Research NATIONAL INSTITUTE ON DRUG ABUSEReport SERIES · prescription drugs that are most commonly abused: ... Despite their many beneficial effects, barbiturates and ben-zodiazepines

PRESCRIPTIONDRUGSWhat are some of the commonlyabused prescriptiondrugs?

A lthough many pre-scription drugs can be abused or misused,

there are three classes of prescription drugs that aremost commonly abused:

■ Opioids, which are mostoften prescribed to treatpain;

■ CNS depressants, whichare used to treat anxietyand sleep disorders;

■ Stimulants, which areprescribed to treat thesleep disorder narcolepsy,attention-deficit hyper-activity disorder (ADHD),and obesity.

OpioidsWhat are opioids?

Opioids are commonly prescribed because oftheir effective analgesic,

or pain-relieving, properties.Medications that fall withinthis class—sometimes referredto as narcotics—include mor-phine, codeine, and relateddrugs. Morphine, for example,is often used before or aftersurgery to alleviate severepain. Codeine, because it isless efficacious than morphine,is used for milder pain. Otherexamples of opioids that canbe prescribed to alleviate paininclude oxycodone (OxyContin),propoxyphene (Darvon),hydrocodone (Vicodin), andhydromorphone (Dilaudid), fr

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Most people who take prescriptionmedications take them responsibly; however, the nonmedical use orabuse of prescription drugs remainsa serious public health concern.Certain prescription drugs—opioids,central nervous system (CNS) depres-sants, and stimulants—when abused,can alter the brain’s activity andlead to dependence and possiblyaddiction.

An estimated 9 million peopleaged 12 and older used prescriptiondrugs for nonmedical reasons in1999; more than a quarter of thatnumber reported using prescriptiondrugs nonmedically for the first timein the previous year. We would like to reverse this trend by increasingawareness and promoting additionalresearch on this topic.

The National Institute on DrugAbuse (NIDA) has developed this pub-lication to answer questions aboutthe consequences of abusing com-monly prescribed medications. Inaddition to offering information onwhat research has taught us abouthow certain medications affect thebrain and body, this publication alsodiscusses treatment options.

This publication was developed tohelp health care providers discuss theconsequences of prescription drugabuse with their patients. Accordingto a recent national survey of primarycare physicians and patients regard-ing substance abuse, 46.6 percent ofphysicians find it difficult to discussprescription drug abuse with theirpatients.

Prescription drug abuse is not anew problem, but one that deservesrenewed attention. We hope this scientific report is useful to the public,particularly to individuals workingwith the elderly, who because of thenumber of medications they may takefor various medical conditions, maybe more vulnerable to misuse orabuse of prescribed medications.

Alan I. Leshner, Ph.D.DirectorNational Institute on Drug Abuse

U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s • N a t i o n a l I n s t i t u t e s o f H e a l t h

ResearchReportN A T I O N A L I N S T I T U T E O N D R U G A B U S E

S E R I E S

Abuseand Addiction

as well as meperidine(Demerol), which is used less often because of its sideeffects. In addition to theirpain-relieving properties, someof these drugs—for example,codeine and diphenoxylate(Lomotil)—can be used torelieve coughs and diarrhea.

How do opioids affect the brain and body?Opioids act by attaching tospecific proteins called opioidreceptors, which are found inthe brain, spinal cord, andgastrointestinal tract. Whenthese drugs attach to certainopioid receptors, they canblock the transmission of painmessages to the brain. In addition, opioids can producedrowsiness, cause constipa-tion, and, depending upon

the amount of drug taken,depress respiration. Opioiddrugs also can cause euphoriaby affecting the brain regionsthat mediate what we perceiveas pleasure.

What are the possible consequences of opioiduse and abuse? Chronic use of opioids canresult in tolerance for thedrugs, which means that usersmust take higher doses toachieve the same initial effects.Long-term use also can lead to physical dependence andaddiction—the body adapts tothe presence of the drug, andwithdrawal symptoms occur if use is reduced or stopped.Symptoms of withdrawalinclude restlessness, muscleand bone pain, insomnia,

diarrhea, vomiting, cold flasheswith goose bumps (“coldturkey”), and involuntary legmovements. Finally, taking alarge single dose of an opioidcould cause severe respiratorydepression that can lead todeath. Many studies haveshown, however, that properlymanaged medical use of opi-oid analgesic drugs is safe andrarely causes clinical addiction,defined as compulsive, oftenuncontrollable use of drugs.Taken exactly as prescribed,opioids can be used to man-age pain effectively.

