National Institute on Drug Abuse (NIDA) Misuse of Prescription … drugs.pdf · 2020. 4. 3. · NIDA’s Monitoring the Future survey of substance use and attitudes in teens found

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NationalInstituteonDrugAbuse(NIDA)MisuseofPrescriptionDrugsLastUpdatedDecember2018https://www.drugabuse.gov

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TableofContentsMisuseofPrescriptionDrugs

Overview

Whatisthescopeofprescriptiondrugmisuse?

Isitsafetouseprescriptiondrugsincombinationwithothermedications?

Whatclassesofprescriptiondrugsarecommonlymisused?

Areprescriptiondrugssafetotakewhenpregnant?

Howcanprescriptiondrugmisusebeprevented?

Howcanprescriptiondrugaddictionbetreated?

WherecanIgetfurtherinformationaboutprescriptiondrugmisuse?

References

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Overview

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,themostsevereformofwhichisanaddiction.Overdosedeathsinvolvingprescriptionopioidswerefivetimeshigherin2016thanin1999.

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Whatisthescopeofprescriptiondrugmisuse?

Misuseofprescriptionopioids,CNSdepressants,andstimulantsisaseriouspublichealthproblemintheUnitedStates.Althoughmostpeopletakeprescriptionmedicationsresponsibly,in2017,anestimated18millionpeople(morethan6percentofthoseaged12andolder)havemisusedsuchmedicationsatleastonceinthepastyear.Accordingtoresultsfromthe2017NationalSurveyonDrugUseandHealth,anestimated2millionAmericansmisusedprescriptionpainrelieversforthefirsttimewithinthepastyear,whichaveragestoapproximately5,480initiatesperday.Additionally,morethanonemillionmisusedprescriptionstimulants,1.5millionmisusedtranquilizers,and271,000misusedsedativesforthefirsttime.

Thereasonsforthehighprevalenceofprescriptiondrugmisusevarybyage,gender,andotherfactors,butlikelyincludeeaseofaccess.Thenumberofprescriptionsforsomeofthesemedicationshasincreaseddramaticallysincetheearly1990s. Moreover,misinformationabouttheaddictivepropertiesofprescriptionopioidsandtheperceptionthatprescriptiondrugsarelessharmfulthanillicitdrugsareotherpossiblecontributorstotheproblem. AlthoughmisuseofprescriptiondrugsaffectsmanyAmericans,certainpopulationssuchasyouthandolderadultsmaybeatparticularrisk.

AdolescentsandYoungAdults

Misuseofprescriptiondrugsishighestamongyoungadultsages18to25,with14.4percentreportingnonmedicaluseinthepastyear.Amongyouthages12to17,4.9percentreportedpast-yearnonmedicaluseofprescriptionmedications.

Afteralcohol,marijuana,andtobacco,prescriptiondrugs(taken

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nonmedically)areamongthemostcommonlyuseddrugsby12graders.NIDA’sMonitoringtheFuturesurveyofsubstanceuseandattitudesinteensfoundthatabout6percentofhighschoolseniorsreportedpast-yearnonmedicaluseoftheprescriptionstimulantAdderall in2017,and2percentreportedmisusingtheopioidpainrelieverVicodin .

Althoughpast-yearnonmedicaluseofCNSdepressantshasremainedfairlystableamong12 graderssince2012,useofprescriptionopioidshasdeclinedsharply.Forexample,past-yearnonmedicaluseofVicodinamong12 graderswasreportedby9.6percentin2002anddeclinedto2.0percentin2017.NonmedicaluseofAdderall increasedbetween2009and2013,buthasbeendecreasingthrough2017.Whenaskedhowtheyobtainedprescriptionstimulantsfornonmedicaluse,around60percentoftheadolescentsandyoungadultssurveyedsaidtheyeitherboughtorreceivedthedrugsfromafriendorrelative.

Youthwhomisuseprescriptionmedicationsarealsomorelikelytoreportuseofotherdrugs.Multiplestudieshaverevealedassociationsbetweenprescriptiondrugmisuseandhigherratesofcigarettesmoking;heavyepisodicdrinking;andmarijuana,cocaine,andotherillicitdruguseamongU.S.adolescents,youngadults,andcollegestudents. Inthecaseofprescriptionopioids,receivingalegitimateprescriptionforthesedrugsduringadolescenceisalsoassociatedwithagreaterriskoffutureopioidmisuse,particularlyinyoungadultswhohavelittletonohistoryofdruguse.

