevelopingadrugproblemorhasamedicalneedforhigherdosestocontrolhisorhersymptoms.Forthisreason,physiciansshouldbevigilantandattentivetotheirpatients’symptomsandleveloffunctioningandshouldscreenforsubstancemisusewhentoleranceordependenceispresent.
Whatarethepossibleconsequencesofprescriptionopioidmisuse?
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Whentakenasprescribed,patientscanoftenuseopioidstomanagepainsafelyandeffectively.However,itispossibletodevelopasubstanceusedisorderwhentakingopioidmedicationsasprescribed.Thisriskandtheriskforoverdoseincreasewhenthesemedicationsaremisused.Evenasinglelargedoseofanopioidcancausesevererespiratorydepression(slowingorstoppingofbreathing),whichcanbefatal;takingopioidswithalcoholorsedativesincreasesthisrisk.
Whenproperlymanaged,short-termmedicaluseofopioidpainrelievers—takenforafewdaysfollowingoralsurgery,forinstance—rarelyleadstoanopioidusedisorderoraddiction.Butregular(e.g.,severaltimesaday,forseveralweeksormore)orlonger-termuseofopioidscanleadtodependence(physicaldiscomfortwhennottakingthedrug),tolerance(diminishedeffectfromtheoriginaldose,leadingtoincreasingtheamounttaken),and,insomecases,addiction(compulsivedrugseekinganduse)(see"UnderstandingDependence,Addiction,andTolerance").Withbothdependenceandaddiction,withdrawalsymptomsmayoccurifdruguseissuddenlyreducedorstopped.Thesesymptomsmayincluderestlessness,muscleandbonepain,insomnia,diarrhea,vomiting,coldflasheswithgoosebumps,andinvoluntarylegmovements.
Misuseofprescriptionopioidsisalsoariskfactorfortransitioningtoheroinuse.Readmoreabouttherelationshipbetweenprescriptionopioidsand
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heroinintheNIDA'sPrescriptionOpioidsandHeroinResearchReport.
Howisprescriptionopioidmisuserelatedtochronicpain?
Healthcareprovidershavelongwrestledwithhowbesttotreatthemorethan100millionAmericanswhosufferfromchronicpain. Opioidshavebeenthemostcommontreatmentforchronicpainsincethelate1990s,butrecentresearchhascastdoubtbothontheirsafetyandtheirefficacyinthetreatmentofchronicpainwhenitisnotrelatedtocancerorpalliativecare. Thepotentialrisksinvolvedwithlong-termopioidtreatment,suchasthedevelopmentofdrugtolerance,hyperalgesia,andaddiction,presentdoctorswithadilemma,asthereislimitedresearchonalternativetreatmentsforchronicpain.Patientsthemselvesmayevenbereluctanttotakeanopioidmedicationprescribedtothemforfearofbecomingaddicted.
Estimatesoftherateofopioidaddictionamongchronicpainpatientsvaryfromabout3percentupto26percent.Thisvariabilityistheresultofdifferencesintreatmentduration,insufficientresearchonlong-termoutcomes,anddisparatestudypopulationsandmeasuresusedtoassessnonmedicaluseoraddiction.
Tomitigateaddictionrisk,physiciansshouldadheretotheCDCGuidelineforPrescribingOpioidsforChronicPain.Beforeprescribing,physiciansshouldassesspainandfunctioning,considerifnon-opioidtreatmentoptionsareappropriate,discussatreatmentplanwiththepatient,evaluatethepatient’sriskofharmormisuse,andcoprescribenaloxonetomitigatetheriskforoverdose(seetheNIDA'swebpageonnaloxone).Whenfirstprescribingopioids,physiciansshouldgivethelowesteffectivedosefortheshortesttherapeuticduration.Astreatmentcontinues,thepatientshouldbemonitoredatregularintervals,andopioidtreatmentshouldbecontinuedonlyifmeaningfulclinicalimprovementsinpainandfunctioningareseenwithoutharm.
Changingtherouteofadministrationcanalsobeafeatureofthemisuse
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ofotherprescriptionmedications,includingstimulants,apracticethatcanleadtoseriousmedicalconsequences.