Is it safe to use opioid drugs with other medications?Opioids are safe to use with other drugs only under a physician’s supervision.Typically, they should not beused with other substancesthat depress the central nervous system, such as alcohol, antihistamines, barbiturates, benzodiazepines,or general anesthetics, as such a combination increasesthe risk of life-threatening respiratory depression.

CNS depressantsWhat are CNS depressants?

CNS depressants are substances that can slownormal brain function.

Because of this property, someCNS depressants are useful inthe treatment of anxiety andsleep disorders. Among themedications that are commonly

2NIDA RESEARCH REPORT SERIES

Approximately 4 Million Americans Reported Current Use of Prescription Drugs

for Nonmedical Purposes in 1999

Source: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse, 1999.

3.0

2.5

2.0

1.5

1.0

0.5

0Stimulants Sedatives and

TranquilizersPain Relievers

Mill

ions

of A

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icans

prescribed for these purposesare the following:

■ Barbiturates, such asmephobarbital (Mebaral)and pentobarbital sodium(Nembutal), which areused to treat anxiety, ten-sion, and sleep disorders.

■ Benzodiazepines, suchas diazepam (Valium),chlordiazepoxide HCl(Librium), and alprazolam(Xanax), which can beprescribed to treat anxiety,acute stress reactions, andpanic attacks; the moresedating benzodiazepines,such as triazolam (Halcion)and estazolam (ProSom)can be prescribed forshort-term treatment ofsleep disorders.

In higher doses, some CNSdepressants can be used asgeneral anesthetics.

How do CNS depressantsaffect the brain and body?There are numerous CNSdepressants; most act on thebrain by affecting the neuro-transmitter gamma-aminobutyricacid (GABA). Neurotransmittersare brain chemicals that facili-tate communication betweenbrain cells. GABA works bydecreasing brain activity.Although the different classesof CNS depressants work inunique ways, ultimately it is through their ability toincrease GABA activity thatthey produce a drowsy orcalming effect that is beneficial

to those suffering from anxietyor sleep disorders.

What are the possible consequences of CNSdepressant use and abuse?Despite their many beneficialeffects, barbiturates and ben-zodiazepines have the poten-tial for abuse and should beused only as prescribed.During the first few days oftaking a prescribed CNSdepressant, a person usuallyfeels sleepy and uncoordinat-ed, but as the body becomesaccustomed to the effects ofthe drug, these feelings beginto disappear. If one uses thesedrugs long term, the body willdevelop tolerance for thedrugs, and larger doses will beneeded to achieve the sameinitial effects. In addition, con-tinued use can lead to physi-cal dependence and—whenuse is reduced or stopped—withdrawal. Because all CNSdepressants work by slowingthe brain’s activity, when anindividual stops taking them,the brain’s activity can reboundand race out of control, possi-bly leading to seizures andother harmful consequences.Although withdrawal frombenzodiazepines can be prob-lematic, it is rarely life threat-ening, whereas withdrawalfrom prolonged use of otherCNS depressants can have life-threatening complications.Therefore, someone who isthinking about discontinuingCNS-depressant therapy orwho is suffering withdrawal

from a CNS depressant shouldspeak with a physician or seekmedical treatment.

Is it safe to use CNSdepressants with othermedications?CNS depressants should beused with other medicationsonly under a physician’ssupervision. Typically, theyshould not be combined withany other medication or sub-stance that causes CNS depres-sion, including prescriptionpain medicines, some over-the-counter cold and allergymedications, or alcohol. UsingCNS depressants with theseother substances—particularlyalcohol—can slow breathing,or slow both the heart andrespiration, and possibly leadto death.

StimulantsWhat are stimulants?

As the name suggests,stimulants are a class ofdrugs that enhance brain

activity—they cause an increasein alertness, attention, andenergy that is accompanied byelevated blood pressure andincreased heart rate and respi-ration. Stimulants were usedhistorically to treat asthma andother respiratory problems,obesity, neurological disorders,and a variety of other ailments.But as their potential for abuseand addiction became apparent,the medical use of stimulantsbegan to wane. Now, stimulants

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are prescribed for the treatmentof only a few health conditions,including narcolepsy, attention-deficit hyperactivity disorder,and depression that has notresponded to other treatments.Stimulants may be used asappetite suppressants for short-term treatment of obesity, andthey also may be used forpatients with asthma.

How do stimulants affectthe brain and body?Stimulants, such as dextroam-phetamine (Dexedrine) andmethylphenidate (Ritalin),have chemical structures thatare similar to a family of keybrain neurotransmitters calledmonoamines, which includenorepinephrine and dopamine.Stimulants increase the amountof these chemicals in the brain.This, in turn, increases bloodpressure and heart rate, con-stricts blood vessels, increasesblood glucose, and opens up the pathways of the respi-ratory system. In addition, the increase in dopamine isassociated with a sense ofeuphoria that can accompanythe use of these drugs.