OlderAdults

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Morethan80percentofolderpatients(ages57to85years)useatleastoneprescriptionmedicationonadailybasis,withmorethan50percenttakingmorethanfivemedicationsorsupplementsdaily. Thiscanpotentiallyleadtohealthissuesresultingfromunintentionallyusingaprescriptionmedicationinamannerotherthanhowitwasprescribed,orfromintentionalnonmedicaluse.Thehighratesofmultiple(comorbid)chronicillnessesinolderpopulations,age-relatedchangesindrugmetabolism,andthepotentialfordruginteractionsmakemedication(andothersubstance)misusemoredangerousinolderpeoplethaninyoungerpopulations. Further,alargepercentageofolderadultsalsouseover-the-countermedicinesanddietaryandherbalsupplements,whichcouldcompoundanyadversehealthconsequencesresultingfromnonmedicaluseofprescriptiondrugs.

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Isitsafetouseprescriptiondrugsincombinationwithothermedications?

Thesafetyofusingprescriptiondrugsincombinationwithothersubstancesdependsonanumberoffactorsincludingthetypesofmedications,dosages,othersubstanceuse(e.g.,alcohol),andindividualpatienthealthfactors.Patientsshouldtalkwiththeirhealthcareprovideraboutwhethertheycansafelyusetheirprescriptiondrugswithothersubstances,includingprescriptionandover-the-counter(OTC)medications,aswellasalcohol,tobacco,andillicitdrugs.Specifically,drugsthatslowdownbreathingrate,suchasopioids,alcohol,antihistamines,CNSdepressants,orgeneralanesthetics,shouldnotbetakentogetherbecausethesecombinationsincreasetheriskoflife-threateningrespiratorydepression.Stimulantsshouldalsonotbeusedwithothermedicationsunlessrecommendedbyaphysician.PatientsshouldbeawareofthedangersassociatedwithmixingstimulantsandOTCcoldmedicinesthatcontaindecongestants,ascombiningthesesubstancesmaycausebloodpressuretobecomedangerouslyhighorleadtoirregularheartrhythms.

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Whatclassesofprescriptiondrugsarecommonlymisused?

Opioids

Whatareopioids?

Opioidsaremedicationsthatactonopioidreceptorsinboththespinalcordandbraintoreducetheintensityofpain-signalperception.Theyalsoaffectbrainareasthatcontrolemotion,whichcanfurtherdiminishtheeffectsofpainfulstimuli.Theyhavebeenusedforcenturiestotreatpain,cough,anddiarrhea. Themostcommonmodernuseofopioidsistotreatacutepain.However,sincethe1990s,theyhavebeenincreasinglyusedtotreatchronicpain,despitesparseevidencefortheireffectivenesswhenusedlongterm. Indeed,somepatientsexperienceaworseningoftheirpainorincreasedsensitivitytopainasaresultoftreatmentwithopioids,aphenomenonknownashyperalgesia.

Importantly,inadditiontorelievingpain,opioidsalsoactivaterewardregionsinthebraincausingtheeuphoria—orhigh—thatunderliesthepotentialformisuseandsubstanceusedisorder.Chemically,thesemedicationsareverysimilartoheroin,whichwasoriginallysynthesizedfrommorphineasapharmaceuticalinthelate19thcentury. Thesepropertiesconferanincreasedriskofsubstanceusedisordereveninpatientswhotaketheirmedicationasprescribed.

Overdoseisanothersignificantdangerwithopioids,becausethesecompoundsalsointeractwithpartsofthebrainstemthatcontrolbreathing.Takingtoomuchofanopioidcansuppressbreathingenoughthattheusersuffocates.Anoverdosecanbereversed(andfatalityprevented)ifthecompoundnaloxoneisadministeredquickly(see"ReversinganOpioidOverdosewithNaloxone").

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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—areusedtorelievecoughsandseverediarrhea.

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.

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Misuseofprescriptionopioidsisalsoariskfactorfortransitioningtoheroinuse.ReadmoreabouttherelationshipbetweenprescriptionopioidsandheroininNIDA'sPrescriptionOpioidsandHeroinResearchReport.

Howisprescriptionopioidmisuserelatedtochronicpain?

