Elephant in the Room? The Problem of Prescription Drug Abuse By Roy M. Arnold, MD

Elephant in the Room? The Problem of Prescription Drug Abuse

By Roy M. Arnold, MD

A growing problem in the US, prescription painkillers accounted for 16,650 deaths in 2010, the most recent complete year for which statistics are available. Drug abuse overtook traffic accidents as a cause of death in 2009. Overdose deaths are only the tip of the iceberg. For every overdose death, there were 733 non-medical users of prescription painkillers, 108 persons with abuse or dependence, 26 Emergency Department visits for abuse or misuse and 10 hospitalizations for abuse or misuse of painkillers.

The most common types of prescription drugs abused are opioid painkillers like hydrocodone, found in Vicodin® or oxycodone found in Oxycontin®. Chronic opioid users account for $72.5 Billion in healthcare costs annually or 8.7 times the cost of non-users.

The United States accounts of 4.6% of the world’s population but consumes 80% of the world production of oxycodone and 99% of the world’s hydrocodone.

The most disturbing aspect of this situation is that many of the people who become addicted to prescription painkillers were initially prescribed these medications for legitimate medical conditions such as injuries or after surgery. Gradually, with frequent use, the opioid medications can cause tolerance, requiring ever increasing doses to achieve the same amount of pain control. Opioids can cause physical dependence with continuous use, often in fairly short periods of time. At this point, patients may experience very unpleasant withdrawal symptoms unless they continue taking the painkillers, even though the medical condition for which the drug was originally prescribed may have improved.

Frequently, persons who are addicted to painkillers may engage in drug-seeking behavior by visiting multiple physicians, or pharmacies, or by obtaining their drugs from non-medical sources. Anti-social behaviors such as theft or assault are not uncommon among persons with addictions. It is important to point out that the anti-social behavior is frequently a result of, not necessarily a cause of the disease of addiction. Most medical experts believe addiction is truly a disease caused by disordered neural pathways in the brain, not a weakness of character or poor willpower. One of the basic tenets of 12-Step recovery programs such as Narcotics Anonymous is the admission of powerless over the addiction.

Having realized out the magnitude of the problem, regulatory agencies and medical organizations are searching for solutions to the problem. Many state governments have established Prescription Drug Monitoring Programs requiring mandatory reporting by pharmacies of all controlled substances prescriptions to a central database. Such programs are currently active in 42 states including Indiana, Kentucky, Illinois, Ohio and Michigan. These programs may be accessed by pharmacies or prescribers for the purpose of patient care, or by law enforcement conducting an investigation. These reporting systems are useful in identifying persons who use multiple prescribers, multiple pharmacies and in monitoring dosage and frequency of narcotic use.

Approximately 10 years ago, the US Food and Drug Administration approved a drug known as buprenorphine for the treatment of opioid addiction. This drug is a partial opioid agonist, meaning it has weak opioid properties. It does produce some of the effects of opioids like euphoria and respiratory depression. Taken in low doses, it can often enable opioid addicts to discontinue the use of other opioids without experiencing withdrawal. It is often combined with a narcotic antagonist to prevent its abuse by injection or inhalation. Prescription of this medication is limited to certain physicians and must be considered substitution therapy for opioid abuse not a “cure.” It simply replaces one opioid with another, much the same way methadone can be substituted for heroin. The use of buprenorphine alone without other treatment and social support systems like 12-Step programs does not address the underlying disease of addiction.

Most recently, professional organizations like Physicians for Responsible Opioid Prescribing (www.supportprop.org) have published white papers urging prescribers to limit opioid prescriptions to no more than 90 days for non-cancer pain. The organization has also petitioned the FDA to change the labeling on oxycodone and hydrocodone to be used only for severe pain and only for 90 days. This petition which is still under consideration by the FDA has been endorsed by the Drug Enforcement Administration and advocacy groups like Public Citizen. (www.citizen.org)

The overall purpose of this article is to point out the magnitude of the problem of prescription drug abuse and explore alternatives to ongoing use or abuse. It also discussed some of the recent regulatory actions. Persons who believe they have a problem with prescription painkillers are encouraged to discuss the issue with their primary healthcare provider and to take advantage of the many treatment and recovery options which are available locally.

1 Prescription Drug Abuse and Overdose: Public Health Perspective (PDF) CDC’s Primary Care and Public Health Initiative, October 24, 2012
2 Ibid.
3 Avila, Jim and Murray, Michael. ABC News (online) April 20, 2011.