Preventing and recognizing prescription drug abuse See page 10. from the director: The nonmedical use and abuse of prescription drugs is a serious public health problem in this country. Although most people take prescription medications 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 pain 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— opioids, central nervous system (CNS) depressants, and stimulants—can lead to a variety of adverse health effects, including addiction. Among those who reported past-year nonmedical use of a prescription drug, 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 medication 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 opioid pain relievers have quadrupled P since 1999, and by 2007, outnumbered national surveys, prescription medications, such as those those involving heroin and cocaine. used to treat pain, attention deficit disorders, and anxiety, 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. Retail Pharmacies, of the commonly 250 1991–2010 abused prescription 210 200 Number of Opioid Rxs 201 202 drugs? Hydrocodone 192 Oxycodone 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 • Central nervous system (CNS) depressants—used to treat 50 Number of Prescriptions (millions) anxiety and sleep 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 modafinil and atomoxetine products relieve pain. They reduce 40 39 the intensity of pain signals Total Market methylphenidate 36 reaching the brain and affect ) 35 amphetamine 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), morphine 15 15 13 (e.g., Kadian, Avinza), codeine, 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 injury-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 physical dependence, 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 physician to evaluate whether a is often used before and after patient 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, physicians need to be vigilant and attentive to their patients’ 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 diphenoxylate 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 depression 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 analgesics 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 constipation, 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 route of administration 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 alcohol, antihistamines, barbiturates, benzodiazepines, or general anesthetics, 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 sedatives 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 bone pain, commonly prescribed for these same as addiction (see text box on insomnia, diarrhea, vomiting, 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 diazepam (Valium) and symptoms may occur if drug use movements. alprazolam (Xanax), are sometimes prescribed to treat anxiety, acute stress reactions, and panic attacks. The more Over-the-Counter Medicines sedating benzodiazepines, Over-the-counter (OTC) medications, such as certain cough such as triazolam (Halcion) suppressants, sleep aids, and antihistamines, can be abused for their psychoactive effects. This typically means taking doses higher and estazolam (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 aspirin 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, psychosis, coma, and even death.