Running Head: THE RISE OF PRESCRIPTION ABUSE

The Rise of Prescription Abuse Hoang Pham Northeastern University

Running Head: THE RISE OF PRESCRIPTION ABUSE

Abstract Over the years, prescription drug abuse has rapidly become the leading substance abuse issue in the United States. This paper aims to analyze the factors in todays current society that has caused this issue to become so prominent. It examines exactly what drugs are most desired by the drug seeking individual and what about their chemistry that makes them so appealing. It also explores the strategies employed by the drug seeking individual to obtain prescription medication illicitly and how to identify them. Governmental funds that are allocated to preventing drug diversion are exceedingly great. Finally, a look is taken at the type of education doctors, pharmacists, and patients receive and how cultural factors also play a role in creating an environment that is not conducive to preventing prescription abuse. Introduction The United States has found success to some degree in undermining the occurrence of substance abuse cases, particularly those incidences that involve alcohol and teenage smoking. Nonetheless, there is little time for celebration, as pharmaceuticals such as opioids, central nervous system depressants, and stimulants are becoming a reason for urgent attention. Prescription drug abuse is classified as an epidemic by the Centers for Disease Control and Prevention. The abuse of pharmaceuticals has gradually risen over the past decade, but more recently experienced an abrupt increase. The issue is particularly prevalent in the United States, as the nation boasts an astounding 80% of the worlds usage of all opioids, 99% of the worlds hydrocodone usage, and consumption of two thirds of the worlds illegal drugs (Pain Physician, 2006). Surely, these dumbfounding statistics cannot be attributed to purely pain relief. The negative consequences of drug abuse weigh heavily on not only users and their families, but society as well. The economic burdens related to workplace, healthcare, and criminal justice

Running Head: THE RISE OF PRESCRIPTION ABUSE

costs are immense. Unfortunately, preventing prescription drug abuse cannot simply be stopped by the mere suspicions of pharmacists. Refusing to dispense medication to a suspicious patient based on intuition is not an effective way of dealing with an issue of this scale. The drugseeking individual will employ whatever strategy necessary in order to effectively divert prescription medication. In order to formulate any resolution to this issue, a close examination of the nature of these drugs and the regulations that exist to prevent drug diversion are required. Data such as trends among demographics, age groups, geographic information, and other related information are also significant. The Most Desired Prescription: Opioids The class of drugs known as the opioids is the most abused prescription substance. Further categorized as analgesics, opioids operate by increasing an individuals pain tolerance, but not without side effects. Typically, addiction to opioids is a result of their ability to produce feelings of euphoria. Over the years, both the dosage and quantity of opioids have increased. From 1997 to 2007, the average dosage of opioids increased from 74 milligrams to 369 milligrams, a 402% increase. It is speculated that the reason increases in opioid abuse have been reported is that there is a growing availability of opioid prescriptions (Drug and Alcohol Dependence, 2006). Retail pharmacies in 2000 dispensed 174 million opioid prescriptions; in 2009, 257 million prescriptions were dispensed (Drug and Alcohol Dependence, 2006). However, it is not necessarily true that the increase of opioid abuse is caused by an increase in number of prescriptions. A study performed by Zacny et al. (2003) indicated that for some opioid derivatives, an increase in number of prescriptions did not result in a proportional increase of abuse cases. From 1994 to 2002, the number of fentanyl related incidences increased by a factor of fifty. The number of prescriptions for fentanyl in that same time period increased only by a

Running Head: THE RISE OF PRESCRIPTION ABUSE

factor of 7.2. Oxycodone also saw a major increase of abuse, but the number of its prescriptions did not increase to the same degree. Thus, it is evident that prescription availability cannot be deemed the sole reason for the increase of prescription abuse. It is also important to delve into medicinal chemistry behind these drugs. Opioids typically act upon three receptors in order to exert their effect: mu, kappa and delta. Though the precise mechanisms by which opioids operate are unclear, studies show that analgesic and addictive effects are directly proportional to an opioids ability to bind to mu receptors. Research aims to target the mu receptor so that analgesia, but not addiction, develops over the course of drug therapy. Another factor to consider is the nature of ones drug therapy, because even the setting in which one is given an opioid affects the rate of prescription related issues. For those with acute pain, opioids are generally administered in a medical setting where professional supervision will help to decrease the likelihood of abuse. However, a patient with chronic pain will generally be given opioids to self-administer. Without the presence of a medical expert, there may be an increased chance of developing an opioid addiction. Behaviors of the Drug Seeking Individual Understanding the strategies employed by the drug seeking individual is pivotal to preventing prescription drug abuse. One of the more difficult problems prescribers face is their obligation to effectively treat a patients health issues versus the concern of drawing attention from the Drug Enforcement Agency (DEA) for frequent prescribing of controlled substances. They are confronted with ambiguous situations. Must they always prescribe prescriptions for pain and anxiety and risk the possibility of having the patient develop an addiction, becoming investigated by agencies, and contributing to possible drug trafficking; or must they exercise an elevated level of discretion and risk the under treatment of a patient, which would result in lost

