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Preventing and recognizing prescription abuse See page 10. from the director:

The nonmedical use and abuse of prescription is a serious public health problem in this country. Although most people take prescription responsibly, an estimated 52 million people (20 percent of those aged 12 and Prescription older) have used prescription drugs for nonmedical reasons at least once in their lifetimes. Young people are strongly represented in this group. In fact, the National Institute on Drug Abuse’s (NIDA) Drug Abuse Monitoring the Future (MTF) survey found that about 1 in 12 high school seniors reported past-year nonmedical use of the prescription reliever Vicodin in 2010, and 1 in 20 reported abusing OxyContin—making these medications among the most commonly abused drugs by adolescents. The abuse of certain prescription drugs— , central (CNS) , and —can lead to a variety of adverse health effects, including . Among those who reported past-year nonmedical use of a , nearly 14 percent met criteria for abuse of or dependence on it. The reasons for the high prevalence of prescription drug abuse vary by age, gender, and other factors, but likely include greater availability. What is The number of prescriptions for some of these medications has increased prescription dramatically since the early 1990s (see figures, page 2). Moreover, a consumer culture amenable to “taking a pill for drug abuse? what ails you” and the perception of 1 prescription drugs as less harmful than rescription drug abuse is the use of a without illicit drugs are other likely contributors a prescription, in a way other than as prescribed, or for to the problem. It is an urgent one: unintentional overdose deaths involving the experience or feelings elicited. According to several pain relievers have quadrupled P since 1999, and by 2007, outnumbered national surveys, prescription medications, such as those those involving and . used to treat pain, attention deficit disorders, and , NIDA hopes to change this situation by are being abused at a rate second only to marijuana among increasing awareness and promoting additional research on prescription drug illicit drug users. The consequences of this abuse have been abuse. Prescription drug abuse is not steadily worsening, reflected in increased treatment admissions, a new problem, but one that deserves renewed attention. It is imperative that as emergency room visits, and overdose deaths. a Nation we make ourselves aware of the consequences associated with abuse of continued inside these medications. 1 Prescription drug abuse, as defined in this report, is equivalent to the term “nonmedical Nora D. Volkow, M.D. use,” used by many of the national surveys or data collection systems. This definition does not Director correspond to the definition of abuse/dependence listed in theDiagnostic and Statistical Manual of National Institute on Drug Abuse Mental Disorders, 4th edition (DSM-IV). Prescription Research Report Series Drug Abuse

Total Number of Opioid Prescriptions What are some Dispensed by U.S. , of the commonly 250 1991–2010 abused prescription 210 200 Number of Opioid Rxs 201 202 drugs? 192 180 Although many medications can be 169 158 abused, the following three classes 151 150 144 139 are most commonly abused: 131 120 • Opioids—usually prescribed to 109 100 100 96 treat pain; 91 86 80 76 78 • (CNS) depressants—used to treat 50

Number of Prescriptions (millions) anxiety and disorders; and • Stimulants—most often 0 prescribed to treat attention- 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 deficit hyperactivity disorder ® Source: SDI’s Vector One : National (VONA) (ADHD).

Total Number of Prescriptions for Opioids— Stimulants* Dispensed by U.S. Retail What are opioids? Pharmacies, 1991–2010 45 45 Opioids are medications that *excludes and products relieve pain. They reduce

40 39 the intensity of pain signals Total Market 36 reaching the brain and affect ) 35 those brain areas controlling 33

30 emotion, which diminishes the 30 29 effects of a painful stimulus. 27 Medications that fall within 25 24 24 21 this class include hydrocodone 20 20 19 (e.g., Vicodin), oxycodone (e.g., 17 16 OxyContin, Percocet), 15 15 13 (e.g., Kadian, Avinza), , and related drugs. Hydrocodone 10 10

Number of Prescriptions (millions 7 products are the most commonly 6 5 4 prescribed for a variety of painful conditions, including dental and 0 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 -related pain. Morphine

Source: SDI’s Vector One®: National (VONA)

2 NIDA Research Report Series Dependence vs. Addiction

Physical dependence occurs because of normal adaptations to chronic exposure to a drug and is not the same as addiction. Addiction, which can include , is distinguished by compulsive drug seeking and use despite sometimes devastating consequences.

Someone who is physically dependent on a medication will experience withdrawal symptoms when use of the drug is abruptly reduced or stopped. These symptoms can be mild or severe (depending on the drug) and can usually be managed medically or avoided by using a slow drug taper.