CNSDepressants
WhatareCNSdepressants?
Centralnervoussystem(CNS)depressants,acategorythatincludestranquilizers,sedatives,andhypnotics,aresubstancesthatcanslowbrainactivity.Thispropertymakesthemusefulfortreatinganxietyandsleepdisorders.Thefollowingareamongthemedicationscommonlyprescribedforthesepurposes :
Benzodiazepines,suchasdiazepam(Valium ),clonazepam(Klonopin ),andalprazolam(Xanax ),aresometimesprescribedtotreatanxiety,acutestressreactions,andpanicattacks.Clonazepammayalsobeprescribedtotreatseizuredisorders.Themoresedatingbenzodiazepines,suchastriazolam(Halcion )andestazolam(Prosom )areprescribedforshort-termtreatmentofsleepdisorders.Usually,benzodiazepinesarenotprescribedforlong-termusebecauseofthehighriskfordevelopingtolerance,dependence,oraddiction.
Non-benzodiazepinesleepmedications,suchaszolpidem(Ambien ),eszopiclone(Lunesta ),andzaleplon(Sonata ),knownasz-drugs,haveadifferentchemicalstructurebutactonthesameGABAtypeAreceptorsinthebrainasbenzodiazepines.Theyarethoughttohavefewersideeffectsandlessriskofdependencethanbenzodiazepines.
Barbiturates,suchasmephobarbital(Mebaral ),phenobarbital(Luminal ),andpentobarbitalsodium(Nembutal ),areusedlessfrequentlytoreduceanxietyortohelpwithsleepproblemsbecauseoftheirhigherriskofoverdosecomparedtobenzodiazepines.However,theyarestillusedinsurgicalproceduresandtotreatseizuredisorders.
HowdoCNSdepressantsaffectthebrainandbody?
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MostCNSdepressantsactonthebrainbyincreasingactivityatreceptorsfortheinhibitoryneurotransmittergamma-aminobutyricacid(GABA).Althoughthedifferentclassesofdepressantsworkinuniqueways,itisthroughtheirabilitytoincreaseGABAsignaling—therebyincreasinginhibitionofbrainactivity—thattheyproduceadrowsyorcalmingeffectthatismedicallybeneficialtothosesufferingfromanxietyorsleepdisorders.
WhatarethepossibleconsequencesofCNSdepressantmisuse?
Despitetheirbeneficialtherapeuticeffects,benzodiazepinesandbarbiturateshavethepotentialformisuseandshouldbeusedonlyasprescribed. Theuseofnon-benzodiazepinesleepaids,orz-drugs,islesswell-studied,butcertainindicatorshaveraisedconcernabouttheirpsychoactivepropertiesaswell.
Duringthefirstfewdaysoftakingadepressant,apersonusuallyfeelssleepyanduncoordinated,butasthebodybecomesaccustomedtotheeffectsofthedrugandtolerancedevelops,thesesideeffectsbegintodisappear.Ifoneusesthesedrugslongterm,heorshemayneedlargerdosestoachievethetherapeuticeffects.Continuedusecanalsoleadtodependenceandwithdrawalwhenuseisabruptlyreducedorstopped(see"UnderstandingDependence,Addiction,andTolerance").Becauseallsedativesworkbyslowingthebrain’sactivity,whenanindividualstopstakingthem,therecanbeareboundeffect,resultinginseizuresorotherharmfulconsequences.
Althoughwithdrawalfrombenzodiazepinescanbeproblematic,itisrarelylifethreatening,whereaswithdrawalfromprolongeduseofbarbituratescanhavelife-threateningcomplications. Therefore,someonewhoisthinkingaboutdiscontinuingasedativeorwhoissufferingwithdrawalfromCNSdepressantsshouldspeakwithaphysicianorseekimmediatemedicaltreatment.
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Stimulants
Whatarestimulants?