Running Head: THE RISE OF PRESCRIPTION ABUSE

productivity, preventable pain and anxiety, and additional health costs? Thus, it is necessary for prescribers to be wary of the typical but subtle characteristics of substance abusers. Drug seeking behavior will usually include a patient aggressively attempting to obtain medication. A classic example would be a patient insisting that the only effective medication is a controlled substance. Doctor shopping is a different type of drug diversion that is much more difficult to detect, occurring when a single patient visits multiple doctors and as a result, obtains multiple prescriptions. However, when physicians collaborate with the pharmacists in their working vicinity, it can become more feasible to identify doctor shopping. Teenagers and Prescriptions A report released by the Office of National Drug Control Policy shows that teens comprise most of the demographic of prescription drug abusers. Second only to marijuana, prescription drugs are the most abused substances by teenagers. It was estimated that in 2003, about nine hundred thousand teenagers took prescription drugs for nonmedical reasons and 1.2 million teenagers used marijuana for the first time (Pain Physician, 2007). Time has shown that the gap between these numbers is slowly closing, and if trends propagate, prescription drugs will overtake marijuana in the near future. Other statistics show that about eight hundred and forty thousand teens aged between 12 and 17 reported that they were currently abusing prescription drugs in 2005. In that same year, teenagers represented a third of the population that abused prescription drugs. Geographical data shows that prescription drug abuse is found more commonly in the western and southeastern areas of the United States (Pain Physician, 2007). A convincing argument that explains why prescription drug abuse in teens is so high is because teens falsely believe the myth that because prescription drugs are manufactured with a high degree of quality control, they inherently produce highs that are safe. Nonetheless, it is worth

Running Head: THE RISE OF PRESCRIPTION ABUSE

noting that many teens are admitting to seeking out prescription medication for reasons other than obtaining a high state. Teens are reporting that they often seek prescription drugs for their analgesic and anxiolytic effects, for experimental reasons, or frequently to augment their attention and focus. A third of teens report that there a significant social factor involved, as consuming a prescription drug is necessary in establishing themselves inside a circle of friends. The abuse of these drugs is particularly dangerous because of the developing neurobiology of adolescents. The time period between 1999 and 2002 saw a 91.2% increase in opioid analgesic poisoning deaths. Heroin saw a 12.4% increase while cocaine showed a 22.8 increase (Pain Physician, 2007), numbers that pale in comparison to that of prescription drugs. Drug Diversion and Statistics A question typically asked is at what point do prescription drugs become diverted from their intended purpose. In general, prescription drugs become diverted through doctor shopping, theft, fraudulent prescriptions, illegitimate prescriptions written by doctors, and illegal online pharmacies. For nonmedical use of pain relievers in particular, 60% of diverted drugs were free from a friend or relative, 17% from a doctor, 8% were purchased from a friend or relative, 4% were stolen from a friend or relative, 4% were purchased from a drug dealer, and 7% were obtained through miscellaneous means. Teenagers obtain prescription drugs primarily by stealing them from their family members, purchasing them from classmates, and the Internet (Pain Physician, 2007). Costs What are the strategies that have been employed to control the diversion of prescription drugs? The White House Office of National Drug Control Policy (ONDCP) was formed by the Anti-drug Abuse Act of 1988 and its mission is to form policies of the United States drug

Running Head: THE RISE OF PRESCRIPTION ABUSE

control program, aiming to undermine illegal drug use, manufacturing, trafficking, crime, and health related consequences. National Drug Control Strategies revolve on three components. The first is preventing abuse before it manifests, rehabilitating those that are currently abusing drugs, and mitigating the black market through which illicit substances are sold. In 2013, $1.4 billion was invested in prevention programs that included education and outreach programs that discourage use of controlled substances and simultaneously promoting community outreach efforts. This represents a 5% increase from 2012s budget. The second component is rehabilitation. $9.3 billion was designated to intervention, treatment, and recovery services representing an 18% increase from the previous year. The last element of the drug control strategy is law enforcement. $9.6 billion were allocated to domestic law enforcement. This money, used to fund state and Federal investigations, prosecutions, and corrections represents a $123.4 million increase from 2012s funding. An additional $5.1 billion was allocated to miscellaneous expenditures. A grand total of $25.4 billion comprises the government budget for national drug control (National Drug Control Budget, 2014). How Knowledge Can Prevent Abuse Education and knowledge is surprisingly nonexistent among physicians, pharmacists, and patients. Statistics show that only 19% of surveyed prescribers were given courses and training in identifying prescription diversion. 43% of physicians do not ask their patients about their drug history. On the other end of the spectrum, 74% of physicians in 2006 did not prescribe controlled prescriptions because of fear that their patient would develop an addiction (Pain Physician, 2007). Data regarding pharmacy personnel shows that a quarter of retail pharmacies do not routinely check the DEA number of the prescriber. Approximately only half of surveyed pharmacists were given training in identifying drug diversion. Pharmacists themselves may be

