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NationalInstituteonDrugAbuse(NIDA)

MisuseofPrescriptionDrugs

LastUpdatedJanuary2018

https://www.drugabuse.gov

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TableofContents

MisuseofPrescriptionDrugs

Summary

Whatisthescopeofprescriptiondrugmisuse?

Howmanypeoplesufferadversehealthconsequencesfrommisuseofprescriptiondrugs?

Isitsafetouseprescriptiondrugsincombinationwithothermedications?

Whichclassesofprescriptiondrugsarecommonlymisused?

Areprescriptiondrugssafetotakewhenpregnant?

Howcanprescriptiondrugmisusebeprevented?

Howcanprescriptiondrugaddictionbetreated?

WherecanIgetfurtherinformationaboutprescriptiondrugmisuse?

References

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Summary

Misuseofprescriptiondrugsmeanstakingamedicationinamannerordoseotherthanprescribed;takingsomeoneelse’sprescription,evenifforalegitimatemedicalcomplaintsuchaspain;ortakingamedicationtofeeleuphoria(i.e.,togethigh).*Thetermnonmedicaluseofprescriptiondrugsalsoreferstothesecategoriesofmisuse.Thethreeclassesofmedicationmostcommonlymisusedare :

opioids—usuallyprescribedtotreatpain

centralnervoussystem[CNS]depressants(thiscategoryincludestranquilizers,sedatives,andhypnotics)—usedtotreatanxietyandsleepdisorders

stimulants—mostoftenprescribedtotreatattention-deficithyperactivitydisorder(ADHD)

Prescriptiondrugmisusecanhaveseriousmedicalconsequences.Increasesinprescriptiondrugmisuse overthelast15yearsarereflectedinincreasedemergencyroomvisits,overdosedeathsassociatedwithprescriptiondrugs ,andtreatmentadmissionsforprescriptiondrugusedisorders,themostsevereformofwhichisaddiction.Amongthosewhoreportedpast-yearnonmedicaluseofaprescriptiondrug,nearly12percentmetcriteriaforprescriptiondrugusedisorder. Unintentionaloverdosedeathsinvolvingopioidpainrelievers

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havemorethanquadrupledsince1999andhaveoutnumberedthoseinvolvingheroinandcocainesince2002.

*Takingprescriptiondrugstogethighissometimescalled"prescriptiondrugabuse."

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Whatisthescopeofprescriptiondrugmisuse?

Misuseofprescriptionopioids,centralnervoussystem(CNS)depressants,andstimulantsisaseriouspublichealthproblemintheUnitedStates.Althoughmostpeopletakeprescriptionmedicationsresponsibly,anestimated54millionpeople(morethan20percentofthoseaged12andolder)haveusedsuchmedicationsfornonmedicalreasonsatleastonceintheirlifetime. Accordingtoresultsfromthe2014NationalSurveyonDrugUseandHealth,anestimated2.1millionAmericansusedprescriptiondrugsnonmedicallyforthefirsttimewithinthepastyear,whichaveragestoapproximately5,750initiatesperday.Fifty-fourpercentwerefemalesandabout30percentwereadolescents.

Thereasonsforthehighprevalenceofprescriptiondrugmisusevarybyage,gender,andotherfactors,butlikelyincludeeaseofaccess. Thenumberofprescriptionsforsomeofthesemedicationshasincreaseddramaticallysincetheearly1990s. Moreover,misinformationabouttheaddictivepropertiesofprescriptionopioidsandtheperceptionthatprescriptiondrugsarelessharmfulthanillicitdrugsareotherpossiblecontributorstotheproblem.

AlthoughmisuseofprescriptiondrugsaffectsmanyAmericans,certainpopulationssuchasyouth,olderadults,andwomenmaybeatparticularrisk.Inaddition,whilemorementhanwomencurrentlymisuseprescriptiondrugs,

theratesofmisuseandoverdoseamongwomenareincreasingfasterthanamongmen.

AdolescentsandYoungAdults

Nonmedicaluseofprescriptiondrugsishighestamongyoungadultsaged18to25,with4.6percentreportingnonmedicaluseinthepastmonth.Amongyouthaged12to17,1.6percentreportedpast-monthnonmedicaluseofprescriptionmedications.

Afteralcohol,marijuana,andtobacco,prescriptiondrugs(takennonmedically)

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areamongthemostcommonlyuseddrugsby12thgraders.TheNIDA’sMonitoringtheFuturesurveyofsubstanceuseandattitudesinteensfoundthatabout6percentofhighschoolseniorsreportedpast-yearnonmedicaluseoftheprescriptionstimulantAdderall in2017,and2percentreportedmisusingtheopioidpainrelieverVicodin .

Althoughpast-yearnonmedicaluseofCNSdepressantsandopioidpainrelieversdecreasedamong12thgradersbetween2011and2015,thisisnotthecaseforthenonmedicaluseofstimulants.NonmedicaluseofAdderallincreasedbetween2009and2013buthassinceappearedtodecline. Whenaskedhowtheyobtainedprescriptionstimulantsfornonmedicaluse,morethanhalfoftheadolescentsandyoungadultssurveyedsaidtheyeitherboughtorreceivedthedrugsfromafriendorrelative.Interestingly,thenumberwhopurchasedthesedrugsthroughtheinternetwasnegligible.