Healthcareprovidershavelongwrestledwithhowbesttotreatthemorethan100millionAmericanswhosufferfromchronicpain. Opioidshavebeenthemostcommontreatmentforchronicpainsincethelate1990s,butrecentresearchhascastdoubtbothontheirsafetyandtheirefficacyinthetreatmentofchronicpainwhenitisnotrelatedtocancerorpalliativecare. Thepotentialrisksinvolvedwithlong-termopioidtreatment,suchasthedevelopmentofdrugtolerance,hyperalgesia,andaddiction,presentdoctorswithadilemma,asthereislimitedresearchonalternativetreatmentsforchronicpain.Patientsthemselvesmayevenbereluctanttotakeanopioidmedicationprescribedtothemforfearofbecomingaddicted.

Estimatesoftherateofopioidmisuseamongchronicpainpatientsvarywidelyasaresultofdifferencesintreatmentduration,insufficientresearchonlong-termoutcomes,disparatestudypopulations,anddifferentoutcomemeasures(e.g.,dependenceversusOUDoraddiction).OnestudyassessingcurrentcriteriaforOUDinalargenumberofchronicpainpatientsreceivingopioidsfoundthat28.1percenthadmildOUD,9.7percenthadmoderateOUD,and3.5percenthadsevereOUD(addiction).

Tomitigateaddictionrisk,physiciansshouldadheretotheCDCGuidelineforPrescribingOpioidsforChronicPain.Beforeprescribing,physiciansshouldassesspainandfunctioning,considerifnon-opioidtreatmentoptionsareappropriate,discussatreatmentplanwiththepatient,evaluatethepatient’sriskofharmormisuse,andco-prescribenaloxonetomitigatetheriskfor

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overdose(seeNIDA'swebpageonnaloxone).Whenfirstprescribingopioids,physiciansshouldgivethelowesteffectivedosefortheshortesttherapeuticduration.Astreatmentcontinues,thepatientshouldbemonitoredatregularintervals,andopioidtreatmentshouldbecontinuedonlyifmeaningfulclinicalimprovementsinpainandfunctioningareseenwithoutharm.

CNSDepressants

WhatareCNSdepressants?

CNSdepressants,acategorythatincludestranquilizers,sedatives,andhypnotics,aresubstancesthatcanslowbrainactivity.Thispropertymakesthemusefulfortreatinganxietyandsleepdisorders.Thefollowingareamongthemedicationscommonlyprescribedforthesepurposes :

Benzodiazepines,suchasdiazepam(Valium ),clonazepam(Klonopin ),andalprazolam(Xanax ),aresometimesprescribedtotreatanxiety,acutestressreactions,andpanicattacks.Clonazepammayalsobeprescribedtotreatseizuredisordersandinsomnia.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 ),

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phenobarbital(Luminal ),andpentobarbitalsodium(Nembutal ),areusedlessfrequentlytoreduceanxietyortohelpwithsleepproblemsbecauseoftheirhigherriskofoverdosecomparedtobenzodiazepines.However,theyarestillusedinsurgicalproceduresandtotreatseizuredisorders.

HowdoCNSdepressantsaffectthebrainandbody?

MostCNSdepressantsactonthebrainbyincreasingactivityatreceptorsfortheinhibitoryneurotransmittergamma-aminobutyricacid(GABA).AlthoughthedifferentclassesofCNSdepressantsworkinuniqueways,itisthroughtheirabilitytoincreaseGABAsignaling—therebyincreasinginhibitionofbrainactivity—thattheyproduceadrowsyorcalmingeffectthatismedicallybeneficialtothosesufferingfromanxietyorsleepdisorders.

WhatarethepossibleconsequencesofCNSdepressantmisuse?

Despitetheirbeneficialtherapeuticeffects,benzodiazepinesandbarbiturateshavethepotentialformisuseandshouldbeusedonlyasprescribed. Theuseofnon-benzodiazepinesleepaids,orz-drugs,islesswell-studied,butcertainindicatorshaveraisedconcernabouttheirmisusepotentialaswell.

Duringthefirstfewdaysoftakingadepressant,apersonusuallyfeelssleepyanduncoordinated,butasthebodybecomesaccustomedtotheeffectsofthedrugandtolerancedevelops,thesesideeffectsbegintodisappear.Ifoneusesthesedrugslongterm,heorshemayneedlargerdosestoachievethetherapeuticeffects.Continuedusecanalsoleadtodependenceandwithdrawalwhenuseisabruptlyreducedorstopped(see"UnderstandingDependence,Addiction,andTolerance").BecauseCNSdepressantsworkbyslowingthebrain’sactivity,whenanindividualstopstakingthem,therecanbeareboundeffect,

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resultinginseizuresorotherharmfulconsequences.