What are the possible consequences of stimu-lant use and abuse?The consequences of stimu-lant abuse can be dangerous.Although their use may notlead to physical dependenceand risk of withdrawal, stimu-lants can be addictive in thatindividuals begin to use themcompulsively. Taking high doses

of some stimulants repeatedlyover a short time can lead tofeelings of hostility or para-noia. Additionally, taking highdoses of a stimulant may resultin dangerously high body temperatures and an irregularheartbeat. There is also thepotential for cardiovascularfailure or lethal seizures.

Is it safe to use stimulantswith other medications?Stimulants should be usedwith other medications onlywhen the patient is under aphysician’s supervision. Forexample, a stimulant may beprescribed to a patient takingan antidepressant. However,health care providers andpatients should be mindfulthat antidepressants enhancethe effects of a stimulant.Patients also should be awarethat stimulants should not bemixed with over-the-countercold medicines that containdecongestants, as this com-bination may cause bloodpressure to become danger-ously high or lead to irregularheart rhythms.

Trends in prescription drug abuse

Several indicators suggestthat prescription drugabuse is on the rise in

the United States. According tothe 1999 National HouseholdSurvey on Drug Abuse, in1998, an estimated 1.6 million

Americans used prescriptionpain relievers nonmedicallyfor the first time. This repre-sents a significant increasesince the 1980s, when therewere generally fewer than500,000 first-time users peryear. From 1990 to 1998, thenumber of new users of painrelievers increased by 181 per-cent; the number of individualswho initiated tranquilizer useincreased by 132 percent; thenumber of new sedative usersincreased by 90 percent; andthe number of people initiatingstimulant use increased by 165 percent. In 1999, an esti-mated 4 million people—almost2 percent of the populationaged 12 and older—were currently (use in past month)using certain prescriptiondrugs nonmedically: painrelievers (2.6 million users),sedatives and tranquilizers(1.3 million users), and stimu-lants (0.9 million users).

Although prescription drugabuse affects many Americans,some trends of concern canbe seen among older adults,adolescents, and women. Inaddition, health care profes-sionals—including physicians,nurses, pharmacists, dentists,anesthesiologists, and veteri-narians—may be at increasedrisk of prescription drug abusebecause of ease of access, as well as their ability to self-prescribe drugs. In spite of thisincreased risk, recent surveysand research in the early1990s indicate that health careproviders probably suffer

4NIDA RESEARCH REPORT SERIES

NIDA RESEARCH REPORT SERIES5

OPIOIDS■ Oxycodone (OxyContin)■ Propoxyphene (Darvon)■ Hydrocodone (Vicodin)■ Hydromorphone (Dilaudid)■ Meperidine (Demerol)■ Diphenoxylate (Lomotil)

Generally prescribed for■ Postsurgical pain relief■ Management of acute or chronic pain■ Relief of coughs and diarrhea

In the bodyOpioids attach to opioid receptors in the brain and spinal cord, blocking the transmission of pain messages to the brain.

Effects of short-term use■ Blocked pain messages■ Drowsiness ■ Constipation■ Depressed respiration

(depending on dose)

Effects of long-term use■ Potential for tolerance, physical

dependence, withdrawal, and/or addiction

Possible negative effects■ Severe respiratory depression or death

following a large single dose

Should not be used withOther substances that cause CNS depression, including■ Alcohol ■ Antihistamines■ Barbiturates■ Benzodiazepines■ General anesthetics

CNS DEPRESSANTSBarbiturates■ Mephobarbital (Mebaral)■ Pentobarbital sodium (Nembutal)

Benzodiazepines■ Diazepam (Valium)■ Chlordiazepoxide hydrochloride (Librium)■ Alprazolam (Xanax)■ Triazolam (Halcion)■ Estazolam (ProSom)

Generally prescribed for■ Anxiety■ Tension■ Panic attacks■ Acute stress reactions■ Sleep disorders■ Anesthesia (at high doses)

In the bodyCNS depressants slow brain activity through actions on the GABA system and, therefore, produce a calming effect.

Effects of short-term use■ A “sleepy” and uncoordinated feeling

during the first few days, as the body becomes accustomed—tolerant—to the effects, these feelings diminish.