Stimulantsincreasealertness,attention,andenergy,aswellaselevatebloodpressure,heartrate,andrespiration.Historically,stimulantswereusedtotreatasthmaandotherrespiratoryproblems,obesity,neurologicaldisorders,andavarietyofotherailments.Butastheirpotentialformisuseandaddictionbecameapparent,thenumberofconditionstreatedwithstimulantshasdecreased. Now,stimulantsareprescribedforthetreatmentofonlyafewhealthconditions,includingattention-deficithyperactivitydisorder(ADHD),narcolepsy,andoccasionallytreatment-resistantdepression.
Howdostimulantsaffectthebrainandbody?
Stimulants,suchasdextroamphetamine(Dexedrine ,Adderall )andmethylphenidate(Ritalin ,Concerta ),actinthebrainonthefamilyofmonoamineneurotransmittersystems,whichincludenorepinephrineanddopamine.Stimulantsenhancetheeffectsofthesechemicals.Anincreaseindopaminesignalingfromnonmedicaluseofstimulantscaninduceafeelingofeuphoria,andthesemedications’effectsonnorepinephrineincreasebloodpressureandheartrate,constrictbloodvessels,increasebloodglucose,andopenupbreathingpassages.
Whatarethepossibleconsequencesofstimulantmisuse?
Aswithotherdrugsinthestimulantcategory,suchascocaine,itispossibleforpeopletobecomedependentonoraddictedtoprescriptionstimulants.Withdrawalsymptomsassociatedwithdiscontinuingstimulantuseincludefatigue,depression,anddisturbedsleeppatterns.Repeatedmisuseofsomestimulants(sometimeswithinashortperiod)canleadtofeelingsofhostilityorparanoia,orevenpsychosis. Further,takinghighdosesofastimulantmayresultindangerouslyhighbodytemperatureandanirregularheartbeat.Thereisalsothepotentialforcardiovascularfailureor
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CognitiveEnhancers
Thedramaticincreasesinstimulantprescriptionsoverthelast2decadeshaveledtotheirgreateravailabilityandtoincreasedriskfordiversionandnonmedicaluse. Whentakentoimproveproperlydiagnosedconditions,thesemedicationscangreatlyenhanceapatient’squalityoflife.However,becausemanyperceivethemtobegenerallysafeandeffective,prescriptionstimulantssuchasAdderall andModafinil arebeingmisusedmorefrequently.
Stimulantsincreasewakefulness,motivation,andaspectsofcognition,learning,andmemory.Somepeopletakethesedrugsintheabsenceofmedicalneedinanefforttoenhancementalperformance. Militarieshavelongusedstimulantstoincreaseperformanceinthefaceoffatigue,andtheUnitedStatesArmedForcesallowfortheiruseinlimitedoperationalsettings. Thepracticeisnowreportedbysomeprofessionalstoincreasetheirproductivity,byolderpeopletooffsetdecliningcognition,andbybothhighschoolandcollegestudentstoimprovetheiracademicperformance.
Nonmedicaluseofstimulantsforcognitiveenhancementposespotentialhealthrisks,includingaddiction,cardiovascularevents,andpsychosis.Theuseofpharmaceuticalsforcognitiveenhancementhasalsosparkeddebateovertheethicalimplicationsofthepractice.Issuesoffairnessariseifthosewithaccessandwillingnesstotakethesedrugshaveaperformanceedgeoverothers,andimplicitcoerciontakesplaceifacultureofcognitiveenhancementgivestheimpressionthatapersonmusttakedrugsinordertobecompetitive.
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Areprescriptiondrugssafetotakewhenpregnant?
Prescriptionmedicationstakenbyapregnantwomancancauseherbabytodevelopdependence,whichcanresultinwithdrawalsymptomsafterbirth,knownasneonatalabstinencesyndrome(NAS).Thiscanrequireaprolongedstayinneonatalintensivecareand,inthecaseofopioids,treatmentwithmedication(see"SexandGenderDifferencesinSubstanceUseDisorderTreatment"intheNIDA'sSubstanceUseinWomenResearchReport).Womenshouldconsultwiththeirdoctorstodeterminewhichmedicationstheycancontinuetakingduringpregnancy.
Opioidpainmedicationsrequireparticularattention;risingratesofNAShavebeenassociatedwithincreasesintheprescriptionofopioidsforpaininpregnantwomen.NASassociatedwithopioiduse(heroinorprescriptionopioids)increasedfivefoldfrom2000to2012,withahigherrateofincreaseinmorerecentyears.
