1 Prescription Drug Abuse: Trends, Surveillance, and Future Implications Dena M. Fisher Case Western Reserve University Master of Public Health I. Prescription Drug Abuse A. What is it? B. What types of drugs are being abused? 1. Opioids, central nervous system depressants, sedatives, and tranquilizers C. Epidemiology of prescription drug abuse: Who is abusing? D. Poisoning and death from prescription drug abuse II. Sources of Abused Prescription Drugs A. Why prescription drugs? 1. How are they obtained? III. Prescribing Trends A. Over-prescribing B. Under-prescribing V. Future Implications A. Screening by physicians B. National and state prevention programs 1. What works? VI. Surveillance and Monitoring (Annotated bibliography with corresponding websites) Appendix A: Treatment and Recovery Resources What is abuse? Advancements in pharmacotherapy have enabled many people to be relieved of persistent and chronic pain and many Americans today benefit from appropriate use of prescription painkillers (ONDCP, 2008). However, when these drugs are used for nonmedical purposes they can alter brain activity and lead to dependence (NIDA, 2007).2Drug abuse is defined as the use of illicit drugs (NIH, 2007). Illicit drugs are classified as marijuana, phencyclidine (PCP), hallucinogens, stimulants, amphetamines, inhalants, and narcotics. While most illicit drugs are purchased from the street including, crack-cocaine or heroin, some of the deadliest illicit drugs are available in one’s medicine cabinet. Many are prescribed narcotics to relieve chronic and acute pain; however prescription drug abuse is on the rise in the United States and appears to be contributing to a growing public health problem riddled with abuse and addiction (NSDUH, 2007). Prescription drug abuse and dependence is slightly more complex than illicit drug or alcohol abuse in that often times, a person is prescribed the drug of abuse for initial therapy to a pain issue. It can be said that no one is prescribed cocaine, marijuana, or alcohol. Medline Plus states that prescription or over-the counter drugs may be abused if you take more than the normal or recommended amount of the medicine, or if you use them for illegal purposes (MedlinePlus, 2008). In a report to The Addiction Technology Transfer Center Network, Jane Carlisle Maxwell defines non-medical use of prescription drugs as the use of prescription-type drugs that are not prescribed for the individual by a physician or the drugs are used only for the experience or feeling they cause (Maxwell, 2006). The National Household Survey on Drug Abuse (NHSDA) has developed criteria to better define prescription drug abuse. According to NHSDA, “heavy use” is considered to be daily nonmedical use of one or more prescription drugs for at least two weeks in the past year (Wastila & Strickler, 2004). Additionally, NHSDA considers one to be abusing when two of the following five criteria are met: (1) inability to cut down; (2) getting less work done; (3) using substance in past month and being depressed,3argumentative, anxious, or upset, feeling isolated, and/or having health problems and/or difficulty thinking clearly; (4) needing larger amounts; or (5) experiencing withdrawal symptoms (Epstein, 1995 & DSM-III, 1987). Addiction is a multi-stage process that involves the initiation of drug use, progression to intermittent and then regular use, followed by dependence or addiction, and frequently, relapses following withdrawal or slowing of drug use (Kreek, et al., 2005). Patients who deviate from their prescribed pain reliever program can be categorized as patients with problematic opioid use (Ballantyne & LaForge, 2007). The terms, abuse, misuse, and dependence are debatable, however the consequences of all three are quite real. What drugs are being abused? Prescription medications are increasingly being abused or used for nonmedical purposes and while the practice is illegal it can also be lethal in some cases. Commonly abused classes of prescription drugs include painkillers, sedatives, and stimulants (www.drugabuse.gov). Prescription psychotherapeutic drugs include pain relievers, tranquilizers, stimulants, and sedatives (Maxwell, 2006). Commonly abused classes of prescription drugs include opioids (often prescribed to treat pain), central nervous system depressants (prescribed to treat anxiety and sleep disorders), and stimulants (used to treat narcolepsy, attention deficit hyperactivity disorder, and obesity) (NIDA, 2007). Derived from opium poppies, opiates include morphine and codeine. Opioids have the same effect of morphine and codeine but are synthetically produced (MedlinePlus, 2008). Included in this class of drugs are oxycodone, heroin, hydromorphone, meperidine, propoxyphene, and methadone. Prescribed as pain killers, these drugs promote sedation, decrease anxiety, and block pain receptors in the brain in order to alleviate acute and4chronic pain (MedlinePlus, 2008). Commercially, these drugs are called, OxyContin, Darvon, Vicodin, Dilaudid, Demerol, and Lomotil (NIDA, 2007). On the street, however the commercial names are broken down further into slang such as, OC’s, Perc’s, OxyCoffin’s, Hillbilly Heroin, Killer’s, and Oxy’s (SAMHSA, 2007). Common central nervous system depressants include barbiturates, such as Nembutol, and benzodiazepines such as Valium and Xanax (NIDA, 2007). Painkillers such as Vicodin and OxyContin are very powerful medications against pain, however they need to be monitored and taken only under close supervision by a prescribing physician. When these controlled medications are taken inappropriately they can trigger addiction as they act on the same places in the brain as heroin. Long-term use of opioids or central nervous system depressants can lead to physical dependence. Taken in high doses, stimulants can lead to compulsive use, paranoia, dangerously high body temperatures, and irregular heartbeat (NIDA, 2007). Typically, time-released opioids, such as OxyContin, are chewed or crushed and inhaled to negate the time-release effect; there is also evidence that some abusers inject the drug intravenously (SAMHSA, 2007). The following table from the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA) illustrates the breakdown of nonmedical prescription drug use in 2003.5 Opioid abuse exceeds stimulants, sedatives, and