Effects of long-term use■ Potential for tolerance, physical

dependence, withdrawal, and/or addiction

Possible negative effects■ Seizures following a rebound in brain

activity after reducing or discontinuing use

Should not be used withOther substances that cause CNS depression, including■ Alcohol ■ Prescription opioid pain medicines ■ Some over-the-counter cold and allergy

medications

STIMULANTS■ Dextroamphetamine (Dexedrine)■ Methylphenidate (Ritalin)■ Sibutramine hydrochloride monohydrate (Meridia)

Generally prescribed for■ Narcolepsy■ Attention-deficit hyperactivity disorder (ADHD) ■ Depression that does not respond to other treatment ■ Short-term treatment of obesity■ Asthma

In the bodyStimulants enhance brain activity, causing an increasein alertness, attention, and energy.

Effects of short-term use■ Elevated blood pressure■ Increased heart rate■ Increased respiration■ Suppressed appetite■ Sleep deprivation

Effects of long-term use■ Potential for addiction

Possible negative effects■ Dangerously high body temperatures

or an irregular heartbeat after taking high doses

■ Cardiovascular failure or lethal seizures■ For some stimulants, hostility or feelings

of paranoia after taking high doses repeatedly over a short period of time

Should not be used with■ Over-the-counter cold medicines containing

decongestants■ Antidepressants, unless supervised by

a physician■ Some asthma medications

Some Commonly Prescribed Medications: Use and Consequences

from substance abuse, includ-ing alcohol and drugs, at arate similar to rates in societyas a whole, in the range of 8to 12 percent.

Older adultsThe misuse of prescriptiondrugs may be the most commonform of drug abuse among the elderly. Elderly personsuse prescription medicationsapproximately three times asfrequently as the general pop-ulation and have been foundto have the poorest rates ofcompliance with directions fortaking a medication. In addi-tion, data from the VeteransAffairs Hospital System suggestthat elderly patients may beprescribed inappropriatelyhigh doses of medicationssuch as benzodiazepines andmay be prescribed these med-ications for longer periodsthan are younger adults. Ingeneral, older people shouldbe prescribed lower doses ofmedications, because thebody’s ability to metabolizemany medications decreaseswith age.

An association between age-related morbidity and abuse ofprescription medications likelyexists. For example, elderlypersons who take benzodi-azepines are at increased riskfor falls that cause hip andthigh fractures, as well as forvehicle accidents. Cognitiveimpairment also is associatedwith benzodiazepine use,although memory impairment

may be reversible when thedrug is discontinued. Finally,use of benzodiazepines forlonger than 4 months is notrecommended for elderlypatients because of the possi-bility of physical dependence.

Adolescents and young adultsData from the NationalHousehold Survey on DrugAbuse indicate that the mostdramatic increase in new usersof prescription drugs for non-medical purposes occurs in12- to 17-year-olds and 18- to25-year-olds. In addition, 12-to 14-year-olds reported psy-chotherapeutics (for example,painkillers or stimulants) asone of two primary drugsused. The 1999 Monitoring theFuture survey showed that forbarbiturates, tranquilizers, and

narcotics other than heroin,the general, long-term declinesin use among young adults inthe 1980s leveled off in theearly 1990s, with modestincreases again in the mid-tolate 1990s. For example, theuse of methylphenidate(Ritalin) among high schoolseniors increased from anannual prevalence (use of thedrug within the precedingyear) of 0.1 percent in 1992 to an annual prevalence of 2.8 percent in 1997 beforereaching a plateau.

It also appears that collegestudents’ nonmedical use ofpain relievers such as oxy-codone with aspirin (Percodan)and hydrocodone (Vicodin) is on the rise. The 1999 DrugAbuse Warning Network,which collects data on drug-related episodes in hospital

6NIDA RESEARCH REPORT SERIES

Illicit Drug Use Among Youths Age 12 to 14

6%

5

4

3

2

1

0Age 12

Perc

ent U

sing

in P

ast M

onth

Age 13 Age 14

MarijuanaPsychotherapeuticsInhalantsHallucinogens

Source: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse, 1999.

emergency departments,reported that mentions ofhydrocodone as a cause forvisiting an emergency roomincreased by 37 percentamong all age groups from1997 to 1999. Mentions of thebenzodiazepine clonazepam(Klonopin) increased by 102percent since 1992.

Gender differencesStudies suggest that womenare more likely than men tobe prescribed an abusableprescription drug, particularlynarcotics and anti-anxietydrugs—in some cases 48 per-cent more likely.

Overall, men and womenhave roughly similar rates ofnonmedical use of prescrip-tion drugs. An exception isfound among 12- to 17-year-olds: In this age group, youngwomen are more likely than

young men to use psychother-apeutic drugs nonmedically. In addition, research hasshown that women and menwho use prescription opioidsare equally likely to becomeaddicted. However, amongwomen and men who useeither a sedative, anti-anxietydrug, or hypnotic, women arealmost two times more likely to become addicted.