Althoughwithdrawalfrombenzodiazepinescanbeproblematic,itisrarelylifethreatening,whereaswithdrawalfromprolongeduseofbarbituratescanhavelife-threateningcomplications.Therefore,someonewhoisthinkingaboutdiscontinuingaCNSdepressantorwhoissufferingwithdrawalafterdiscontinuinguseshouldspeakwithaphysicianorseekimmediatemedicaltreatment.

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,and

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thesemedications’effectsonnorepinephrineincreasebloodpressureandheartrate,constrictbloodvessels,increasebloodglucose,andopenupbreathingpassages.

Whatarethepossibleconsequencesofstimulantmisuse?

Aswithotherdrugsinthestimulantcategory,suchascocaine,itispossibleforpeopletobecomedependentonoraddictedtoprescriptionstimulants.Withdrawalsymptomsassociatedwithdiscontinuingstimulantuseincludefatigue,depression,anddisturbedsleeppatterns.Repeatedmisuseofsomestimulants(sometimeswithinashortperiod)canleadtofeelingsofhostilityorparanoia,orevenpsychosis. Further,takinghighdosesofastimulantmayresultindangerouslyhighbodytemperatureandanirregularheartbeat.Thereisalsothepotentialforcardiovascularfailureorseizures.

CognitiveEnhancers

Thedramaticincreasesinstimulantprescriptionsoverthelast2decadeshaveledtotheirgreateravailabilityandtoincreasedriskfordiversionandnonmedicaluse. Whentakentoimproveproperlydiagnosedconditions,thesemedicationscangreatlyenhanceapatient’squalityoflife.However,becausemanyperceivethemtobegenerallysafeandeffective,prescriptionstimulantssuchasAdderall andModafinil arebeingmisusedmorefrequently.

Stimulantsincreasewakefulness,motivation,andaspectsofcognition,learning,andmemory.Somepeopletakethesedrugsintheabsenceofmedicalneedinanefforttoenhancementalperformance. Militarieshavelongusedstimulantstoincreaseperformanceinthefaceoffatigue,andtheUnitedStatesArmedForcesallowfortheiruseinlimitedoperationalsettings. Thepracticeisnowreportedbysomeprofessionalstoincreasetheir

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productivity,byolderpeopletooffsetdecliningcognition,andbybothhighschoolandcollegestudentstoimprovetheiracademicperformance.

Nonmedicaluseofstimulantsforcognitiveenhancementposespotentialhealthrisks,includingaddiction,cardiovascularevents,andpsychosis.Theuseofpharmaceuticalsforcognitiveenhancementhasalsosparkeddebateovertheethicalimplicationsofthepractice.Issuesoffairnessariseifthosewithaccessandwillingnesstotakethesedrugshaveaperformanceedgeoverothers,andimplicitcoerciontakesplaceifacultureofcognitiveenhancementgivestheimpressionthatapersonmusttakedrugsinordertobecompetitive.

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Areprescriptiondrugssafetotakewhenpregnant?

Someprescriptionmedicationstakenbyapregnantwomancancauseherbabytodevelopdependence,whichcanresultinwithdrawalsymptomsafterbirth,knownasneonatalabstinencesyndrome(NAS).Thiscanrequireaprolongedstayinneonatalintensivecareand,inthecaseofopioids,treatmentwithmedication(see"SexandGenderDifferencesinSubstanceUseDisorderTreatment"inNIDA'sSubstanceUseinWomenResearchReport).Womenshouldconsultwiththeirdoctorstodeterminewhichmedicationstheycancontinuetakingduringpregnancy.

Opioidpainmedicationsrequireparticularattention;risingratesofNAShavebeenassociatedwithincreasesintheprescriptionofopioidsforpaininpregnantwomen.NASassociatedwithopioiduse(heroinor

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prescriptionopioids)increasedfivefoldfrom2000to2012,withahigherrateofincreaseinmorerecentyears.52,53

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Howcanprescriptiondrugmisusebeprevented?

Clinicians,Patients,andPharmacists

Physicians,theirpatients,andpharmacistsallcanplayaroleinidentifyingandpreventingnonmedicaluseofprescriptiondrugs.