Dependence is often accompanied by tolerance, or the need to take higher doses of a medication to get the same effect. When tolerance occurs, it can be difficult for a to evaluate whether a is often used before and after is developing a drug problem, or has a real medical need for surgical procedures to alleviate higher doses to control their symptoms. For this reason, need to be vigilant and attentive to their ’ symptoms and severe pain. Codeine, on the other level of functioning to treat them appropriately. hand, is often prescribed for mild pain. In addition to their pain- relieving properties, some of these drugs—codeine and upon the amount of drug taken, What are the possible (Lomotil) for example—can be can depress respiration. Some consequences of opioid used to relieve coughs and severe people experience a euphoric use and abuse? diarrhea. response to opioid medications, Taken as prescribed, opioids can since these drugs also affect the be used to manage pain safely How do opioids affect brain regions involved in reward. and effectively. However, when the brain and body? Those who abuse opioids may seek abused, even a single large dose Opioids act by attaching to to intensify their experience by can cause severe respiratory specific proteins called opioid taking the drug in ways other than and death. Properly receptors, which are found in the those prescribed. For example, managed, short-term medical brain, spinal cord, gastrointestinal OxyContin is an oral medication use of opioid rarely tract, and other organs in the used to treat moderate to severe causes addiction—characterized body. When these drugs attach pain through a slow, steady release by compulsive drug seeking to their receptors, they reduce of the opioid. People who abuse and use despite serious adverse the perception of pain. Opioids OxyContin may snort or inject consequences. Regular (e.g., several can also produce drowsiness, it,2 thereby increasing their risk times a day, for several weeks or mental confusion, nausea, for serious medical complications, more) or longer term use or abuse , and, depending including overdose. of opioids can lead to physical dependence and, in some cases,

In 2007, the number of overdose deaths from prescription opioids outnumbered deaths from heroin and cocaine combined.

2 Changing the also contributes to the abuse of other prescription medications, including stimulants, a practice that can lead to serious medical consequences.

NIDA Research Report Series 3 Is it safe to use opioid drugs with other medications? Only under a physician’s supervision can opioids be used safely with other drugs. Typically, they should not be used with other substances that depress the CNS, such as , , , , or general , because these combinations increase the risk of life-threatening respiratory depression.

OxyContin and heroin CNS have similar depressants— chemical structures and What are CNS depressants? bind to the CNS depressants, sometimes same receptors referred to as and in the brain. tranquilizers, are substances that can slow brain activity. This property makes them useful addiction. Physical dependence is suddenly reduced or stopped. for treating anxiety and sleep is a normal adaptation to chronic These symptoms can include disorders. Among the medications exposure to a drug and is not the restlessness, muscle and pain, commonly prescribed for these same as addiction (see text box on , diarrhea, , cold purposes are the following: “Dependence vs. Addiction” on flashes with goose bumps (“cold • Benzodiazepines, such as page 3). In either case, withdrawal turkey”), and involuntary leg (Valium) and symptoms may occur if drug use movements. (Xanax), are sometimes prescribed to treat anxiety, acute stress reactions, and attacks. The more Over-the-Counter sedating benzodiazepines, Over-the-counter (OTC) medications, such as certain cough such as (Halcion) suppressants, sleep aids, and antihistamines, can be abused for their psychoactive effects. This typically means taking doses higher and (ProSom) are than recommended or combining OTC medications with alcohol, or prescribed for short-term with illicit or prescription drugs. Either practice can have dangerous treatment of sleep disorders. results, depending on the medications involved. Some contain Usually, benzodiazepines or acetaminophen (e.g., Tylenol), which can be toxic to the are not prescribed for long- liver at high doses. Others, when taken for their “hallucinogenic” term use because of the risk properties, can cause confusion, , , and even death. for developing tolerance, Cough syrups and cold medications are the most commonly dependence, or addiction. abused OTC medications. In 2010, for example, 6.6 percent of high school seniors took cough syrup ”to get high.” At high doses, —a key ingredient found in cough syrup—can act like PCP or , producing or out-of-body experiences.