Preventing anddetecting prescrip-tion drug abuse

Although most patientsuse medications asdirected, abuse of and

addiction to prescription drugsare public health problems formany Americans. However,addiction rarely occurs amongthose who use pain relievers,

CNS depressants, or stimulantsas prescribed; the risk foraddiction exists when thesemedications are used in waysother than as prescribed.Health care providers such as primary care physicians,nurse practitioners, and phar-macists as well as patients canall play a role in preventing and detecting prescriptiondrug abuse.

Role of health careproviders About 70 percent ofAmericans—approximately191 million people—visit ahealth care provider, such as a primary care physician, atleast once every 2 years. Thus,health care providers are in aunique position not only toprescribe needed medicationsappropriately, but also toidentify prescription drugabuse when it exists and helpthe patient recognize theproblem, set goals for recov-ery, and seek appropriatetreatment when necessary.Screening for any type of substance abuse can be incorporated into routine history taking with questionsabout what prescriptions andover-the-counter medicinesthe patient is taking and why. Screening also can beperformed if a patient presentswith specific symptoms associ-ated with problem use of asubstance.

Over time, providers should

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Assessing Prescription Drug Abuse:Four Simple Questions for You and Your Physician

■ Have you ever felt the need to Cut down on your use ofprescription drugs?

■ Have you ever felt Annoyed by remarks your friends orloved ones made about your use of prescription drugs?

■ Have you ever felt Guilty or remorseful about your use of prescription drugs?

■ Have you Ever used prescription drugs as a way to “get going” or to “calm down?”

Adapted from Ewing, J.A. “Detecting Alcoholism: The CAGE Questionnaire.”Journal of the American Medical Association 252(14):1905-1907, 1984.

note any rapid increases in the amount of a medicationneeded—which may indicate

the development of tolerance—or frequent requests for refillsbefore the quantity prescribed

should have been used. Theyshould also be alert to the fact that those addicted to prescription medications mayengage in “doctor shopping,”moving from provider toprovider in an effort to getmultiple prescriptions for the drug they abuse.

Preventing or stopping prescription drug abuse is an important part of patientcare. However, health careproviders should not avoidprescribing or administeringstrong CNS depressants and painkillers, if they areneeded. (See box on pain and opiophobia.)

Role of pharmacistsPharmacists can play a keyrole in preventing prescriptiondrug misuse and abuse byproviding clear informationand advice about how to takea medication appropriately,about the effects the medica-tion may have, and about anypossible drug interactions.Pharmacists can help preventprescription fraud or diversionby looking for false or alteredprescription forms. Many phar-macies have developed “hotlines” to alert other phar-macies in the region when afraud is detected.

Role of patientsThere are several ways thatpatients can prevent prescrip-tion drug abuse. When visitingthe doctor, provide a completemedical history and a descrip-

It is estimated that more than 50 million Americans suffer fromchronic pain. When treating pain, health care providers have

long wrestled with a dilemma: How to adequately relieve apatient’s suffering while avoiding the potential for that patient tobecome addicted to pain medication?

Many health care providers underprescribe painkillers becausethey overestimate the potential for patients to become addictedto medications such as morphine and codeine. Although thesedrugs carry a heightened risk of addiction, research has shownthat providers’ concerns that patients will become addicted topain medication are largely unfounded. This fear of prescribingopioid pain medications is known as “opiophobia.”

Most patients who are prescribed opioids for pain, even thoseundergoing long-term therapy, do not become addicted to thedrugs. The few patients who do develop rapid and marked tolerance for and addiction to opioids usually have a history of psychological problems or prior substance abuse. In fact,studies have shown that abuse potential of opioid medicationsis generally low in healthy, nondrug-abusing volunteers. Onestudy found that only 4 out of about 12,000 patients whowere given opioids for acute pain became addicted. In a studyof 38 chronic pain patients, most of whom received opioids for4 to 7 years, only 2 patients became addicted, and both hada history of drug abuse.

The issues of underprescription of opioids and the suffering of millions of patients who do not receive adequate pain relief has led to the development of guidelines for pain treatment.These guidelines may help bring an end to underprescribing,but alternative forms of pain control are still needed. NIDA-funded scientists continue to search for new ways to controlpain and to develop new pain medications that are effectivebut do not have the potential for addiction.