Youthwhomisuseprescriptionmedicationsarealsomorelikelytoreportuseofotherdrugs.Multiplestudieshaverevealedassociationsbetweenprescriptiondrugmisuseandhigherratesofcigarettesmoking;heavyepisodicdrinking;andmarijuana,cocaine,andotherillicitdruguseamongU.S.adolescents,youngadults,andcollegestudents. Inthecaseofprescriptionopioids,medicaluseisalsoassociatedwithagreaterriskoffutureopioidmisuse,particularlyinadolescentswhodisapproveofillegaldruguseandhavelittletonohistoryofdruguse.

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OlderAdults

Morethan80percentofolderpatients(aged57to85years)useatleastoneprescriptionmedicationonadailybasis,withmorethan50percenttakingmorethanfivemedicationsorsupplementsdaily. Thiscanpotentiallyleadtohealthissuesresultingfromunintentionallyusingaprescriptionmedicationinamannerotherthanhowitwasprescribed,orfromintentionalnonmedicaluse.Thehighratesofmultiple(comorbid)chronicillnessesinolderpopulations,age-relatedchangesindrugmetabolism,andthepotentialfordruginteractionsmakesmedication(andothersubstance)misusemoredangerousinolderpeoplethaninyoungerpopulations. Further,alargepercentageofolderadultsalsouseover-the-countermedicinesanddietarysupplements,which(inadditiontoalcohol)couldcompoundanyadversehealthconsequencesresultingfromnonmedicaluseofprescriptiondrugs.

Women

Source:McCabeetal.,2012

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Overall,moremalesthanfemalesmisuseprescriptiondrugsinallagegroupsexceptadolescence(12to17years);adolescentgirlsexceedboysinthenonmedicaluseofallprescriptiondrugs,includingpainrelievers,sedatives,andstimulants.Amongnonmedicalusersofprescriptiondrugs,females12to17yearsoldarealsomorelikelytomeetsubstanceusedisordercriteriaforprescriptiondrugs. Additionally,whilemorementhanwomendieofprescriptionopioidoverdose,therateofoverdoseisincreasingmoresharplyinwomenthaninmen.

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Howmanypeoplesufferadversehealthconsequencesfrommisuseofprescriptiondrugs?

TheDrugAbuseWarningNetwork(DAWN)monitoredemergencydepartment(ED)visitsinselectedareasacrosstheNationthrough2011.DAWNreportedthatmorethan1.2millionEDvisitsin2011couldbeattributedtononmedicaluseofprescriptiondrugs;thisrepresentsabouthalf(50.5percent)ofallEDvisitsrelatedtodrugmisuse.Roughly488,000,or39.2percent,oftheseEDvisitsinvolvedprescriptionopioidpainrelievers,aratenearlytriplethatof6yearsprior.EDvisitsalsomorethanquadrupledforcentralnervoussystem(CNS)stimulantstonearly41,000visitsin2011andincreased138percentforCNSdepressantsto422,000visits.Ofthelatter,85percentinvolvedbenzodiazepines(e.g.,Xanax ).EDvisitsrelatedtouseofzolpidem(Ambien ),apopularprescribednon-benzodiazepinesleepaid,rosefromroughly13,000in2004to30,000in2011.MorethanhalfofEDvisitsfornonmedicaluseofprescriptiondrugsinvolvedmultipledrugs. Analysisofhospitalinpatientdataalsorevealeda72percentincreaseinhospitalizationsrelatedtoopioiduseoverthedecadefrom2002to2012,includingincreasesinseriousinfectionassociatedwithintravenousdrugadministration.Inpatientcostsforthesehospitalizationsquadrupledoverthesametimeperiod.

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Isitsafetouseprescriptiondrugsincombinationwithothermedications?

Thesafetyofusingprescriptiondrugsincombinationwithothersubstancesdependsonanumberoffactorsincludingthetypesofmedications,dosages,othersubstanceuse(e.g.,alcohol),andindividualpatienthealthfactors.Patientsshouldtalkwiththeirhealthcareprovideraboutwhethertheycansafelyusetheirprescriptiondrugswithothersubstances,includingprescriptionandover-the-counter(OTC)medicationsaswellasalcohol,tobacco,andillicitdrugs.Specifically,drugsthatslowdownbreathingrate,suchasopioids,alcohol,antihistamines,prescriptioncentralnervoussystemdepressants(includingbarbituratesandbenzodiazepines),orgeneralanesthetics,shouldnotbetakentogetherbecausethesecombinationsincreasetheriskoflife-threateningrespiratorydepression. Stimulantsshouldalsonotbeusedwithothermedicationsunlessrecommendedbyaphysician.PatientsshouldbeawareofthedangersassociatedwithmixingstimulantsandOTCcoldmedicinesthatcontaindecongestants,ascombiningthesesubstancesmaycausebloodpressuretobecomedangerouslyhighorleadtoirregularheartrhythms.

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Whichclassesofprescriptiondrugsarecommonlymisused?

Opioids

Whatareopioids?