4 NIDA Research Report Series • Non- sleep an individual stops taking them, medications, such as there can be a , (Ambien), resulting in or other (Lunesta), and zalepon harmful consequences. Although (Sonata), have a different withdrawal from benzodiazepines chemical structure, but act can be problematic, it is rarely life on some of the same brain threatening, whereas withdrawal receptors as benzodiazepines. from prolonged use of barbiturates They are thought to have can have life-threatening fewer side effects and less complications. Therefore, risk of dependence than someone who is thinking about benzodiazepines. discontinuing CNS or who is suffering • Barbiturates, such as withdrawal from a CNS depressant mephobarbital (Mebaral), should speak with a physician or (Luminal seek immediate medical treatment. Sodium), and sodium (Nembutal), are used Is it safe to use CNS less frequently to reduce anxiety depressants with other or to help with sleep problems medications? because of their higher risk Only under a physician’s of overdose compared to What are the possible supervision is it safe to use benzodiazepines. However, consequences of CNS CNS depressants with other they are still used in surgical depressant use and abuse? medications. Typically, they should procedures and for Despite their many beneficial not be combined with any other disorders. effects, benzodiazepines and medication or substance that barbiturates have the potential causes CNS depression, including How do CNS depressants for abuse and should be used prescription pain medicines, affect the brain and body? only as prescribed. The use of some OTC cold and Most CNS depressants act non-benzodiazepine sleep aids medications, and alcohol. Using on the brain by affecting the is less well studied, but certain CNS depressants with these other gamma- indicators have raised concern substances—particularly alcohol— aminobutyric acid (GABA). about their abuse liability as well. can affect heart rhythm, slow are brain During the first few days of taking respiration, and even lead to death. chemicals that facilitate a prescribed CNS depressant, a between brain person usually feels sleepy and cells. Although the different uncoordinated, but as the body classes of CNS depressants work becomes accustomed to the in unique ways, it is through their effects of the drug and tolerance ability to increase GABA—and develops, these side effects begin thereby inhibit brain activity—that to disappear. If one uses these they produce a drowsy or calming drugs long term, larger doses effect beneficial to those suffering may be needed to achieve the from anxiety or sleep disorders. therapeutic effects. Continued use can also lead to physical dependence and withdrawal when use is abruptly reduced or stopped (see text box on “Dependence vs. Addiction” on page 3). Because all CNS depressants work by slowing the brain’s activity, when

NIDA Research Report Series 5 only a few health conditions, After Marijuana, Prescription and Over-the-Counter including ADHD, , and Medications* Account for Most of the occasionally depression—in those Commonly Abused Drugs who have not responded to other Prevalence of Past-Year Drug Use Among 12th Graders treatments. Categories are not mutually exclusive 35 34.8 How do stimulants affect the brain and body? 30 Stimulants, such as (Dexedrine 25 and ) and methylphenidate (Ritalin and Concerta), act in 20 the brain similarly to a family of key brain neurotransmitters Percen t 15 called monoamines, which include norepinephrine and . 10 8.0 Stimulants enhance the effects 6.6 6.5 5.6 5.5 5.5 5.1 4.8 4.5 of these chemicals in the brain. 5 3.6 2.9 2.7 The associated increase in dopamine can induce a feeling

0 of when stimulants are Salvia codin* MDMA Cough Ritalin * Cocaine Hashis h Vi taken nonmedically. Stimulants s Adderall* (Ecstasy) * (any form) Marijuana/ Sedatives* OxyContin*

ranquilizers* also increase pressure and T , constrict blood vessels,

SOURCE: University of Michigan, 2010 Monitoring the Future Study increase blood glucose, and open * Nonmedical Use up breathing passages.

Stimulants— Cognitive Enhancers

What are stimulants? The dramatic increases in prescriptions over the last 2 As the name suggests, stimulants decades have led to their greater environmental availability and increase , attention, increased risk for diversion and abuse. For those who take these and energy, as well as elevate medications to improve properly diagnosed conditions, they , heart rate, can be transforming, greatly enhancing a person’s quality of life. and respiration. Stimulants However, because they are perceived by many to be generally historically were used to treat safe and effective, prescription stimulants, such as Concerta or and other respiratory Adderall, are increasingly being abused to address nonmedical problems, , neurological conditions or situations. Indeed, reports suggest that the practice disorders, and a variety of other is occurring among some academic professionals, athletes, performers, older people, and both high school and college ailments. But as their potential students. Such nonmedical cognitive enhancement poses for abuse and addiction became potential health risks, including addiction, cardiovascular events, apparent, the medical use of and psychosis. stimulants began to wane. Now, stimulants are prescribed to treat

Youth who abuse prescription medications are also more likely to report use of other drugs.

6 NIDA Research Report Series What are the possible Source of Prescription consequences of stimulant among Those Who Used in the use and abuse? Past-Year, 12th Grade* As with other drugs of abuse, it is * Categories are not mutually exclusive possible for individuals to become 60 59.1 dependent upon or addicted to stimulants. Withdrawal symptoms 50 associated with discontinuing stimulant use include , depression, and disturbance of 40 37.8 sleep patterns. Repeated abuse of 32.5 some stimulants (sometimes within 30 a short period) can lead to feelings Percen t of hostility or , even psychosis. Further, taking high 20 18.8 19.5 doses of a stimulant may result in