Pain and Opiophobia

8NIDA RESEARCH REPORT SERIES

tion of the reason for the visitto ensure that the doctorunderstands the complaint and can prescribe appropriatemedication. If a doctor pre-scribes a pain medication,stimulant, or CNS depressant,follow the directions for usecarefully and learn about theeffects that the drug couldhave, especially during thefirst few days during whichthe body is adapting to themedication. Also be aware of potential interactions withother drugs by reading allinformation provided by thepharmacist. Do not increase or decrease doses or abruptlystop taking a prescriptionwithout consulting a healthcare provider first. For exam-ple, if you are taking a painreliever for chronic pain andthe medication no longerseems to be effectively con-trolling the pain, speak with

your physician; do not increasethe dose on your own. Finally,never use another person’sprescription.

Treating prescription drug addiction

Years of research haveshown us that addictionto any drug, illicit or

prescribed, is a brain diseasethat can, like other chronicdiseases, be effectively treated.But no single type of treatmentis appropriate for all individualsaddicted to prescription drugs.Treatment must take intoaccount the type of drug usedand the needs of the individual.To be successful, treatmentmay need to incorporate several components, such ascounseling in conjunction witha prescribed medication, and

multiple courses of treatmentmay be needed for the patientto make a full recovery.

The two main categories ofdrug addiction treatment arebehavioral and pharmacolo-gical. Behavioral treatmentsteach people how to functionwithout drugs, how to handlecravings, how to avoid drugsand situations that could leadto drug use, how to preventrelapse, and how to handlerelapse should it occur. Whendelivered effectively, behav-ioral treatments—such as indi-vidual counseling, group orfamily counseling, contingencymanagement, and cognitive-behavioral therapies—also canhelp patients improve theirpersonal relationships andability to function at work and in the community.

Some addictions, such asopioid addiction, can also betreated with medications. Thesepharmacological treatmentscounter the effects of the drugon the brain and behavior.Medications also can be usedto relieve the symptoms ofwithdrawal, to treat an over-dose, or to help overcomedrug cravings.

Although a behavioral orpharmacological approachalone may be effective fortreating drug addiction,research shows that a com-bination of both, when available, is most effective.

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Treating addiction to prescription opioidsSeveral options are availablefor effectively treating addic-tion to prescription opioids.These options are drawn from experience and researchregarding the treatment ofheroin addiction. They in-clude medications, such asmethadone and LAAM (levo-alpha-acetyl-methadol),and behavioral counselingapproaches.

A useful precursor to long-term treatment of opioidaddiction is detoxification.Detoxification in itself is not

a treatment foropioid addiction.Rather, its primaryobjective is torelieve withdrawalsymptoms whilethe patient adjuststo being drug free. To be effective,detoxification mustprecede long-termtreatment thateither requirescomplete abstinenceor incorporates amedication, such asmethadone, into the treatment plan.

Methadone is asynthetic opioidthat blocks theeffects of heroinand other opioids,eliminates with-drawal symptoms,and relieves drug

craving. It has been used successfully for more than 30 years to treat peopleaddicted to opioids. Othermedications include LAAM, an alternative to methadonethat blocks the effects of opi-oids for up to 72 hours, andnaltrexone, an opioid blockerthat is often employed forhighly motivated individuals in treatment programs pro-moting complete abstinence.Buprenorphine, another effec-tive medication, is awaitingFood and Drug Administration(FDA) approval for treatmentof opioid addiction. Finally,

naloxone, which counteractsthe effects of opioids, is usedto treat overdoses.

Treating addiction to CNS depressantsPatients addicted to barbitu-rates and benzodiazepinesshould not attempt to stoptaking them on their own, aswithdrawal from these drugscan be problematic, and in thecase of certain CNS depressants,potentially life-threatening.Although no extensive bodyof research regarding the treat-ment of barbiturate and ben-zodiazepine addiction exists,patients addicted to thesemedications should undergomedically supervised detoxi-fication because the dose must be gradually tapered off.Inpatient or outpatient coun-seling can help the individualduring this process. Cognitivebehavioral therapy also hasbeen used successfully to help individuals adapt to theremoval from benzodiazepines.

Often the abuse of barbitu-rates and benzodiazepinesoccurs in conjunction with the abuse of another substanceor drug, such as alcohol orcocaine. In these cases ofpolydrug abuse, the treatmentapproach must address themultiple addictions.

10NIDA RESEARCH REPORT SERIES

Many Physicians HaveDifficulty Discussing Substance

Abuse With Patients

Over 40% of physicians report having difficulty discussing substance abuse, including abuse of prescription drugs, with their patients. In contrast, less than 20% have difficultydiscussing depression.

National Center on Addiction and Substance Abuse at Columbia University(CASA). Missed Opportunity: National Survey of Primary Care Physicians andPatients on Substance Abuse. New York: CASA, 2000.