Clinicians.Morethan84percentofAmericanshadcontactwithahealthcareprofessionalin2016 ,placingdoctorsinauniquepositiontoidentifynonmedicaluseofprescriptiondrugsandtakemeasurestopreventtheescalationofapatient’smisusetoasubstanceusedisorder.Byaskingaboutalldrugs,physicianscanhelptheirpatientsrecognizewhetheraproblemexists,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,inpartbypromotingmore

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cautiousandresponsibleprescribingofopioidmedications.Inlinewiththeseefforts,in2016theCentersforDiseaseControlandPrevention(CDC)publisheditsCDCGuidelineforPrescribingOpioidsforChronicPaintoestablishclinicalstandardsforbalancingthebenefitsandrisksofchronicopioidtreatment. Then,in2017,PresidentTrumpestablishedthePresident'sCommissiononCombatingDrugAddictionandtheOpioidCrisis.Thecommissionoutlinedseveralpriorityareasaimedatimprovingthepreventionandtreatmentofopioidaddiction.

Coordinatedfederaleffortstoreduceopioidaddictionandoverdoseareongoing.

Preventingorstoppingnonmedicaluseofprescriptiondrugsisanimportantpartofpatientcare.However,certainpatientscanbenefitfromprescriptionstimulants,sedatives,oropioidpainrelievers.Therefore,physiciansshouldbalancethelegitimatemedicalneedsofpatientswiththepotentialriskformisuseandrelatedharms.

Patients.Patientscantakestepstoensurethattheyuseprescriptionmedicationsappropriatelyby:

followingthedirectionsasexplainedonthelabelorbythepharmacist

beingawareofpotentialinteractionswithotherdrugsaswellasalcohol

neverstoppingorchangingadosingregimenwithoutfirstdiscussingitwiththedoctor

neverusinganotherperson’sprescriptionandnevergivingtheirprescriptionmedicationstoothers

storingprescriptionstimulants,sedatives,andopioidssafely

Additionally,patientsshouldproperlydiscardunusedorexpiredmedicationsbyfollowingU.S.FoodandDrugAdministration(FDA)guidelinesorvisitingU.S.DrugEnforcementAdministrationcollection

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sites. Inadditiontodescribingtheirmedicalproblem,patientsshouldalwaysinformtheirhealthcareprofessionalsaboutalltheprescriptions,over-the-countermedicines,anddietaryandherbalsupplementstheyaretakingbeforetheyobtainanyothermedications.

Pharmacists.Pharmacistscanhelppatientsunderstandinstructionsfortakingtheirmedicationsalongwithhowthemedicationworksfortheircondition.Inaddition,bybeingwatchfulforprescriptionfalsificationsoralterations,pharmacistscanserveasthefirstlineofdefenseinrecognizingproblematicpatternsinprescriptiondruguse.Somepharmacieshavedevelopedhotlinestoalertotherpharmaciesintheregionwhentheydetectafraudulentprescription.Alongwithphysicians,pharmacistscanusePDMPstohelptrackopioid-prescribinganddispensingpatternsinpatients.

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Manufacturersofprescriptiondrugscontinuetoworkonnewformulationsofopioidmedications,knownasabuse-deterrentformulations(ADF),whichincludetechnologiesdesignedtopreventpeoplefrommisusingthembysnortingorinjection.Approachescurrentlybeingusedorstudiedforuseinclude:

physicalorchemicalbarriersthatpreventthecrushing,grinding,ordissolvingofdrugproducts

agonist/antagonistcombinationsthatcauseanantagonist(whichwillcounteractthedrugeffect)tobereleasediftheproductismanipulated

aversivesubstancesthatareaddedtocreateunpleasantsensationsifthedrugistakeninawayotherthandirected

deliverysystemssuchaslong-actinginjectionsorimplantsthatslowlyreleasethedrugovertime

newmolecularentitiesorprodrugsthatattachachemicalextensiontoadrugthatrendersitinactiveunlessitistakenorally

SeveralADFopioidsareonthemarket,andtheFDAhasalsocalledforthedevelopmentofADFstimulants. Abuse-deterrentformulationshavebeenshowntodecreasetheillicitvalueofdrugs. Medicationregulationhasbeenshowntobeeffectiveindecreasingtheprescribingofopioidmedications.In2014,theDrugEnforcementAdministrationmovedhydrocodoneproductsfromscheduleIIItothemorerestrictivescheduleII,whichresultedinadecreaseinhydrocodoneprescribingthatdidnotresultinanyattendantincreasesintheprescribingofotheropioids.