11 dangerously high body temperature 10 and an irregular heartbeat. There is also the potential for 1.1 0 cardiovascular failure or seizures. Internet OtherTook Bought Prescription Bought Given by from from from friend/ friend/ dealer/ friend/ relative relative stranger relative Is it safe to use stimulants SOURCE: University of Michigan, 2010 Monitoring the Future Study with other medications? Stimulants should not be used with other medications unless authorized by a physician. Patients also should Greater Lifetime Use of Illicit Drugs be aware of the dangers associated among Prescription Abusers 100 with mixing stimulants and OTC Any Nonmedical Use of Pain Relievers (in lifetime) cold medicines that contain No Nonmedical Use of Pain Relievers , as combining these substances may cause blood 80 77.0 pressure to become dangerously high or lead to irregular heart rhythms. 60

49.0

Percent 44.5 Trends in 40 prescription 35.0 33.8 drug abuse

How many people abuse 20 prescription drugs? 10.0 9.3 According to results from the 6.0 2010 National Survey on Drug 0 Use and Health (NSDUH), Marijuana Cocaine Hallucinogens an estimated 2.4 million The rate of use of other drugs is significantly higher among those who have abused prescription drugs in their lifetimes. The same is true for past-year users. Americans used prescription

SOURCE: SAMHSA. Misuse of prescription drugs: Data from the 2002, 2003, and 2004 drugs nonmedically for the National Surveys on Drug Use and Health. HHS . No. (SMA)06-4192. Rockville, MD: first time within the past year, Office of Applied Studies, 2006.

NIDA Research Report Series 7 which averages to approximately Older adults 6,600 initiates per day. More Persons aged 65 years and older than one-half were females and comprise only 13 percent of about a third were aged 12 to 17. the population, yet account Although prescription drug abuse for more than one-third of affects many Americans, certain total outpatient spending populations, such as youth, older on prescription medications adults, and women, may be at in the United States. Older particular risk. patients are more likely to be prescribed long-term and Adolescents and young adults multiple prescriptions, and Abuse of prescription drugs is some experience cognitive highest among young adults aged decline, which could lead to 18 to 25, with 5.9 percent reporting improper use of medications. nonmedical use in the past month Alternatively, those on a fixed (NSDUH, 2010). Among youth income may abuse another aged 12 to 17, 3.0 percent reported person’s remaining medication past-month nonmedical use of to save money. prescription medications. The high rates of comorbid According to the 2010 MTF, illnesses in older populations, prescription and OTC drugs age-related changes in drug are among the most commonly , and the potential abused drugs by 12th graders relative. Interestingly, the number for drug interactions may make (see figure on page 6), after of students who purchased opioids any of these practices more alcohol, marijuana, and . over the Internet was negligible dangerous than in younger While past-year nonmedical use (see top chart on previous page). populations. Further, a large of sedatives and tranquilizers Youth who abuse prescription percentage of older adults decreased among 12th graders medications are also more likely to also use OTC medicines and over the last 5 years, this is not report use of other drugs. Multiple dietary supplements, which the case for the nonmedical use studies have revealed associations (in addition to alcohol) could of or opioid pain between prescription drug abuse compound any adverse health relievers. and higher rates of cigarette consequences resulting from When asked how prescription ; heavy episodic drinking; prescription drug abuse. opioids were obtained for and marijuana, cocaine, and other nonmedical use, more than half illicit drug use among adolescents, of the 12th graders surveyed young adults, and college students said they were given the drugs in the United States (see bottom or bought them from a friend or chart on previous page).

Older patients are more likely to be prescribed long-term and multiple prescriptions, which could lead to improper use of medications.

8 NIDA Research Report Series Past-Year Nonmedical Use of Gender differences Psychotherapeutics Among Persons Overall, more males than females 12 or Older, by Gender and Age Group abuse prescription drugs in all Annual averages based on 2002-2005 age groups except the youngest 20 (aged 12 to 17 years); that is, Male Female females in this age group exceed males in the nonmedical use of 15.7 all psychotherapeutics, including 15 pain relievers, tranquilizers, and 13.5 stimulants. Among nonmedical users of prescription drugs, females 12 to 17 years old are also more 10 9.7

Percen t likely to meet abuse or dependence 8* criteria for psychotherapeutics (see figure, left). 5 4.6* 4.2 How many people suffer adverse health consequences from abusing prescription drugs? 0 12 to 17 18 to 25 26 and older The Drug Abuse Warning * Difference from male to female significant at p<0.01. Network (DAWN), which SOURCE: Cotto, J.H, et al. Gender effects on drug use, abuse, and dependence: An analysis of results from the National Survey on Drug Use and Health. Gend Med 7(5):402–413, 2010. monitors emergency department (ED) visits in selected areas across the Nation, reported that Past-Year Dependence or Abuse of approximately 1 million ED visits Psychotherapeutics Among Past-Year in 2009 could be attributed to Nonmedical Users 12 or Older, by prescription drug abuse. Roughly Gender and Age Group 343,000 involved prescription Annual averages based on 2002-2005 opioid pain relievers, a rate more Male than double that of 5 years prior. 20 Female ED visits also more than doubled 18 for CNS stimulants, involved in nearly 22,000 visits in 2009, as well 15 as CNS depressants (, sedatives, and ), involved 13.4* 13.1 13.2 13.1 12.5 in 363,000 visits. Of the latter, benzodiazepines (e.g., Xanax) 10 comprised the vast majority. Rates Percen t for a popular prescribed non- benzodiazepine sleep aid, zolpidem (Ambien), rose from roughly 5 13,000 in 2004 to 29,000 in 2009. More than half of ED visits for prescription drug abuse involved 0 multiple drugs. 12 to 17 18 to 25 26 and older * Difference from male to female significant at p<0.01. SOURCE: Cotto, J.H, et al. Gender effects on drug use, abuse, and dependence: An analysis of results from the National Survey on Drug Use and Health. Gend Med 7(5):402–413, 2010.