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Howcanprescriptiondrugmisusebeprevented?
Clinicians,Patients,andPharmacists
Physicians,theirpatients,andpharmacistsallcanplayaroleinidentifyingandpreventingnonmedicaluseofprescriptiondrugs.
Clinicians.Morethan80percentofAmericanshadcontactwithahealthcareprofessionalinthepastyear ,placingdoctorsinauniquepositiontoidentifynonmedicaluseofprescriptiondrugsandtakemeasurestopreventtheescalationofapatient’smisusetoasubstanceusedisorder.Byaskingaboutalldrugs,physicianscanhelptheirpatientsrecognizethataproblemexists,provideorreferthemtoappropriatetreatment,andsetrecoverygoals.Evidence-basedscreeningtoolsfornonmedicaluseofprescriptiondrugscanbeincorporatedintoroutinemedicalvisits(seetheNIDAMEDwebpageforresourcesformedicalandhealthprofessionals).Doctorsshouldalsotakenoteofrapidincreasesintheamountofmedicationneededorfrequent,unscheduledrefillrequests.Doctorsshouldbealerttothefactthatthosemisusingprescriptiondrugsmayengagein"doctorshopping"—movingfromprovidertoprovider—inanefforttoobtainmultipleprescriptionsfortheirdrug(s)ofchoice.
Prescriptiondrugmonitoringprograms(PDMPs),state-runelectronicdatabasesusedtotracktheprescribinganddispensingofcontrolledprescriptiondrugstopatients,arealsoimportanttoolsforpreventingandidentifyingprescriptiondrugmisuse.Whileresearchregardingtheimpactoftheseprogramsiscurrentlymixed,theuseofPDMPsinsomestateshasbeenassociatedwithlowerratesofopioidprescribingandoverdose ,thoughissuesofbestpractices,easeofuse,andinteroperabilityremaintoberesolved.
In2015,thefederalgovernmentlaunchedaninitiativedirectedtowardreducingopioidmisuseandoverdose,inpartbypromotingmorecautiousandresponsibleprescribingofopioidmedications.Inlinewiththeseefforts,
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in2016theCentersforDiseaseControlandPrevention(CDC)publisheditsCDCGuidelineforPrescribingOpioidsforChronicPaintoestablishclinicalstandardsforbalancingthebenefitsandrisksofchronicopioidtreatment.Preventingorstoppingnonmedicaluseofprescriptiondrugsisanimportantpartofpatientcare.However,certainpatientscanbenefitfromprescriptionstimulants,sedatives,oropioidpainrelievers.Therefore,physiciansshouldbalancethelegitimatemedicalneedsofpatientswiththepotentialriskformisuseandrelatedharms.
Patients.Patientscantakestepstoensurethattheyuseprescriptionmedicationsappropriatelyby:
followingthedirectionsasexplainedonthelabelorbythepharmacist
beingawareofpotentialinteractionswithotherdrugsaswellasalcohol
neverstoppingorchangingadosingregimenwithoutfirstdiscussingitwiththedoctor
neverusinganotherperson’sprescription,andnevergivingtheirprescriptionmedicationstoothers
storingprescriptionstimulants,sedatives,andopioidssafely
Additionally,patientsshouldproperlydiscardunusedorexpiredmedicationsbyfollowingU.S.FoodandDrugAdministration(FDA)guidelinesorvisitingU.S.DrugEnforcementAdministrationcollectionsites. Inadditiontodescribingtheirmedicalproblem,patientsshouldalwaysinformtheirhealthcareprofessionalsaboutalltheprescriptions,over-the-countermedicines,anddietaryandherbalsupplementstheyaretakingbeforetheyobtainanyothermedications.
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Pharmacists.Pharmacistscanhelppatientsunderstandinstructionsfortakingtheirmedications.Inaddition,bybeingwatchfulforprescriptionfalsificationsoralterations,pharmacistscanserveasthefirstlineofdefenseinrecognizingproblematicpatternsinprescriptiondruguse.Somepharmacieshavedevelopedhotlinestoalertotherpharmaciesintheregionwhentheydetectafraudulentprescription.Alongwithphysicians,pharmacistscanusePDMPstohelptrackopioid-prescribingpatternsinpatients.