Opioidsaremedicationsthatactonopioidreceptorsinboththespinalcordandbraintoreducetheintensityofpain-signalperception.Theyalsoaffectbrainareasthatcontrolemotion,whichcanfurtherdiminishtheeffectsofpainfulstimuli.Theyhavebeenusedforcenturiestotreatpain,cough,anddiarrhea. Themostcommonmodernuseofopioidsistotreatacutepain.However,sincethe1990s,theyhavebeenincreasinglyusedtotreatchronicpain,despitesparseevidencefortheireffectivenesswhenusedlongterm. Indeed,somepatientsexperienceaworseningoftheirpainorincreasedsensitivitytopainasaresultoftreatmentwithopioids,aphenomenonknownashyperalgesia. Importantly,inadditiontorelievingpain,opioidsalsoactivaterewardregionsinthebraincausingtheeuphoria—orhigh—thatunderliesthepotentialformisuseandaddiction.Chemically,thesemedicationsareverysimilartoheroin,whichwasoriginallysynthesizedfrommorphineasapharmaceuticalinthelate19thcentury. Thesepropertiesconferanincreasedriskofaddictionandoverdoseeveninpatientswhotaketheirmedicationasprescribed.

Prescriptionopioidmedicationsincludehydrocodone(e.g.,Vicodin ),oxycodone(e.g.,OxyContin ,Percocet ),oxymorphone(e.g.,Opana ),morphine(e.g.,Kadian ,Avinza ),codeine,fentanyl,andothers.HydrocodoneproductsarethemostcommonlyprescribedintheUnitedStatesforavarietyofindications,includingdental-andinjury-relatedpain. Oxycodoneandoxymorphonearealsoprescribedformoderatetoseverepainrelief. Morphineisoftenusedbeforeandaftersurgicalprocedurestoalleviateseverepain,andcodeineistypicallyprescribedformilderpain. Inadditiontotheirpain-relievingproperties,someofthesedrugs—codeineanddiphenoxylate(Lomotil ),forexample—areusedto

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Howdoopioidsaffectthebrainandbody?

Opioidsactbyattachingtoandactivatingopioidreceptorproteins,whicharefoundonnervecellsinthebrain,spinalcord,gastrointestinaltract,andotherorgansinthebody. Whenthesedrugsattachtotheirreceptors,theyinhibitthetransmissionofpainsignals.Opioidscanalsoproducedrowsiness,mentalconfusion,nausea,constipation,andrespiratorydepression,andsincethesedrugsalsoactonbrainregionsinvolvedinreward,theycaninduceeuphoria,particularlywhentheyaretakenatahigher-than-prescribeddoseoradministeredinotherwaysthanintended. Forexample,OxyContin isanoralmedicationusedtotreatmoderatetoseverepainthroughaslow,steadyreleaseoftheopioid.SomepeoplewhomisuseOxyContin intensifytheirexperiencebysnortingorinjectingit. Thisisaverydangerouspractice,greatlyincreasingtheperson’sriskforseriousmedicalcomplications,includingoverdose.

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UnderstandingDependence,Addiction,andTolerance

Dependenceoccursasaresultofphysiologicaladaptationstochronicexposuretoadrug.Itisoftenapartofaddiction,buttheyarenotequivalent.Addictioninvolvesotherchangestobraincircuitryandisdistinguishedbycompulsivedrugseekingandusedespitenegativeconsequences.

Thosewhoaredependentonamedicationwillexperienceunpleasantphysicalwithdrawalsymptomswhentheyabruptlyreduceorstopuseofthedrug.Thesesymptomscanbemildtosevere(dependingonthedrug)andcanusuallybemanagedmedicallyoravoidedbyslowlytaperingdownthedrugdosage.

Tolerance,ortheneedtotakehigherdosesofamedicationtogetthesameeffect,oftenaccompaniesdependence.Whentoleranceoccurs,itcanbedifficultforaphysiciantoevaluatewhetherapatientisdevelopingadrugproblemorhasamedicalneedforhigherdosestocontrolhisorhersymptoms.Forthisreason,physiciansshouldbevigilantandattentivetotheirpatients’symptomsandleveloffunctioningandshouldscreenforsubstancemisusewhentoleranceordependenceispresent.

Whatarethepossibleconsequencesofprescriptionopioidmisuse?

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Whentakenasprescribed,patientscanoftenuseopioidstomanagepainsafelyandeffectively.However,itispossibletodevelopasubstanceusedisorderwhentakingopioidmedicationsasprescribed.Thisriskandtheriskforoverdoseincreasewhenthesemedicationsaremisused.Evenasinglelargedoseofanopioidcancausesevererespiratorydepression(slowingorstoppingofbreathing),whichcanbefatal;takingopioidswithalcoholorsedativesincreasesthisrisk.

Whenproperlymanaged,short-termmedicaluseofopioidpainrelievers—takenforafewdaysfollowingoralsurgery,forinstance—rarelyleadstoanopioidusedisorderoraddiction.Butregular(e.g.,severaltimesaday,forseveralweeksormore)orlonger-termuseofopioidscanleadtodependence(physicaldiscomfortwhennottakingthedrug),tolerance(diminishedeffectfromtheoriginaldose,leadingtoincreasingtheamounttaken),and,insomecases,addiction(compulsivedrugseekinganduse)(see"UnderstandingDependence,Addiction,andTolerance").Withbothdependenceandaddiction,withdrawalsymptomsmayoccurifdruguseissuddenlyreducedorstopped.Thesesymptomsmayincluderestlessness,muscleandbonepain,insomnia,diarrhea,vomiting,coldflasheswithgoosebumps,andinvoluntarylegmovements.

Misuseofprescriptionopioidsisalsoariskfactorfortransitioningtoheroinuse.Readmoreabouttherelationshipbetweenprescriptionopioidsand

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heroinintheNIDA'sPrescriptionOpioidsandHeroinResearchReport.