NIDA Research Report Series 9 visits. Doctors should also take note of rapid increases in the amount of medication needed or frequent, unscheduled refill requests. Doctors should be alert to the fact that those addicted to prescription drugs may engage in “doctor shopping”—moving from provider to provider—in an effort to obtain multiple prescriptions for the drug(s) they abuse. Preventing or stopping prescription drug abuse is an important part of patient care. However, healthcare providers should not avoid prescribing To ensure proper stimulants, CNS depressants, or medical care, opioid pain relievers if needed. patients should (See text box on “Chronic Pain discuss any and all Treatment and Addiction” on drug use—including prescription and page 13.) over-the-counter Patients. For their part, medications—with patients can take steps to ensure their doctors. that they use prescription medications appropriately: always follow the prescribed directions, Physicians. More than 80 Preventing and be aware of potential interactions percent of Americans had contact with other drugs, never stop recognizing with a healthcare professional or change a dosing regimen prescription in the past year, placing doctors without first discussing it with a drug abuse in a unique position, not only to healthcare provider, and never prescribe medications, but also use another person’s prescription. The risks for addiction to to identify abuse (or nonmedical In addition to describing their prescription drugs increase when use) of prescription drugs medical problem, patients should they are used in ways other than as and prevent the escalation to always inform their healthcare prescribed (e.g., at higher doses, by addiction. By asking about all professionals about all the different routes of administration, drugs, physicians can help their prescriptions, OTC medicines, and or combined with alcohol or other patients recognize that a problem dietary and supplements drugs). Physicians, their patients, exists, set recovery goals, and seek they are taking, before they and all can play a appropriate treatment. Screening obtain any other medications. role in identifying and preventing for prescription drug abuse can be Additionally, unused or expired prescription drug abuse. incorporated into routine medical medications should be properly

Prescription Drug Monitoring Programs allow physicians and pharmacists to track prescriptions and help identify patients who are “doctor shopping.”

10 NIDA Research Report Series discarded per U.S. and Drug Administration (FDA) guidelines or at U.S. Drug Enforcement Administration collection sites. Pharmacists. Pharmacists dispense medications and can help patients understand instructions for taking them. By being watchful for prescription falsifications or alterations, pharmacists can serve as the first line of defense in recognizing prescription drug abuse. Some pharmacies have developed hotlines to alert other pharmacies in the region when a fraudulent prescription is detected. Moreover, prescription drug monitoring programs (PDMPs), Although a behavioral or pharmacological which require physicians and approach alone may be sufficient for pharmacists to log each filled treating some patients, research shows prescription into a State database, that a combined approach may be best. can assist medical professionals in identifying patients who are The two main categories of can be used to relieve withdrawal getting prescriptions from multiple drug addiction treatment are symptoms, help overcome drug sources. As of May 2011, 48 behavioral and pharmacological. cravings, or treat an overdose. States and 1 territory have enacted Behavioral treatments help patients Although a behavioral or legislation authorizing PDMPs, 34 stop drug use by teaching them pharmacological approach alone of which are operational. strategies to function without may be sufficient for treating some drugs, deal with cravings, avoid patients, research shows that a Treating drugs and situations that could combined approach may be best. lead to drug use, and handle a prescription should it occur. When Treating addiction to drug addiction delivered effectively, behavioral prescription opioids Several options are available for Years of research have shown treatments, such as individual effectively treating prescription that addiction to any drug (illicit counseling, group or family opioid addiction. These options or prescribed) is a brain counseling, contingency are drawn from research on the that can be treated effectively. management, and cognitive- treatment of heroin addiction Treatment must take into account behavioral , also can help and include medications (e.g., the type of drug used and the patients improve their personal , , and needs of the individual. Successful relationships and their ability ) as well as treatment may need to incorporate to function at work and in the behavioral counseling approaches. several components, including community. Naltrexone is an antagonist detoxification, counseling, and Some , such medication that prevents opioids sometimes the use of addiction as opioid addiction, can be from activating their receptors. medications. Multiple courses of treated with medications. These It is used to treat overdose and treatment may be needed for the pharmacological treatments addiction, although its use for patient to make a full recovery. counter the effects of the drug on the brain and behavior, and addiction has been limited due to

NIDA Research Report Series 11 expectations, and behaviors while increasing skills for coping with various life stressors, also has been used successfully to help individuals adapt to discontinuing benzodiazepines. Often and benzodiazepine abuse occurs in conjunction with the abuse of other drugs, such as alcohol or cocaine. In such cases of polydrug abuse, the treatment approach should address the multiple addictions.