Running Head: THE RISE OF PRESCRIPTION ABUSE

components in drug diversion by creating fake prescriptions through their pharmacies computer systems. Finally patients are severely misled by the advertising carried out by pharmaceutical companies that contend the effectiveness of their product. The media has also created a stigma associated with prescribers reluctance in prescribing opioid analgesics, vouching for the undertreated patient suffering from pain. Overall, the publics desire to educate themselves on the dangerous side effects of controlled substances is non-existent. It would be in the United States self-interest to create regulations requiring prescribers and pharmacists to receive training that is effective in identifying drug diversion. Regarding the public, it is vital that they acknowledge that non-opioid alternatives are realistic and feasible methods in treating pain. Education should assert that the specific mechanisms through which opioids operate are unclear and that they may not be as effective as they think. Even when administered properly, the chance for addiction and abuse is never out of the realm of possibility. Counter Argument There is a stigma associated with addiction. Many do not regard addiction as a real disease, and that those who seek out substances of abuse are in quest of nothing more than a temporary high. However, addiction can arise from chronic mental illnesses and real physical or mental issues. There is an overall difficulty in many cultures in viewing mental diseases as equivalent to physical impairments because psychological diseases do not manifest themselves as explicitly as increased blood pressure or decreased thyroid levels. Furthermore, those that are predisposed to psychological diseases may develop addictions even more rapidly because of the cultural factors that pressure them to take these types of drugs and the effects on the neurobiology by the drug itself. Ignoring prescription abuse as a real issue and letting those

Running Head: THE RISE OF PRESCRIPTION ABUSE

afflicted waste away with their disease is strategically ineffective and would be in violation of the oaths taken by healthcare professionals to serve their communities. Conclusion Especially in this period of the United States economic struggle, it is paramount that funds are used efficiently, innovatively, and effectively. Prescription drug abuse is the most rapidly growing drug issue in America. With any issue of this magnitude, there is no panacea that will remedy the issue completely. A problem of this scale must be attacked at multiple angles. If efforts in educating health professionals and patients alike are given, mitigation of the problem is possible One must understand the chemistry, engineering, and mechanism behind an opioid pill; how it operates, the most hazardous side effects, and its addictive nature. Cultural and social aspects should also be considered. High school and college students may be pressured by the desire to succeed academically to take narcotics, or by the desire to belong to a social group. It is indeed a very costly struggle, as billions of dollars are being expended to counter the issue. Perhaps it is ultimately the responsibility of the healthcare team to provide their service upon an entirely new level. Rather than treat patients like numbers and statistics, perhaps giving the effort to develop a trusting and genuine patient-professional relationship may help to alleviate the issue to some degree.

Reflective Note: This is a document that I would incorporate into my professional portfolio. I did have difficulty however in integrating a counter argument however, as the nature of my topic does not have a very clear opposing point of view.

Running Head: THE RISE OF PRESCRIPTION ABUSE

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Works Cited Compton, Wilson, and Nora D. Volkow. "Major Increases in Opioid Analgesic Abuse in the United States: Concerns and Strategies." Drug and Alcohol Dependence 81.2 (2007): n. pag. Web. EPIDEMIC: RESPONDING TO AMERICAS PRESCRIPTION DRUG ABUSE CRISIS. Rep. N.p.: n.p., n.d. Print. Longo, Lance P., MD, Ted Parran, MD, Brian Johnson, MD, and William Kinsey, MD. "Addiction: Part II. Identification and Management of the Drug-Seeking Patient." American Family Physician. American Family Physician, 15 Apr. 2000. Web. 03 Nov. 2013. Manchikanti, Laxmaiah. "National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies." Pain Physician Journal (2007): n. pag. Web. <http://www.cfbhn.org/Documents/RX/National%20Drug%20Control%20Policy%20and %20Prescription%20Drug%20Abuse%20Facts%20and%20Fallacies.pdf>. Manchikanti, Laxmaiah. "Prescription Drug Abuse: What Is Being Done to Add Ress This New Drug Epidemic? Testimony Before the Subcommittee on Criminal Justice, Drug Policy and Human Resources." Pain Physician Journal (n.d.): n. pag. Web. National Drug Control Budget. Rep. N.p.: n.p., n.d. Print.