Howisprescriptionopioidmisuserelatedtochronicpain?

Healthcareprovidershavelongwrestledwithhowbesttotreatthemorethan100millionAmericanswhosufferfromchronicpain. Opioidshavebeenthemostcommontreatmentforchronicpainsincethelate1990s,butrecentresearchhascastdoubtbothontheirsafetyandtheirefficacyinthetreatmentofchronicpainwhenitisnotrelatedtocancerorpalliativecare. Thepotentialrisksinvolvedwithlong-termopioidtreatment,suchasthedevelopmentofdrugtolerance,hyperalgesia,andaddiction,presentdoctorswithadilemma,asthereislimitedresearchonalternativetreatmentsforchronicpain.Patientsthemselvesmayevenbereluctanttotakeanopioidmedicationprescribedtothemforfearofbecomingaddicted.

Estimatesoftherateofopioidaddictionamongchronicpainpatientsvaryfromabout3percentupto26percent.Thisvariabilityistheresultofdifferencesintreatmentduration,insufficientresearchonlong-termoutcomes,anddisparatestudypopulationsandmeasuresusedtoassessnonmedicaluseoraddiction.

Tomitigateaddictionrisk,physiciansshouldadheretotheCDCGuidelineforPrescribingOpioidsforChronicPain.Beforeprescribing,physiciansshouldassesspainandfunctioning,considerifnon-opioidtreatmentoptionsareappropriate,discussatreatmentplanwiththepatient,evaluatethepatient’sriskofharmormisuse,andcoprescribenaloxonetomitigatetheriskforoverdose(seetheNIDA'swebpageonnaloxone).Whenfirstprescribingopioids,physiciansshouldgivethelowesteffectivedosefortheshortesttherapeuticduration.Astreatmentcontinues,thepatientshouldbemonitoredatregularintervals,andopioidtreatmentshouldbecontinuedonlyifmeaningfulclinicalimprovementsinpainandfunctioningareseenwithoutharm.

Changingtherouteofadministrationcanalsobeafeatureofthemisuse

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ofotherprescriptionmedications,includingstimulants,apracticethatcanleadtoseriousmedicalconsequences.

CNSDepressants

WhatareCNSdepressants?

Centralnervoussystem(CNS)depressants,acategorythatincludestranquilizers,sedatives,andhypnotics,aresubstancesthatcanslowbrainactivity.Thispropertymakesthemusefulfortreatinganxietyandsleepdisorders.Thefollowingareamongthemedicationscommonlyprescribedforthesepurposes :

Benzodiazepines,suchasdiazepam(Valium ),clonazepam(Klonopin ),andalprazolam(Xanax ),aresometimesprescribedtotreatanxiety,acutestressreactions,andpanicattacks.Clonazepammayalsobeprescribedtotreatseizuredisorders.Themoresedatingbenzodiazepines,suchastriazolam(Halcion )andestazolam(Prosom )areprescribedforshort-termtreatmentofsleepdisorders.Usually,benzodiazepinesarenotprescribedforlong-termusebecauseofthehighriskfordevelopingtolerance,dependence,oraddiction.

Non-benzodiazepinesleepmedications,suchaszolpidem(Ambien ),eszopiclone(Lunesta ),andzaleplon(Sonata ),knownasz-drugs,haveadifferentchemicalstructurebutactonthesameGABAtypeAreceptorsinthebrainasbenzodiazepines.Theyarethoughttohavefewersideeffectsandlessriskofdependencethanbenzodiazepines.

Barbiturates,suchasmephobarbital(Mebaral ),phenobarbital(Luminal ),andpentobarbitalsodium(Nembutal ),areusedlessfrequentlytoreduceanxietyortohelpwithsleepproblemsbecauseoftheirhigherriskofoverdosecomparedtobenzodiazepines.However,theyarestillusedinsurgicalproceduresandtotreatseizuredisorders.

HowdoCNSdepressantsaffectthebrainandbody?

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MostCNSdepressantsactonthebrainbyincreasingactivityatreceptorsfortheinhibitoryneurotransmittergamma-aminobutyricacid(GABA).Althoughthedifferentclassesofdepressantsworkinuniqueways,itisthroughtheirabilitytoincreaseGABAsignaling—therebyincreasinginhibitionofbrainactivity—thattheyproduceadrowsyorcalmingeffectthatismedicallybeneficialtothosesufferingfromanxietyorsleepdisorders.

WhatarethepossibleconsequencesofCNSdepressantmisuse?

Despitetheirbeneficialtherapeuticeffects,benzodiazepinesandbarbiturateshavethepotentialformisuseandshouldbeusedonlyasprescribed. Theuseofnon-benzodiazepinesleepaids,orz-drugs,islesswell-studied,butcertainindicatorshaveraisedconcernabouttheirpsychoactivepropertiesaswell.

Duringthefirstfewdaysoftakingadepressant,apersonusuallyfeelssleepyanduncoordinated,butasthebodybecomesaccustomedtotheeffectsofthedrugandtolerancedevelops,thesesideeffectsbegintodisappear.Ifoneusesthesedrugslongterm,heorshemayneedlargerdosestoachievethetherapeuticeffects.Continuedusecanalsoleadtodependenceandwithdrawalwhenuseisabruptlyreducedorstopped(see"UnderstandingDependence,Addiction,andTolerance").Becauseallsedativesworkbyslowingthebrain’sactivity,whenanindividualstopstakingthem,therecanbeareboundeffect,resultinginseizuresorotherharmfulconsequences.