Treating addiction to prescription stimulants Treatment of addiction to prescription stimulants, such as Adderall and Concerta, is poor and by can reduce cravings and is well based on behavioral therapies patients. Recently, an injectable, tolerated by patients. NIDA is used in treating cocaine and long-acting form of naltrexone supporting research needed to addiction. At (Vivitrol), originally approved determine the effectiveness of these this time, there are no medications for treating , has also medications in treating addiction that are FDA-approved for treating received FDA approval to treat to opioid pain relievers. stimulant addiction. Thus, NIDA opioid addiction (i.e., heroin is supporting research in this area. Treating addiction to or other opioids). Because its Depending on the patient’s CNS depressants effects last for weeks, Vivitrol situation, the first steps in treating Patients addicted to barbiturates is ideal for patients who do not prescription stimulant addiction and benzodiazepines should have ready access to healthcare may be to taper the drug dosage not attempt to stop taking or who struggle with taking their and attempt to ease withdrawal them on their own. Withdrawal medications regularly. Methadone symptoms. The detoxification symptoms from these drugs can is a synthetic opioid that process could then be followed by be problematic, and—in the case eliminates withdrawal symptoms behavioral therapy. Contingency of certain CNS depressants— and relieves drug cravings by acting management, for example, uses a potentially life-threatening. on the same brain targets as other system that enables patients to earn Research on treating barbiturate opioids like heroin, morphine, vouchers for drug-free urine tests. and benzodiazepine addiction and opioid pain medications. It (These vouchers can be exchanged is sparse; however, addicted has been used successfully for for items that promote healthy patients should undergo medically more than 40 years to treat heroin living.) Cognitive-behavioral supervised detoxification because addiction, but must be dispensed therapy also may be an effective the dosage they take should be through opioid treatment treatment for addressing stimulant gradually tapered. Inpatient programs. Buprenorphine is a addiction. Finally, recovery or outpatient counseling can partial opioid agonist (i.e., it has support groups may be helpful help individuals through this agonist and antagonist properties), in conjunction with behavioral process. Cognitive-behavioral which can be prescribed by therapy. certified physicians in an office therapy, which focuses on setting. Like methadone, it modifying the patient’s thinking,

12 NIDA Research Report Series Chronic Pain Treatment and Addiction

Healthcare providers have long wrestled with how best to treat patients who suffer from chronic pain, roughly 116 million in this country. Their dilemma stems from the potential risks involved with long-term treatment, such as the development of (and the need for escalating doses), hyperalgesia (increased pain sensitivity), and addiction. Patients themselves may even be reluctant to take an opioid medication prescribed to them for fear

of becoming addicted. Estimates of addiction among chronic pain patients vary widely—from about 3 percent to 40 percent. This variability is the result of differences in treatment duration, insufficient research on long-term outcomes, and disparate study populations and measures used to assess abuse or addiction.

To mitigate addiction risk, physicians should screen patients for potential risk factors, including personal or family history of drug abuse or mental illness. Monitoring patients for signs of abuse is also crucial, and yet some indicators can signify multiple conditions, making accurate assessment challenging. Early or frequent requests for prescription pain medication refills, for example, could represent illness progression, the development of drug tolerance, or the emergence of a drug problem.

The development of effective, nonaddicting pain medications is a public health priority. A growing elderly population and an increasing number of injured military only add to the urgency of this issue. Researchers are exploring alternative medications that can alleviate pain but have less abuse potential. More research is needed to better understand effective chronic , including identifying factors that predispose some patients to addiction and developing measures to prevent abuse.