50%

40

30

20

10

0Depression

Perc

ent o

f Phy

sicia

ns

AlcoholAbuse

PrescriptionDrug Abuse

Treating addiction to prescription stimulantsTreatment of addiction to prescription stimulants, suchas Ritalin, is often based onbehavioral therapies proveneffective for treating cocaineor methamphetamine addic-tion. At this time, there are noproven medications for thetreatment of stimulant addic-tion. However, antidepressantsmay help manage the symp-toms of depression that canaccompany the early days ofabstinence from stimulants.

Depending on the patient’ssituation, the first steps intreating prescription stimulantaddiction may be tapering offthe drug’s dose and attempt-ing to treat withdrawal symp-toms. The detoxificationprocess could then be followedby one of many behavioraltherapies. Contingency man-agement, for example, uses asystem that enables patients toearn vouchers for drug-freeurine tests. The vouchers canbe exchanged for items thatpromote healthy living.

Another behavioral approachis cognitive-behavioral inter-vention, which focuses onmodifying the patient’s think-ing, expectations, and behav-iors while at the same timeincreasing skills for copingwith various life stressors.Recovery support groups mayalso be effective in conjunc-tion with behavioral therapy.

NIDA RESEARCH REPORT SERIES11GlossaryAddiction: A chronic, relapsing disease, characterized by compulsive drug seeking and use and by neurochemical and molecularchanges in the brain.

Barbiturate: A type of central nervous system (CNS) depressant often prescribed to promote sleep.

Benzodiazepine: A type of CNS depressantprescribed to relieve anxiety; among the mostwidely prescribed medications, includingValium and Librium.

Buprenorphine: A new medication awaitingFDA approval for treatment of opioid addic-tion. It blocks the effects of opioids on thebrain.

Central nervous system (CNS): The brainand spinal cord.

CNS depressants: A class of drugs that slow CNS function, some of which are used totreat anxiety and sleeping disorders; includesbarbiturates and benzodiazepines.

Detoxification: A process that allows thebody to rid itself of a drug while at the sametime managing the individual’s symptoms ofwithdrawal; often the first step in a drug treatment program.

Dopamine: A neurotransmitter present inregions of the brain that regulate movement,emotion, motivation, and feelings of pleasure.

LAAM (levo-alpha-acetyl-methadol):An approved medication for the treatment of opioid addiction, taken 3 to 4 times a week.

Methadone: A long-acting synthetic medication that is effective in treating opioidaddiction.

Narcolepsy: A disorder characterized byuncontrollable episodes of deep sleep.

Norepinephrine: A neurotransmitter present in some areas of the brain and theadrenal glands; decreases smooth muscle contraction and increases heart rate; oftenreleased in response to low blood pressure or stress.

Opioids: Controlled drugs or narcotics mostoften prescribed for the management of pain;natural or synthetic chemicals based on

opium’s active component—morphine—that work by mimicking the actions of pain-relieving chemicals produced in the body.Opiophobia: A health care provider’sunfounded fear that patients will becomephysically dependent upon or addicted to opioids even when using them appropriately;can lead to the underprescribing of opioids for pain management.Physical dependence: An adaptive physio-logical state that can occur with regular druguse and results in withdrawal when drug use is discontinued.Polydrug abuse: The abuse of two or moredrugs at the same time, such as CNS depres-sant abuse accompanied by abuse of alcohol.Prescription drug abuse: The intentionalmisuse of a medication outside of the normally accepted standards of its use.Prescription drug misuse: Taking a med-ication in a manner other than that prescribedor for a different condition than that for whichthe medication is prescribed.Psychotherapeutics: Drugs that have aneffect on the function of the brain and thatoften are used to treat psychiatric disorders;can include opioids, CNS depressants, andstimulants.Respiratory depression: Depression of respiration (breathing) that results in thereduced availability of oxygen to vital organs.Stimulants: Drugs that enhance the activityof the brain and lead to increased heart rate,blood pressure, and respiration; used to treatonly a few disorders, such as narcolepsy andattention-deficit hyperactivity disorder.Tolerance: A condition in which higher dosesof a drug are required to produce the sameeffect as experienced initially.Tranquilizers: Drugs prescribed to promotesleep or reduce anxiety; this NationalHousehold Survey on Drug Abuse classificationincludes benzodiazepines, barbiturates, andother types of CNS depressants.Withdrawal: A variety of symptoms thatoccur after chronic use of some drugs isreduced or stopped.