Althoughwithdrawalfrombenzodiazepinescanbeproblematic,itisrarelylifethreatening,whereaswithdrawalfromprolongeduseofbarbituratescanhavelife-threateningcomplications. Therefore,someonewhoisthinkingaboutdiscontinuingasedativeorwhoissufferingwithdrawalfromCNSdepressantsshouldspeakwithaphysicianorseekimmediatemedicaltreatment.

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Stimulants

Whatarestimulants?

Stimulantsincreasealertness,attention,andenergy,aswellaselevatebloodpressure,heartrate,andrespiration.Historically,stimulantswereusedtotreatasthmaandotherrespiratoryproblems,obesity,neurologicaldisorders,andavarietyofotherailments.Butastheirpotentialformisuseandaddictionbecameapparent,thenumberofconditionstreatedwithstimulantshasdecreased. Now,stimulantsareprescribedforthetreatmentofonlyafewhealthconditions,includingattention-deficithyperactivitydisorder(ADHD),narcolepsy,andoccasionallytreatment-resistantdepression.

Howdostimulantsaffectthebrainandbody?

Stimulants,suchasdextroamphetamine(Dexedrine ,Adderall )andmethylphenidate(Ritalin ,Concerta ),actinthebrainonthefamilyofmonoamineneurotransmittersystems,whichincludenorepinephrineanddopamine.Stimulantsenhancetheeffectsofthesechemicals.Anincreaseindopaminesignalingfromnonmedicaluseofstimulantscaninduceafeelingofeuphoria,andthesemedications’effectsonnorepinephrineincreasebloodpressureandheartrate,constrictbloodvessels,increasebloodglucose,andopenupbreathingpassages.

Whatarethepossibleconsequencesofstimulantmisuse?

Aswithotherdrugsinthestimulantcategory,suchascocaine,itispossibleforpeopletobecomedependentonoraddictedtoprescriptionstimulants.Withdrawalsymptomsassociatedwithdiscontinuingstimulantuseincludefatigue,depression,anddisturbedsleeppatterns.Repeatedmisuseofsomestimulants(sometimeswithinashortperiod)canleadtofeelingsofhostilityorparanoia,orevenpsychosis. Further,takinghighdosesofastimulantmayresultindangerouslyhighbodytemperatureandanirregularheartbeat.Thereisalsothepotentialforcardiovascularfailureor

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CognitiveEnhancers

Thedramaticincreasesinstimulantprescriptionsoverthelast2decadeshaveledtotheirgreateravailabilityandtoincreasedriskfordiversionandnonmedicaluse. Whentakentoimproveproperlydiagnosedconditions,thesemedicationscangreatlyenhanceapatient’squalityoflife.However,becausemanyperceivethemtobegenerallysafeandeffective,prescriptionstimulantssuchasAdderall andModafinil arebeingmisusedmorefrequently.

Stimulantsincreasewakefulness,motivation,andaspectsofcognition,learning,andmemory.Somepeopletakethesedrugsintheabsenceofmedicalneedinanefforttoenhancementalperformance. Militarieshavelongusedstimulantstoincreaseperformanceinthefaceoffatigue,andtheUnitedStatesArmedForcesallowfortheiruseinlimitedoperationalsettings. Thepracticeisnowreportedbysomeprofessionalstoincreasetheirproductivity,byolderpeopletooffsetdecliningcognition,andbybothhighschoolandcollegestudentstoimprovetheiracademicperformance.

Nonmedicaluseofstimulantsforcognitiveenhancementposespotentialhealthrisks,includingaddiction,cardiovascularevents,andpsychosis.Theuseofpharmaceuticalsforcognitiveenhancementhasalsosparkeddebateovertheethicalimplicationsofthepractice.Issuesoffairnessariseifthosewithaccessandwillingnesstotakethesedrugshaveaperformanceedgeoverothers,andimplicitcoerciontakesplaceifacultureofcognitiveenhancementgivestheimpressionthatapersonmusttakedrugsinordertobecompetitive.

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Areprescriptiondrugssafetotakewhenpregnant?

Prescriptionmedicationstakenbyapregnantwomancancauseherbabytodevelopdependence,whichcanresultinwithdrawalsymptomsafterbirth,knownasneonatalabstinencesyndrome(NAS).Thiscanrequireaprolongedstayinneonatalintensivecareand,inthecaseofopioids,treatmentwithmedication(see"SexandGenderDifferencesinSubstanceUseDisorderTreatment"intheNIDA'sSubstanceUseinWomenResearchReport).Womenshouldconsultwiththeirdoctorstodeterminewhichmedicationstheycancontinuetakingduringpregnancy.

Opioidpainmedicationsrequireparticularattention;risingratesofNAShavebeenassociatedwithincreasesintheprescriptionofopioidsforpaininpregnantwomen.NASassociatedwithopioiduse(heroinorprescriptionopioids)increasedfivefoldfrom2000to2012,withahigherrateofincreaseinmorerecentyears.

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Howcanprescriptiondrugmisusebeprevented?

Clinicians,Patients,andPharmacists

Physicians,theirpatients,andpharmacistsallcanplayaroleinidentifyingandpreventingnonmedicaluseofprescriptiondrugs.