DevelopmentofSaferMedications

Thedevelopmentofeffective,non-addictingpainmedicationsisapublichealthpriority.Agrowingnumberofolderadultsandanincreasingnumberofinjuredmilitaryservicemembersaddtotheurgencyoffindingnewtreatments.Researchersare

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exploringalternativetreatmentapproachesthattargetothersignalingsystemsinthebodysuchastheendocannabinoidsystem,whichisalsoinvolvedinpain. Moreresearchisalsoneededtobetterunderstandeffectivechronicpainmanagement,includingidentifyingfactorsthatpredisposesomepatientstosubstanceusedisordersanddevelopingmeasurestopreventthenonmedicaluseofprescriptionmedications.

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Howcanprescriptiondrugaddictionbetreated?

Yearsofresearchhaveshownthatsubstanceusedisordersarebraindisordersthatcanbetreatedeffectively.Treatmentmusttakeintoaccountthetypeofdrugusedandtheneedsoftheindividual.Successfultreatmentmayneedtoincorporateseveralcomponents,includingdetoxification,counseling,andmedications,whenavailable.Multiplecoursesoftreatmentmaybeneededforthepatienttomakeafullrecovery.

Thetwomaincategoriesofdrugusedisordertreatmentarebehavioraltreatments(suchascontingencymanagementandcognitive-behavioraltherapy)andmedications.Behavioraltreatmentshelppatientsstopdrugusebychangingunhealthypatternsofthinkingandbehavior;teachingstrategiestomanagecravingsandavoidcuesandsituationsthatcouldleadtorelapse;or,insomecases,providingincentivesforabstinence.Behavioraltreatments,whichmaytaketheformofindividual,family,orgroupcounseling,alsocanhelppatientsimprovetheirpersonalrelationshipsandtheirabilitytofunctionatworkandinthecommunity.

Addictiontoprescriptionopioidscanadditionallybetreatedwithmedicationsincludingbuprenorphine,methadone,andnaltrexone(see"MedicationsforOpioidUseDisorder"below).Thesedrugscanpreventotheropioidsfromaffectingthebrain(naltrexone)orrelievewithdrawalsymptomsandcravings(buprenorphineandmethadone),helpingthepatientavoidrelapse.Medicationsforthetreatmentofopioidaddictionareoftenadministeredincombinationwithpsychosocialsupportsorbehavioraltreatments,knownasmedication-assistedtreatment(MAT). Amedicationtoreducethephysicalsymptomsofwithdrawal(lofexidine)isalsoavailable.

MedicationsforOpioidUseDisorder

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Methadoneisasyntheticopioidagonistthatpreventswithdrawalsymptomsandrelievesdrugcravings.Itworksbyactingonthesamemu-opioidreceptorsasotheropioidssuchasheroin,morphine,andopioidpainmedicationsbutatlessintensityandforlongerduration.Methadonehasbeenusedsuccessfullyformorethan40yearstotreatheroinaddictionbutisgenerallyonlyavailablethroughspeciallylicensedopioidtreatmentprograms.

Buprenorphineisapartialopioidagonist—itbindstothemu-opioidreceptorbutonlypartiallyactivatesit—andcanbeprescribedbycertifiedphysicians,nursepractitioners,andphysicianassistantsinanofficesetting.Likemethadone,itcanreducecravingsandiswelltoleratedbypatients.In2016,theU.S.FoodandDrugAdministration(FDA)approvedtheNIDA-supporteddevelopmentofanimplantableformulationofbuprenorphinethatprovides6monthsofsustainedmedicationdelivery;andin2017,amonth-longinjectableformulationwasapproved.Theseformulationseliminatetheneedfordailydosingandwillgivepatientsgreatereaseintreatmentadherence,especiallyiftheylivefarfromtheirtreatmentprovider.

Therehasbeenapopularmisconceptionthatmethadoneandbuprenorphinereplaceoneaddictionwithanother.Thisisnotthecase.Inpeopleaddictedtoopioids,thesedrugsdonotproduceahighbutsimplypreventwithdrawalandcravingsothattheycanfunctioninlifeandengagewithtreatmentwhilebalanceisrestoredtobraincircuitsthathavebeenaffectedbytheirdisorder.