MedicationFormulationandRegulation
Manufacturersofprescriptiondrugscontinuetoworkonnewformulationsofopioidmedications,knownasabuse-deterrentformulations(ADF),whichincludetechnologiesdesignedtopreventpeoplefrommisusingthembysnortingorinjection.Approachescurrentlybeingusedorstudiedforuseinclude:
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physicalorchemicalbarriersthatpreventthecrushing,grinding,ordissolvingofdrugproducts
agonist/antagonistcombinationsthatcauseanantagonist(whichwillcounteractthedrugeffect)tobereleasediftheproductismanipulated
aversivesubstancesthatareaddedtocreateunpleasantsensationsifthedrugistakeninawayotherthandirected
deliverysystemssuchaslong-actinginjectionsorimplantsthatslowlyreleasethedrugovertime
newmolecularentitiesorprodrugsthatattachachemicalextensiontoadrugthatrendersitinactiveunlessitistakenorally
SeveralADFopioidsareonthemarket,andtheFDAhasalsocalledforthedevelopmentofADFstimulants. WhileADFopioidshavebeenshowntodecreasetheillicitvalueofadrug,intheabsenceofreduceddemand,theycanshiftusetootherformulations. Medicationregulationhasbeenshowntobeeffectiveindecreasingtheprescribingofopioidmedications.In2014,theDrugEnforcementAdministrationmovedhydrocodoneproductsfromscheduleIIItothemorerestrictivescheduleII,whichresultedinadecreaseinhydrocodoneprescribingthatdidnotresultinanyattendantincreasesintheprescribingofotheropioids.
DevelopmentofSaferMedications
Thedevelopmentofeffective,nonaddictingpainmedicationsisapublichealthpriority.Agrowingnumberofolderadultsandanincreasingnumberofinjuredmilitaryservicemembersaddtotheurgencyoffindingnewtreatments.Researchersareexploringalternativetreatmentapproachesthattargetothersignalingsystemsinthebodysuchastheendocannabinoidsystem,whichisalsoinvolvedinpain. Moreresearchisalsoneededtobetterunderstandeffectivechronicpainmanagement,includingidentifyingfactorsthatpredisposesomepatientstosubstanceusedisordersanddevelopingmeasurestopreventthenonmedicaluseofprescriptionmedications.
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Howcanprescriptiondrugaddictionbetreated?
Yearsofresearchhaveshownthatsubstanceusedisordersarebraindisordersthatcanbetreatedeffectively.Treatmentmusttakeintoaccountthetypeofdrugusedandtheneedsoftheindividual.Successfultreatmentmayneedtoincorporateseveralcomponents,includingdetoxification,counseling,andmedications,whenavailable.Multiplecoursesoftreatmentmaybeneededforthepatienttomakeafullrecovery.
Thetwomaincategoriesofdrugaddictiontreatmentarebehavioraltreatments(suchascontingencymanagementandcognitive-behavioraltherapy)andmedications.Behavioraltreatmentshelppatientsstopdrugusebychangingunhealthypatternsofthinkingandbehavior;teachingstrategiestomanagecravingsandavoidcuesandsituationsthatcouldleadtorelapse;or,insomecases,providingincentivesforabstinence.Behavioraltreatments,whichmaytaketheformofindividual,family,orgroupcounseling,alsocanhelppatientsimprovetheirpersonalrelationshipsandtheirabilitytofunctionatworkandinthecommunity.
Addictiontoprescriptionopioidscanadditionallybetreatedwithmedicationsincludingbuprenorphine,methadone,andnaltrexone[see"Medication-AssistedTreatment(MAT)"below].Thesedrugscancountertheeffectsofopioidsonthebrainorrelievewithdrawalsymptomsandcravings,helpingthepatientavoidrelapse.Medicationsforthetreatmentofaddictionareadministeredincombinationwithpsychosocialsupportsorbehavioraltreatments,knownasmedication-assistedtreatment(MAT).