Clinicians.Morethan80percentofAmericanshadcontactwithahealthcareprofessionalinthepastyear ,placingdoctorsinauniquepositiontoidentifynonmedicaluseofprescriptiondrugsandtakemeasurestopreventtheescalationofapatient’smisusetoasubstanceusedisorder.Byaskingaboutalldrugs,physicianscanhelptheirpatientsrecognizethataproblemexists,provideorreferthemtoappropriatetreatment,andsetrecoverygoals.Evidence-basedscreeningtoolsfornonmedicaluseofprescriptiondrugscanbeincorporatedintoroutinemedicalvisits(seetheNIDAMEDwebpageforresourcesformedicalandhealthprofessionals).Doctorsshouldalsotakenoteofrapidincreasesintheamountofmedicationneededorfrequent,unscheduledrefillrequests.Doctorsshouldbealerttothefactthatthosemisusingprescriptiondrugsmayengagein"doctorshopping"—movingfromprovidertoprovider—inanefforttoobtainmultipleprescriptionsfortheirdrug(s)ofchoice.

Prescriptiondrugmonitoringprograms(PDMPs),state-runelectronicdatabasesusedtotracktheprescribinganddispensingofcontrolledprescriptiondrugstopatients,arealsoimportanttoolsforpreventingandidentifyingprescriptiondrugmisuse.Whileresearchregardingtheimpactoftheseprogramsiscurrentlymixed,theuseofPDMPsinsomestateshasbeenassociatedwithlowerratesofopioidprescribingandoverdose ,thoughissuesofbestpractices,easeofuse,andinteroperabilityremaintoberesolved.

In2015,thefederalgovernmentlaunchedaninitiativedirectedtowardreducingopioidmisuseandoverdose,inpartbypromotingmorecautiousandresponsibleprescribingofopioidmedications.Inlinewiththeseefforts,

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in2016theCentersforDiseaseControlandPrevention(CDC)publisheditsCDCGuidelineforPrescribingOpioidsforChronicPaintoestablishclinicalstandardsforbalancingthebenefitsandrisksofchronicopioidtreatment.Preventingorstoppingnonmedicaluseofprescriptiondrugsisanimportantpartofpatientcare.However,certainpatientscanbenefitfromprescriptionstimulants,sedatives,oropioidpainrelievers.Therefore,physiciansshouldbalancethelegitimatemedicalneedsofpatientswiththepotentialriskformisuseandrelatedharms.

Patients.Patientscantakestepstoensurethattheyuseprescriptionmedicationsappropriatelyby:

followingthedirectionsasexplainedonthelabelorbythepharmacist

beingawareofpotentialinteractionswithotherdrugsaswellasalcohol

neverstoppingorchangingadosingregimenwithoutfirstdiscussingitwiththedoctor

neverusinganotherperson’sprescription,andnevergivingtheirprescriptionmedicationstoothers

storingprescriptionstimulants,sedatives,andopioidssafely

Additionally,patientsshouldproperlydiscardunusedorexpiredmedicationsbyfollowingU.S.FoodandDrugAdministration(FDA)guidelinesorvisitingU.S.DrugEnforcementAdministrationcollectionsites. Inadditiontodescribingtheirmedicalproblem,patientsshouldalwaysinformtheirhealthcareprofessionalsaboutalltheprescriptions,over-the-countermedicines,anddietaryandherbalsupplementstheyaretakingbeforetheyobtainanyothermedications.

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Pharmacists.Pharmacistscanhelppatientsunderstandinstructionsfortakingtheirmedications.Inaddition,bybeingwatchfulforprescriptionfalsificationsoralterations,pharmacistscanserveasthefirstlineofdefenseinrecognizingproblematicpatternsinprescriptiondruguse.Somepharmacieshavedevelopedhotlinestoalertotherpharmaciesintheregionwhentheydetectafraudulentprescription.Alongwithphysicians,pharmacistscanusePDMPstohelptrackopioid-prescribingpatternsinpatients.

MedicationFormulationandRegulation

Manufacturersofprescriptiondrugscontinuetoworkonnewformulationsofopioidmedications,knownasabuse-deterrentformulations(ADF),whichincludetechnologiesdesignedtopreventpeoplefrommisusingthembysnortingorinjection.Approachescurrentlybeingusedorstudiedforuseinclude:

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physicalorchemicalbarriersthatpreventthecrushing,grinding,ordissolvingofdrugproducts

agonist/antagonistcombinationsthatcauseanantagonist(whichwillcounteractthedrugeffect)tobereleasediftheproductismanipulated

aversivesubstancesthatareaddedtocreateunpleasantsensationsifthedrugistakeninawayotherthandirected

deliverysystemssuchaslong-actinginjectionsorimplantsthatslowlyreleasethedrugovertime

newmolecularentitiesorprodrugsthatattachachemicalextensiontoadrugthatrendersitinactiveunlessitistakenorally

SeveralADFopioidsareonthemarket,andtheFDAhasalsocalledforthedevelopmentofADFstimulants. WhileADFopioidshavebeenshowntodecreasetheillicitvalueofadrug,intheabsenceofreduceddemand,theycanshiftusetootherformulations. Medicationregulationhasbeenshowntobeeffectiveindecreasingtheprescribingofopioidmedications.In2014,theDrugEnforcementAdministrationmovedhydrocodoneproductsfromscheduleIIItothemorerestrictivescheduleII,whichresultedinadecreaseinhydrocodoneprescribingthatdidnotresultinanyattendantincreasesintheprescribingofotheropioids.

