Substance Abuse Treatment May 2006 Volume 5 Issue 2 ADVISORYNews for the Treatment Field Prescription Medications: Misuse, Abuse, Dependence, and Addiction How serious are prescription Older adults are particularly vulnerable to misuse and medication use problems? abuse of prescription medications. Persons ages 65 and older make up only 13 percent of the population but Development and increased availability of prescription account for one-third of all medications prescribed,3 drugs have significantly improved treatment of pain, and many of these prescriptions are for psychoactive mental disorders, anxiety, and other conditions. Millions medications with high abuse and addiction liability.4 of Americans use prescription medications safely and Data from the National Survey on Drug Use and Health responsibly. However, increased availability and vari- indicate that nonmedical use of prescription medications ety of medications with psychoactive effects (see Table was the second most common form of substance abuse 1) have contributed to prescription misuse, abuse, among adults older than 55.5 dependence, and addiction. In 2004,1 the number of Americans reporting abuse2 of prescription medications Use of prescription medications in ways other than was higher than the combined total of those reporting prescribed can have a variety of adverse health conse- abuse of cocaine, hallucinogens, inhalants, and heroin. quences, including overdose, toxic reactions, and serious More than 14.5 million persons reported having used drug interactions leading to life-threatening conditions, prescription medications nonmedically within the past such as respiratory depression, hypertension or hypoten- year. Of this 14.5 million, more than 2 million were sion, seizures, cardiovascular collapse, and death.6 between ages 12 and 17. Table 1: Drug Classes, Medical Uses, and Examples of Commonly Prescribed Medications Drug Class Legitimate Medical Uses Examples of Medications Opioid analgesics Management of acute or chronic pain, relief Codeine (Empirin®, Tylenol 1, 2, 3), Hydrocodone of coughs, antidiarrheal (Vicodin®), Hydromorphone (Dilaudid®), Meperidine (Demerol®), Methadone (Dolophine®), Morphine, Oxycodone (OxyContin®, Percodan®), Propoxyphene (Darvon®) Sedative- Anxiety and panic disorders, acute stress Alprazolam (Xanax®), Chlordiazepoxide HCL (Librium®), hypnotics: reactions Clonazepam (Klonopin®), Diazepam (Valium®), Lorazepam Benzodiazepines (Ativan®) Sedative- Insomnia, anxiety, seizure control Butalbital (Fiorinal®), Meprobamate (Miltown®), Pentobarbital hypnotics: sodium (Nembutal®), Phenobarbital, Secobarbital (Seconal®) Barbiturates Stimulants Attention deficit disorder and attention deficit/ Amphetamine-dextroamphetamine (Adderall®), hyperactivity disorder (ADD, AD/HD), Dextroamphetamine (Dexedrine®), Methylphenidate narcolepsy, weight loss, depression (rarely) (Ritalin®), Sibutramine (Meridia®) May 2006, Volume 5, Issue 2 Substance Abuse Treatment ADVISORY .............................................................................. What are the differences among non­ Pseudoaddiction: Drug-seeking and other behavior that is medical use of prescriptions, misuse, abuse, consistent with addiction but actually results from inadequate physiological dependence, psychological pain relief. Once the pain is adequately treated, the person no 8 dependence (addiction), and pseudoaddiction? longer abuses the medication. The Diagnostic and Statistical Manual of Mental Disorders, How do people become dependent on 4th Edition, Text Revision (DSM-IV-TR),7 provides diagnostic prescription medications? criteria for substance abuse and substance dependence. Within the context of good medical care, substance misuse, Counselors working with clients who use prescription medica­ abuse, physiological dependence, and dependence/addiction are tions, however, need to distinguish among nonmedical use of potential treatment complications. For example, physiological substances, substance misuse, abuse, physiological dependence, dependence is an expected outcome of long-term use of opioid psychological dependence (also known as “addiction”), and medications for pain. A minority of patients may have predispos­ pseudoaddiction. Prescription medications that are on the Drug ing factors that lead to problems of psychological dependence Enforcement Administration’s list of controlled substances have (addiction). Drug use may quickly escalate to unintended and high abuse potential and can lead to physiological or psycho­ initially unanticipated levels beyond the initial intended use, logical dependence, or both, in some patients. alarming both the patient and treatment provider. Nonmedical use: Use of prescription drugs that were not Some people obtain prescription