Medication-AssistedTreatment(MAT)
Naltrexoneisanantagonistmedicationthatpreventsotheropioidsfrombindingtoandactivatingopioidreceptors.Itisusedtotreatoverdoseandaddiction.Aninjectable,long-actingformofnaltrexone(Vivitrol )canbeausefultreatmentchoiceforpatientswhodonothavereadyaccessto
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healthcareorwhostrugglewithtakingtheirmedicationsregularly.
Methadoneisasyntheticopioidagonistthatpreventswithdrawalsymptomsandrelievesdrugcravingsbyactingonthesamebraintargetsasotheropioidssuchasheroin,morphine,andopioidpainmedications.Ithasbeenusedsuccessfullyformorethan40yearstotreatheroinaddictionbutisgenerallyonlyavailablethroughspeciallylicensedopioidtreatmentprograms.
Buprenorphineisapartialopioidagonist—itbindstotheopioidreceptorbutonlypartiallyactivatesit—thatcanbeprescribedbycertifiedphysiciansinanofficesetting.Likemethadone,itcanreducecravingsandiswelltoleratedbypatients.InMay2016,theU.S.FoodandDrugAdministration(FDA)approvedtheNIDA-supporteddevelopmentofanimplantableformulationofbuprenorphineandaoncemonthlybuprenorphineinjectioninNovember2017.Bothwillgivebuprenorphine-stabilizedpatientsgreateaseintreatmentadherence.
ANIDAstudycomparingtheeffectivenessofabuprenorphine/naloxonecombinationandanextendedreleasenaltrexoneformulationontreatingopioidusedisorderhasfoundthatbothmedicationsaresimilarlyeffectiveintreatingopioidusedisorderoncetreatmentisinitiated.Becausenaltrexonerequiresfulldetoxification,initiatingtreatmentamongactiveopioiduserswasmoredifficultwiththismedication.However,oncedetoxificationwascomplete,thenaltrexoneformulationhadasimilareffectivenessasthebuprenorphine/naloxonecombination.
Therehasbeenapopularmisconceptionthatmedicationswithagonistactivity,suchasmethadoneorbuprenorphine,replaceoneaddictionwithanother.Thisisnotthecase.Opioidusedisorderisassociatedwithimbalancesinbraincircuitsthatmediatereward,decision-making,impulsecontrol,learning,andotherfunctions.Thesemedicationsrestorebalancetothesebraincircuits,preventingopioidwithdrawalandrestoringthepatienttoanormalaffectivestatetoallowforeffectivepsychosocialtreatmentandsocialfunctioning.
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WhileMATisthestandardofcarefortreatingopioidusedisorder,farfewerpeoplereceiveMATthancouldpotentiallybenefitfromit.Notallpeoplewithopioidusedisorderseektreatment.Evenwhentheyseektreatment,theywillnotnecessarilyreceiveMAT.Themostrecenttreatmentadmissionsdataavailableshowthatonly18percentofpeopleadmittedforprescriptionopioidusedisorderhaveatreatmentplanthatincludesMAT.However,evenifthenationwideinfrastructurewereoperatingatcapacity,between1.3and1.4millionmorepeoplehaveopioidusedisorderthancouldcurrentlybetreatedwithMATduetolimitedavailabilityofopioidtreatmentprogramsthatcandispensemethadoneandtheregulatorylimitonthenumberofpatientsthatphysicianscantreatwithbuprenorphine.CoordinatedeffortsareunderwaynationwidetoexpandaccesstoMAT,includingarecentincreaseinthebuprenorphinepatientlimitfrom100patientsto275forqualifiedphysicianswhorequestthehigherlimit.
TheNIDAissupportingresearchneededtodeterminethemosteffectivewaystoimplementMAT.Forexample,recentworkhasshownthatbuprenorphinemaintenancetreatmentismoreeffectivethantaperingpatientsoffofbuprenorphine. Also,startingbuprenorphinetreatmentwhenapatientisadmittedtotheemergencydepartment,suchasforanoverdose,isamoreeffectivewaytoengageapatientintreatmentthanreferralorbriefintervention. Finally,datahaveshownthattreatmentwithmethadone,buprenorphine,ornaltrexoneforincarceratedindividualsimprovespost-releaseoutcomes.