Naltrexoneisanothertypeofmedication,anantagonist,whichpreventsotheropioidsfrombindingtoandactivatingopioidreceptors.Aninjectable,long-actingformofnaltrexone(Vivitrol )canbeausefultreatmentchoiceforpatientswhodonothavereadyaccesstohealthcareorwhostrugglewithtakingtheirmedicationsregularly.

Whilemedicationsarethestandardofcarefortreatingopioiduse

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disorder,farfewerpeoplereceivemedicationsthancouldpotentiallybenefitfromit.Notallpeoplewithopioidusedisorderseektreatment.Evenwhentheyseektreatment,theywillnotnecessarilyreceivemedications.Themostrecenttreatmentadmissionsdataavailableshowthatonly21percentofpeopleadmittedforprescriptionopioidusedisorderhaveatreatmentplanthatincludesmedications. However,evenifthenationwideinfrastructurewereoperatingatcapacity,between1.3and1.4millionmorepeoplehaveopioidusedisorderthancouldcurrentlybetreatedwithmedications;thisisduetolimitedavailabilityofopioidtreatmentprogramsthatcandispensemethadoneandtheregulatorylimitonthenumberofpatientsthatphysicianscantreatwithbuprenorphine. Coordinatedeffortsareunderwaynationwidetoexpandaccesstoopioidusedisordermedications,includingarecentincreaseinthebuprenorphinepatientlimitfrom100patientsto275forqualifiedphysicianswhorequestthehigherlimit.

NIDAissupportingresearchneededtodeterminethemosteffectivewaystoimplementmedicationsforopioidusedisorder.Forexample,recentworkhasshownthatbuprenorphinemaintenancetreatmentismoreeffectivethantaperingpatientsoffofbuprenorphine. Also,startingbuprenorphinetreatmentwhenapatientisadmittedtotheemergencydepartment,suchasforanoverdose,isamoreeffectivewaytoengageapatientintreatmentthanreferralorbriefintervention. Finally,datahaveshownthattreatmentwithmethadone,buprenorphine,ornaltrexoneforincarceratedindividualsimprovespost-releaseoutcomes.

Formoreinformationonmedicationstotreatopioidusedisorder,seeNIDA’sMedicationstoTreatOpioidUseDisorderResearchReport.

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ReversinganOpioidOverdosewithNaloxone

Theopioidoverdose-reversaldrugnaloxoneisanopioidantagonistthatcanrapidlyrestorenormalrespirationtoapersonwhohasstoppedbreathingasaresultofoverdoseonprescriptionopioidsorheroin.Naloxonecanbeusedbyemergencymedicalpersonnel,firstresponders,andbystanders.Formoreinformation,visitNIDA'swebpageonnaloxone.

TreatingAddictiontoCNSDepressants

PatientsaddictedtoCNSdepressantssuchastranquilizers,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

TreatmentofaddictiontoprescriptionstimulantssuchasAdderallandConcerta isbasedonbehavioraltherapiesthatareeffectivefortreatingcocaineandmethamphetamineaddiction.Atthistime,therearenoFDA-approvedmedicationsfortreatingstimulantaddiction.NIDAissupportingresearchinthisarea.

Dependingonthepatient,thefirststepsintreatingprescriptionstimulantaddictionmaybetotaperthedrugdosageandattempttoeasewithdrawalsymptoms.Behavioraltreatmentmaythenfollowthedetoxificationprocess(see"BehavioralTherapies"inNIDA'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

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irp.drugabuse.gov

Forphysicianinformation

NIDAMED:drugabuse.gov/nidamed

Otherwebsites

Informationaboutprescriptiondrugmisuseisalsoavailablethroughthefollowingwebsites:

SubstanceAbuseandMentalHealthServicesAdministration:samhsa.gov

U.S.DrugEnforcementAdministration:dea.gov

MonitoringtheFuture:monitoringthefuture.org

PartnershipforDrug-FreeKids:drugfree.org/drug-guide

ThispublicationisavailableforyouruseandmaybereproducedinitsentiretywithoutpermissionfromNIDA.Citationofthesourceisappreciated,usingthefollowinglanguage:Source:NationalInstituteonDrugAbuse;NationalInstitutesofHealth;U.S.DepartmentofHealthandHumanServices.

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