medications illicitly and prescribed by a medical professional (i.e., obtained illicitly) experiment with their effects. Others may find that a particular or use for the experience or feeling a drug causes. drug helps them self-medicate undiagnosed or undertreated dis­ Misuse: Incorrect use of a medication by patients, who may orders (e.g., anxiety, depression, ADD). use a drug for a purpose other than that for which it was pre­ scribed, take too little or too much of a drug, take it too often, How can prescription medication abuse or or take it for too long (misuse does not apply to off-label pre­ dependence be treated effectively? scribing [prescribing a medication for a condition other than People treated with any controlled medication should be moni­ the conditions for which the Food and Drug Administration tored closely for the development of a substance use disorder. approved the medication] when such use is supported by com­ Physiological dependence may be the first symptom of a poten­ mon medical practice, research, or rational pharmacology). tial problem. While physiologically dependent, people may Abuse: A maladaptive pattern of substance use, leading to also develop symptoms of abuse or psychological dependence. clinically significant impairment or distress as manifested by When the decision is made to stop medication therapy, a patient one or more behaviorally based criteria.7 who is physiologically dependent should be expected to develop Physiological dependence: Increasing tolerance for a drug, withdrawal signs and symptoms when a drug is discontinued, or the continued use of a substance to avoid withdrawal. Chronic pain may complicate substance abuse treatment by9— Psychological dependence (addiction): A set of psychological symptoms that demonstrate overall loss of control or obsessive- • Motivating drug-seeking behavior. compulsive drug-seeking and continued use of a substance in spite • Decreasing clients’ quality of life, which may increase of clearly adverse consequences. Symptoms may include specific their attraction to any drug that produces euphoria. physiological signs of dependence such as increasing tolerance or • Creating psychiatric problems, such as depression and withdrawal signs and symptoms when the drug is discontinued. anxiety. Clients whose pain is the result of trauma may have symptoms of posttraumatic stress disorder (PTSD). • Creating functional and social disability that can impede participation and success in treatment. 2 Prescription Medications Substance Abuse Treatment ADVISORY .............................................................................. withdrawal symptoms unless care is taken to slowly taper the Frequently, a problem that begins as prescription drug misuse drug using a standard detoxification or withdrawal protocol. is complicated by illicit use of that same drug or illicit use of During the detoxification or withdrawal period, symptoms another drug. Sometimes, a patient’s use of an illicit drug may of abuse or psychological dependence may emerge. evolve into dependence on a drug that is subsequently pre­ Detoxification alone is not sufficient for a person who meets scribed for him or her. DSM-IV-TR criteria for abuse or dependence. Providers should Effective counseling and medication-assisted treatments use evidence-based brief interventions such as motivational apply to all patients identified with any substance use disor­ enhancement, cognitive–behavioral therapy, or 12-Step facilita­ der. However, to ensure treatment effectiveness, clients with tion, along with referrals to an addiction medicine/psychiatry ongoing pain and those with underlying anxiety disorders, specialist for patients with more severe drug dependence. ADD, AD/HD, and other mental disorders will need services Patients found to be drug dependent should be assessed for beyond standard addiction counseling. Not providing these ser­ the correct level of care for both detoxification and treat­ vices ensures treatment failure. ment according to standards such as the American Society of In summary, counselors treating individuals with prescription Addiction Medicine’s patient placement criteria.10 These patients medication-related problems must use their established approaches also should be considered for appropriate medication-assisted and resources, modified or expanded to address the specific issues therapy by qualified, licensed providers, such as opioid treatment identified in this Advisory. programs or physicians with buprenorphine waivers. Recom­ mendations for effective treatment of substance use disorders do Resources for Additional Information not differentiate between prescription drug and illicit drug use Substance Abuse and Mental Health Services problems. Among these