12NIDA RESEARCH REPORT SERIES

American Psychiatric Association. BenzodiazepineDependence, Toxicity, and Abuse: A TaskForce Report of the American PsychiatricAssociation. Washington, DC: AmericanPsychiatric Association, 1990.

Center for Substance Abuse Treatment (CSAT).Detoxification from Alcohol and Other Drugs,Treatment Improvement Protocol (TIP) #19.Department of Health and Human Services(DHHS) Pub. No. BKD172. Substance Abuseand Mental Health Services Administration(SAMHSA),1995.

CSAT. Substance Abuse Among Older Adults,TIP #26. DHHS Pub. No. BKD250. SAMHSA,1997.

CSAT. Substance Abuse Among Older Adults(TIP #26): Physicians Guide. DHHS Pub. No. (SMA) 00-3394. SAMHSA, 2000.

Hardman, J.G.; Limbird, L.E.; Molinoff, P.B.;Ruddon, R.W.; and Gilman, A.G., eds.Goodman & Gilman’s The PharmacologicalBasis of Therapeutics 9th Ed. New York:McGraw-Hill, 1996.

Isaacson, J.H. Preventing Prescription DrugAbuse. Cleveland Clinic Journal of Medicine67(7): 473-475, 2000.

Johnston, L.D.; O’Malley, P.M.; and Bachman,J.G. Monitoring the Future: National SurveyResults on Drug Use, 1975-1999, 2 Vols. NIH Pub. No. 00-4803. National Instituteon Drug Abuse (NIDA), NIH, DHHS, 2000.

Joransson, D.E.; Ryan, K.M.; Gilson, A.M.; andDahl, J.L. Trends in medical use and abuse ofopioid analgesics. Journal of the AmericanMedical Association 283(13):1710-1714,2000.

Longo, L.P., and Johnson, B. Addiction: Part I.Benzodiazepines—side effects, abuse risk,and alternatives. American Family Physician61:2121-2131, 2000.

Longo, L.P.; Parran, T.; Johnson, B.; and Kinsey,W. Addiction: Part II. Identification and management of the drug-seeking patient.American Family Physician 61:2401-2408,2000.

National Center on Addiction and SubstanceAbuse at Columbia University (CASA).Missed Opportunity: National Survey ofPrimary Care Physicians and Patients onSubstance Abuse. New York: CASA, 2000.

NIDA. NIDA Infofax #13553, Pain Medications,1999.

NIDA. Principles of Drug Addiction Treatment: A Research-Based Guide. NIH Pub. No. 99-4180. NIDA, NIH, DHHS, 1999.

NIDA NOTES. Research eases concerns aboutuse of opioids to relieve pain, NIDA NOTES15(1):12-13, 2000.

Office of Applied Studies. Substance Use AmongWomen in the United States. DHHS Pub. No.(SMA) 97-3162. SAMHSA, 1997.

Office of Applied Studies. Summary of Findingsfrom the National Household Survey on DrugAbuse. DHHS Pub. No. (SMA) 00-3466.SAMHSA, 2000.

Office of Applied Studies. Year-End 1999Emergency Department Data from the DrugAbuse Warning Network. DHHS Pub.No.(SMA) 00-3462. SAMHSA, 2000.

Patterson, T.L., and Jeste, D.V. The potentialimpact of the baby-boom generation on substance abuse among elderly persons.Psychiatric Services 50:1184-1188, 1999.

Phillips, D.M. JCAHO pain management stan-dards are unveiled. Journal of the AmericanMedical Association 284(4):428-429, 2000.

Simoni-Wastila, L. The use of abusable prescrip-tion drugs: The role of gender. Journal ofWomen’s Health and Gender-based Medicine9(3):289-297, 2000.

Snyder, S.H. Drugs and the Brain. New York:Scientific American Library, 1996.

Wilford, B.B; Finch, J.; Czechowicz, D.J.; andWarren D. An overview of prescription drugmisuse and abuse: Defining the problem andseeking solutions. Journal of Law, Medicine& Ethics 22(3):197-203, 1994.

Access information on the NIDA web site

■ Information on prescription drugs andother drugs of abuse

■ Publications and communications (including NIDA NOTES)

■ Calendar of events

■ Links to NIDA organizational units

■ Funding information (including programannouncements and deadlines)

■ International activities

■ Links to related Web sites (access to Web sites of many other organizations inthe field)

NIDA Web Siteswww.drugabuse.gov

www.steroidabuse.orgwww.clubdrugs.org

National Clearinghousefor Alcohol and DrugInformation (NCADI)

Web Site: www.health.orgPhone No.: 1-800-729-6686

References

NIH Publication Number 01-4881Printed July 2001

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