DevelopmentofSaferMedications

Thedevelopmentofeffective,nonaddictingpainmedicationsisapublichealthpriority.Agrowingnumberofolderadultsandanincreasingnumberofinjuredmilitaryservicemembersaddtotheurgencyoffindingnewtreatments.Researchersareexploringalternativetreatmentapproachesthattargetothersignalingsystemsinthebodysuchastheendocannabinoidsystem,whichisalsoinvolvedinpain. Moreresearchisalsoneededtobetterunderstandeffectivechronicpainmanagement,includingidentifyingfactorsthatpredisposesomepatientstosubstanceusedisordersanddevelopingmeasurestopreventthenonmedicaluseofprescriptionmedications.

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Howcanprescriptiondrugaddictionbetreated?

Yearsofresearchhaveshownthatsubstanceusedisordersarebraindisordersthatcanbetreatedeffectively.Treatmentmusttakeintoaccountthetypeofdrugusedandtheneedsoftheindividual.Successfultreatmentmayneedtoincorporateseveralcomponents,includingdetoxification,counseling,andmedications,whenavailable.Multiplecoursesoftreatmentmaybeneededforthepatienttomakeafullrecovery.

Thetwomaincategoriesofdrugaddictiontreatmentarebehavioraltreatments(suchascontingencymanagementandcognitive-behavioraltherapy)andmedications.Behavioraltreatmentshelppatientsstopdrugusebychangingunhealthypatternsofthinkingandbehavior;teachingstrategiestomanagecravingsandavoidcuesandsituationsthatcouldleadtorelapse;or,insomecases,providingincentivesforabstinence.Behavioraltreatments,whichmaytaketheformofindividual,family,orgroupcounseling,alsocanhelppatientsimprovetheirpersonalrelationshipsandtheirabilitytofunctionatworkandinthecommunity.

Addictiontoprescriptionopioidscanadditionallybetreatedwithmedicationsincludingbuprenorphine,methadone,andnaltrexone[see"Medication-AssistedTreatment(MAT)"below].Thesedrugscancountertheeffectsofopioidsonthebrainorrelievewithdrawalsymptomsandcravings,helpingthepatientavoidrelapse.Medicationsforthetreatmentofaddictionareadministeredincombinationwithpsychosocialsupportsorbehavioraltreatments,knownasmedication-assistedtreatment(MAT).

Medication-AssistedTreatment(MAT)

Naltrexoneisanantagonistmedicationthatpreventsotheropioidsfrombindingtoandactivatingopioidreceptors.Itisusedtotreatoverdoseandaddiction.Aninjectable,long-actingformofnaltrexone(Vivitrol )canbeausefultreatmentchoiceforpatientswhodonothavereadyaccessto

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healthcareorwhostrugglewithtakingtheirmedicationsregularly.

Methadoneisasyntheticopioidagonistthatpreventswithdrawalsymptomsandrelievesdrugcravingsbyactingonthesamebraintargetsasotheropioidssuchasheroin,morphine,andopioidpainmedications.Ithasbeenusedsuccessfullyformorethan40yearstotreatheroinaddictionbutisgenerallyonlyavailablethroughspeciallylicensedopioidtreatmentprograms.

Buprenorphineisapartialopioidagonist—itbindstotheopioidreceptorbutonlypartiallyactivatesit—thatcanbeprescribedbycertifiedphysiciansinanofficesetting.Likemethadone,itcanreducecravingsandiswelltoleratedbypatients.InMay2016,theU.S.FoodandDrugAdministration(FDA)approvedtheNIDA-supporteddevelopmentofanimplantableformulationofbuprenorphineandaoncemonthlybuprenorphineinjectioninNovember2017.Bothwillgivebuprenorphine-stabilizedpatientsgreateaseintreatmentadherence.

ANIDAstudycomparingtheeffectivenessofabuprenorphine/naloxonecombinationandanextendedreleasenaltrexoneformulationontreatingopioidusedisorderhasfoundthatbothmedicationsaresimilarlyeffectiveintreatingopioidusedisorderoncetreatmentisinitiated.Becausenaltrexonerequiresfulldetoxification,initiatingtreatmentamongactiveopioiduserswasmoredifficultwiththismedication.However,oncedetoxificationwascomplete,thenaltrexoneformulationhadasimilareffectivenessasthebuprenorphine/naloxonecombination.

Therehasbeenapopularmisconceptionthatmedicationswithagonistactivity,suchasmethadoneorbuprenorphine,replaceoneaddictionwithanother.Thisisnotthecase.Opioidusedisorderisassociatedwithimbalancesinbraincircuitsthatmediatereward,decision-making,impulsecontrol,learning,andotherfunctions.Thesemedicationsrestorebalancetothesebraincircuits,preventingopioidwithdrawalandrestoringthepatienttoanormalaffectivestatetoallowforeffectivepsychosocialtreatmentandsocialfunctioning.

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WhileMATisthestandardofcarefortreatingopioidusedisorder,farfewerpeoplereceiveMATthancouldpotentiallybenefitfromit.Notallpeoplewithopioidusedisorderseektreatment.Evenwhentheyseektreatment,theywillnotnecessarilyreceiveMAT.Themostrecenttreatmentadmissionsdataavailableshowthatonly18percentofpeopleadmittedforprescriptionopioidusedisorderhaveatreatmentplanthatincludesMAT.However,evenifthenationwideinfrastructurewereoperatingatcapacity,between1.3and1.4millionmorepeoplehaveopioidusedisorderthancouldcurrentlybetreatedwithMATduetolimitedavailabilityofopioidtreatmentprogramsthatcandispensemethadoneandtheregulatorylimitonthenumberofpatientsthatphysicianscantreatwithbuprenorphine.CoordinatedeffortsareunderwaynationwidetoexpandaccesstoMAT,includingarecentincreaseinthebuprenorphinepatientlimitfrom100patientsto275forqualifiedphysicianswhorequestthehigherlimit.