NIDA Research Report Series 13 Glossary Opioid: A compound or drug that binds to receptors in the brain involved in the control of pain and other Addiction: A chronic, relapsing disease characterized functions (e.g., morphine, heroin, hydrocodone, by compulsive drug seeking and use, despite serious oxycodone). adverse consequences, and by long-lasting changes Physical Dependence: An adaptive physiological in the brain. state that occurs with regular drug use and results in Agonist: A chemical entity that binds to a a withdrawal syndrome when drug use is stopped; and activates it, mimicking the action of the natural often occurs with tolerance. Physical dependence (or abused) substance that binds there. can happen with chronic—even appropriate—use of many medications, and by itself does not constitute Antagonist: A chemical entity that binds to a receptor addiction. and blocks its activation. Antagonists prevent the natural (or abused) substance from activating its Polydrug Abuse: The abuse of two or more drugs at receptor. the same time, such as CNS depressants and alcohol. Barbiturate: A type of CNS depressant prescribed to Prescription Drug Abuse: The use of a medication promote sleep (usually in surgical procedures) or as without a prescription; in a way other than as an . prescribed; or for the experience or feeling elicited. This term is used interchangeably with “nonmedical” Benzodiazepine: A type of CNS depressant use, a term employed by many of the national prescribed to relieve anxiety and sleep problems. surveys. Valium and Xanax are among the most widely prescribed medications. Psychotherapeutics: Drugs that have an effect on the function of the brain and that often are used to treat Buprenorphine: A mixed opiate agonist/antagonist psychiatric/neurologic disorders; includes opioids, medication approved by the FDA in October 2002 for CNS depressants, and stimulants. the treatment of opioid addiction (e.g., heroin). Respiratory Depression: Slowing of respiration Central Nervous System: The brain and spinal cord. (breathing) that results in the reduced availability of CNS Depressants: A class of drugs that slow CNS oxygen to vital organs. function (also called sedatives and tranquilizers), Sedatives: Drugs that suppress anxiety and some of which are used to treat anxiety and promote sleep; the NSDUH classification includes sleep disorders; includes barbiturates and benzodiazepines, barbiturates, and other types of benzodiazepines. CNS depressants. Comorbidity: The occurrence of two disorders or Stimulants: A class of drugs that enhances the illnesses in the same person, also referred to as activity of monamines (such as dopamine) in the co-occurring conditions or dual diagnosis. Patients brain, increasing , heart rate, blood pressure, with comorbid illnesses may experience a more and respiration, and decreasing appetite; includes severe illness course and require treatment for each some medications used to treat attention-deficit or all conditions. hyperactivity disorder (e.g., methylphenidate Detoxification:A process in which the body rids itself and amphetamines), as well as cocaine and of a drug (or its ). During this period, methamphetamine. withdrawal symptoms can emerge that may require Tolerance: A condition in which higher doses of medical treatment. This is often the first step in drug a drug are required to produce the same effect abuse treatment. achieved during initial use; often associated with Dopamine: A brain chemical, classified as a physical dependence. neurotransmitter, found in regions that regulate Tranquilizers: Drugs prescribed to promote sleep or movement, emotion, motivation, and pleasure. reduce anxiety; the NSDUH classification includes Methadone: A long-acting synthetic opioid benzodiazepines, barbiturates, and other types of medication that is effective in treating opioid CNS depressants. addiction and pain. Withdrawal: Symptoms that occur after chronic use Narcolepsy: A disorder characterized by of a drug is reduced abruptly or stopped. uncontrollable episodes of deep sleep. Norepinephrine: A neurotransmitter present in the brain and the peripheral (sympathetic) nervous system; and a released by the adrenal glands. Norepinephrine is involved in attention, responses to stress, and it regulates smooth muscle contraction, heart rate, and blood pressure.