ReversinganOpioidOverdosewithNaloxone
Theopioidoverdose-reversaldrugnaloxoneisanopioidantagonistthatcanrapidlyrestorenormalrespirationtoapersonwhohasstoppedbreathingasaresultofoverdoseonprescriptionopioidsorheroin.Naloxonecanbeusedbyemergencymedicalpersonnel,firstresponders,andbystanders.Formoreinformation,visittheNIDA'swebpageonnaloxone.
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TreatingAddictiontoCNSDepressants
Patientsaddictedtocentralnervoussystem(CNS)depressantssuchastranquilizers,sedatives,andhypnoticsshouldnotattempttostoptakingthemontheirown.Withdrawalsymptomsfromthesedrugscanbesevereand—inthecaseofcertainmedications—potentiallylife-threatening.ResearchontreatingaddictiontoCNSdepressantsissparse;however,patientswhoaredependentonthesemedicationsshouldundergomedicallysuperviseddetoxificationbecausethedosagetheytakeshouldbetaperedgradually.Inpatientoroutpatientcounselingcanhelpindividualsthroughthisprocess.Cognitive-behavioraltherapy,whichfocusesonmodifyingthepatient’sthinking,expectations,andbehaviorswhileincreasingskillsforcopingwithvariouslifestressors,hasalsobeenusedsuccessfullytohelpindividualsadapttodiscontinuingbenzodiazepines.
OftenCNSdepressantmisuseoccursinconjunctionwiththeuseofotherdrugs(polydruguse),suchasalcoholoropioids. Insuchcases,thetreatmentapproachshouldaddressthemultipleaddictions.
Atthistime,therearenoFDA-approvedmedicationsfortreatingaddictiontoCNSdepressants,thoughresearchisongoinginthisarea.
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TreatingAddictiontoPrescriptionStimulants
TreatmentofaddictiontoprescriptionstimulantssuchasAdderall andConcerta isbasedonbehavioraltherapiesthatareeffectivefortreatingcocaineandmethamphetamineaddiction.Atthistime,therearenoFDA-approvedmedicationsfortreatingstimulantaddiction.TheNIDAissupportingresearchinthisarea.
Dependingonthepatient,thefirststepsintreatingprescriptionstimulantaddictionmaybetotaperthedrugdosageandattempttoeasewithdrawalsymptoms.Behavioraltreatmentmaythenfollowthedetoxificationprocess(see"BehavioralTherapies"intheNIDA'sPrinciplesofDrugAddictionTreatment:AResearch-BasedGuide).
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WherecanIgetfurtherinformationaboutprescriptiondrugmisuse?
Tolearnmoreaboutprescriptiondrugsandotherdrugs,visittheNIDAwebsiteatdrugabuse.govorcontacttheDrugPubsResearchDisseminationCenterat877-NIDA-NIH(877-643-2644;TTY/TDD:240-645-0228).
TheNIDA'swebsiteincludes:
informationondrugsandrelatedhealthconsequences
NIDApublications,news,andevents
resourcesforhealthcareprofessionals
fundinginformation(includingprogramannouncementsanddeadlines)
internationalactivities
linkstorelatedwebsites(accesstowebsitesofmanyotherorganizationsinthefield)
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
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NIDAMED:drugabuse.gov/nidamed
Otherwebsites
Informationaboutprescriptiondrugmisuseisalsoavailablethroughthefollowingwebsites:
SubstanceAbuseandMentalHealthServicesAdministration:samhsa.gov
U.S.DrugEnforcementAdministration:dea.gov
MonitoringtheFuture:monitoringthefuture.org
PartnershipforDrug-FreeKids:drugfree.org/drug-guide
ThispublicationisavailableforyouruseandmaybereproducedinitsentiretywithoutpermissionfromtheNIDA.Citationofthesourceisappreciated,usingthefollowinglanguage:Source:NationalInstituteonDrugAbuse;NationalInstitutesofHealth;U.S.DepartmentofHealthandHumanServices.
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