TheNIDAissupportingresearchneededtodeterminethemosteffectivewaystoimplementMAT.Forexample,recentworkhasshownthatbuprenorphinemaintenancetreatmentismoreeffectivethantaperingpatientsoffofbuprenorphine. Also,startingbuprenorphinetreatmentwhenapatientisadmittedtotheemergencydepartment,suchasforanoverdose,isamoreeffectivewaytoengageapatientintreatmentthanreferralorbriefintervention. Finally,datahaveshownthattreatmentwithmethadone,buprenorphine,ornaltrexoneforincarceratedindividualsimprovespost-releaseoutcomes.

ReversinganOpioidOverdosewithNaloxone

Theopioidoverdose-reversaldrugnaloxoneisanopioidantagonistthatcanrapidlyrestorenormalrespirationtoapersonwhohasstoppedbreathingasaresultofoverdoseonprescriptionopioidsorheroin.Naloxonecanbeusedbyemergencymedicalpersonnel,firstresponders,andbystanders.Formoreinformation,visittheNIDA'swebpageonnaloxone.

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TreatingAddictiontoCNSDepressants

Patientsaddictedtocentralnervoussystem(CNS)depressantssuchastranquilizers,sedatives,andhypnoticsshouldnotattempttostoptakingthemontheirown.Withdrawalsymptomsfromthesedrugscanbesevereand—inthecaseofcertainmedications—potentiallylife-threatening.ResearchontreatingaddictiontoCNSdepressantsissparse;however,patientswhoaredependentonthesemedicationsshouldundergomedicallysuperviseddetoxificationbecausethedosagetheytakeshouldbetaperedgradually.Inpatientoroutpatientcounselingcanhelpindividualsthroughthisprocess.Cognitive-behavioraltherapy,whichfocusesonmodifyingthepatient’sthinking,expectations,andbehaviorswhileincreasingskillsforcopingwithvariouslifestressors,hasalsobeenusedsuccessfullytohelpindividualsadapttodiscontinuingbenzodiazepines.

OftenCNSdepressantmisuseoccursinconjunctionwiththeuseofotherdrugs(polydruguse),suchasalcoholoropioids. Insuchcases,thetreatmentapproachshouldaddressthemultipleaddictions.

Atthistime,therearenoFDA-approvedmedicationsfortreatingaddictiontoCNSdepressants,thoughresearchisongoinginthisarea.

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TreatingAddictiontoPrescriptionStimulants

TreatmentofaddictiontoprescriptionstimulantssuchasAdderall andConcerta isbasedonbehavioraltherapiesthatareeffectivefortreatingcocaineandmethamphetamineaddiction.Atthistime,therearenoFDA-approvedmedicationsfortreatingstimulantaddiction.TheNIDAissupportingresearchinthisarea.

Dependingonthepatient,thefirststepsintreatingprescriptionstimulantaddictionmaybetotaperthedrugdosageandattempttoeasewithdrawalsymptoms.Behavioraltreatmentmaythenfollowthedetoxificationprocess(see"BehavioralTherapies"intheNIDA'sPrinciplesofDrugAddictionTreatment:AResearch-BasedGuide).

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WherecanIgetfurtherinformationaboutprescriptiondrugmisuse?

Tolearnmoreaboutprescriptiondrugsandotherdrugs,visittheNIDAwebsiteatdrugabuse.govorcontacttheDrugPubsResearchDisseminationCenterat877-NIDA-NIH(877-643-2644;TTY/TDD:240-645-0228).

TheNIDA'swebsiteincludes:

informationondrugsandrelatedhealthconsequences

NIDApublications,news,andevents

resourcesforhealthcareprofessionals

fundinginformation(includingprogramannouncementsanddeadlines)

internationalactivities

linkstorelatedwebsites(accesstowebsitesofmanyotherorganizationsinthefield)

informationinSpanish(enespañol)

NIDAwebsitesandwebpages

drugabuse.gov

teens.drugabuse.gov

easyread.drugabuse.gov

drugabuse.gov/drugs-abuse/prescription-drugs-cold-medicines

researchstudies.drugabuse.gov

irp.drugabuse.gov

Forphysicianinformation

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NIDAMED:drugabuse.gov/nidamed

Otherwebsites

Informationaboutprescriptiondrugmisuseisalsoavailablethroughthefollowingwebsites:

SubstanceAbuseandMentalHealthServicesAdministration:samhsa.gov

U.S.DrugEnforcementAdministration:dea.gov

MonitoringtheFuture:monitoringthefuture.org

PartnershipforDrug-FreeKids:drugfree.org/drug-guide

ThispublicationisavailableforyouruseandmaybereproducedinitsentiretywithoutpermissionfromtheNIDA.Citationofthesourceisappreciated,usingthefollowinglanguage:Source:NationalInstituteonDrugAbuse;NationalInstitutesofHealth;U.S.DepartmentofHealthandHumanServices.

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