14 NIDA Research Report Series References Lord, S.; Brevard, J.; and Budman, S. Connecting to Young Adults: An Online Social Network Baillargeon, L.; Landreville, P.; Verreault, R.; Survey of Beliefs and Attitudes Associated With Beauchemin, J.-P.; Grégoire, J.-P.; and Morin, Prescription Opioid Misuse Among College C.M. Discontinuation of benzodiazepines Students. Substance Use Misuse 46:66–76, 2011. among older insomniac adults treated with cognitive-behavioural therapy combined Maher, B. Poll results: Look who’s doping. with gradual tapering: A randomized Nature 452:674–675, 2008. trial. CMAJ 169:1015–1020, 2003. McCabe, S.E.; Boyd, C.J.; Cranford, J.A.; and Boyer, E.W. Dextromethorphan abuse. Pediatr Teter, C.J. Motives for nonmedical use of Emerg Care 20(12):858–863, 2004. prescription opioids among high school seniors in the United States, self-treatment and beyond. Cai, R.; Crane, E.; Poneleit, K.; and Paulozzi, Arch Pediatr Adolesc Med 163(8):106, 2009. L. Emergency department visits involving nonmedical use of selected prescription drugs McCabe, S.E.; Boyd, C.J.; and Teter, C.J. Subtypes in the United States, 2004–2008. J Pain Palliat of nonmedical prescription drug misuse. Care Pharmacother 24(3):293–297, 2010. Drug Alcohol Depend 102:63–70, 2009. Centers for Disease Control and Prevention (CDC). McCabe, S.E.; Teter, C.J.; and Boyd, C.J. Medical use, Unintentional Drug Poisoning in the United illicit use, and diversion of abusable prescription States. CDC Data Brief, July 2010: http:// drugs. J Am Coll Health 54:269–278, 2006. www.cdc.gov/HomeandRecreationalSafety/ Pleis, J.R.; Lucas, J.W.; and Ward, B.W. Summary pdf/-issue-brief.pdf. health statistics for U.S. adults: National Health Cheatle, M.D., and O’Brien, C.P. Opioid therapy Interview Survey, 2008. National Center for Health in patients with chronic noncancer pain: Statistics. Vital Health Stat 10 (242), 2009. Diagnostic and clinical challenges. Adv Simoni-Wastila, L.; Ritter, G.; and Strickler, G. Psychosom Med 30:61–91, 2011. Gender and other factors associated with Cotto, J.H.; Davis, E.; Dowling, G.J.; Elcano, J.C.; the nonmedical use of abusable prescription Staton, A.B.; Weiss, S.R.B. Gender effects on drugs. Subst Use Misuse 39(1):1–23, 2004. drug use, abuse, and dependence: An analysis Simoni-Wastila, L. The use of abusable prescription of results from the National Survey on Drug Use drugs: The role of gender. J Womens Health and Health. Gend Med 7(5):402–413, 2010. Gend Based Med 9(3):289–297, 2000. Dowling, G.J., Weiss, S.R., and Condon, and Services T.P. Drugs of abuse and the aging brain. Administration, Results from the 2010 33(2):209–218, 2008. National Survey on Drug Use and Health: Fishbain, D.A.; Cole, B.; Lewis, J.; Rosomoff, Summary of National Findings, NSDUH Series H.L.; Rosomoff, R.S. What percentage of H-41, HHS Publication No. (SMA) 11-4658. chronic nonmalignant pain patients exposed Rockville, MD: Substance Abuse and Mental to chronic opioid therapy develop Health Services Administration, 2011. abuse/addiction and/or aberrant drug-related SAMHSA. Misuse of prescription drugs: Data from the behaviors? A structured evidence-based 2002, 2003, and 2004 National Surveys on Drug review. Pain Med 9(4):444–459, 2008. Use and Health. HHS Pub. No. (SMA)06-4192. Institute of Medicine (IOM). Relieving Pain in America: Rockville, MD: Office of Applied Studies, 2006. A Blueprint for Transforming Prevention, Care, SAMHSA. Detailed Tables: National Estimates, Education, and Research. Washington, DC: Drug-Related Emergency Department Visits The National Academies Press, 2011. http:// for 2004–2009. Rockville, MD: Office of www.iom.edu/Reports/2011/Relieving-Pain- Applied Studies, 2010. https://dawninfo. in-America-A-Blueprint-for-Transforming- samhsa.gov/data/default.asp?met=All. Prevention-Care-Education-Research.aspx. Svetlov, S.I.; Kobeissy, F.H.; and Gold, M.S. Johnston, L.D.; O’Malley, P.M.; and Bachman, Performance enhancing, non-prescription use J.G. Monitoring the Future: National Survey of Ritalin: A comparison with amphetamines Results on Drug Use, Overview of Key Findings and cocaine. J Addict Dis 26(4):1–6, 2007. 2010. Bethesda, MD: NIDA, NIH, DHHS, 2010. Available at: www.monitoringthefuture.org. Licata, S.C., and Rowlett, J.K. Abuse and dependence liability of benzodiazepine-type drugs: GABA(A) receptor modulation and beyond. Pharmacol Biochem Behav 90(1):74–89, 2008.

NIDA Research Report Series 15 Where can I get further information about prescription drug abuse?

To learn more about prescription What’s on the NIDA Web Site NIDA Web Sites drugs and other drugs of abuse, • Information on drugs of abuse and www.drugabuse.gov visit the NIDA Web site at related health consequences www.backtoschool.drugabuse.gov www.drugabuse.gov or contact • NIDA publications, news, and the DrugPubs Research www.clubdrugs.gov events Dissemination Center at www.teens.drugabuse.gov 877-NIDA-NIH (877-643-2644; • Resources for health care TTY/TDD: 240-645-0228). professionals For Physician Information • Funding information (including program announcements and deadlines) www.drugabuse.gov/nidamed • International activities Other Web Sites • Links to related Web sites (access Information on prescription drug to Web sites of many other abuse is also available through the organizations in the field) following Web site: • Substance Abuse and Mental Health Services Administration Health Information Network: www.samhsa.gov/shin

NIH Publication Number 11-4881 Printed July 2001, Revised October 2011. Feel free to reprint this publication.