Prescription Drug Abuse

Dr Madhu Oswal

What is prescription drug abuse? It is the use of a prescription medication in a way not

intended by the prescribing doctor -the nonmedical use or abuse of prescription drugs.

Has the problem of prescription drug abuse increased, and if so, why? In 1999, the Ministry

of Social Justice and Empowerment, Government of India (MSJE, GOI) and the United Nations

International Drug Control Programme, Regional Office for South Asia (UNIDCP, ROSA)

decided to undertake a large-scale national survey to obtain information on extent, pattern and

magnitude of substance abuse in the country. Results show that nationally about 10 per cent of

drug abuse involves prescription drugs. We have a huge population that knowingly or

unknowingly is hooked on to prescription drugs. What’s the reason? First reason is the way in

which drugs like benzodiazepines are prescribed as anxiolytics or sedatives right and left without

giving patient enough warning about its dependence potential. Secondly, in India we have

rampant unlawful selling of these drugs without prescription. Thirdly it’s the very act which was

enacted to prevent this menace, is fuelling this problem. We in India have always had a tradition

of substances like ganja and charas which did not do any great harm. The Narcotic Drugs and

Psychotropic Substances Act (NDPS), 1985 put all of them at a par with hardcore drugs making

all drugs illegal and equally punishable. This led to a surge in heroin and increase in intravenous

drug use. During the late 1980s and early 1990s, the pharmaceutical buprenorphine became

popular and its availability in ampoule form made it injectable - this drug and mode of

administration became popular throughout most major cites of India and adjoining states. They're

cheaper too, at only Rs 20 per cocktail ampoule, compared to Rs 80-150 for the same amount of

heroin. The other main advantage of prescription drugs for addicts is their easy and lawful

availability. These are also difficult to detect. Even better, when caught-one just needs to feign a

cough or headache convincingly and explain the need for possessing that drug

Which are the commonly abused prescription drugs?

Opioids, which are most often prescribed to treat pain;

CNS depressants, which are used to treat anxiety and sleep disorders;

Stimulants, which are prescribed to treat the attention-deficit hyperactivity disorder

(ADHD) and obesity.

Steroids (Anabolic-Androgenic steroids) used to treat conditions resulting from steroid

hormone deficiency, such as delayed puberty, or to increase lean muscle mass esp. cancer

and AIDS.

Most of these drugs are schedule H drugs- that is these are to be sold only on prescription of a

registered medical practitioner. But there is rampant over the counter(OTC) sell of these drugs.

Opioids like morphine, codeine, and related drugs are commonly prescribed because of their

effective analgesic, anti-tussive and anti- diarrheal properties. Commercially available

preparations include propoxyphene (Darvocet), pentazocine (Fortwin) injections, fentanyl

(Duragesic), dextropropoxyphene (Proxyvon), dextromethorphan (Dexcof) buprenorphine

(Tidegesic), codeine (III/IV) and diphenoxylate (Lomotil). Cough syrups such as Corex and

Phensedyl have opiates, and antihistamines as well as alcohol. Opioid drugs cause euphoria by

affecting the brain regions that mediate what we perceive as pleasure and that’s the reason of it

being abused.

CNS depressants like benzodiazepines and barbiturates are the class of drugs most frequently

abused. Commonly used molecules are diazepam (Valium), chlordiazepoxide HCl (Librium),

alprazolam (Restyl), lorazopam (Larpoze), and nitrazepam (Nitrosun). Barbituarates are

available as phenobarbital( Gardinal). Benzodiazepines should not be taken for more than 2-3

weeks and then the drug should be tapered off gradually. But patients often easily acquire the

medicines without prescription or re-fill their prescriptions from a chemist. Also, they suffer

withdrawal symptoms when they try to reduce or stop the drugs and the withdrawal symptoms

are very similar to the illness for which they started the drug. So they again take the drug and in

progressively higher doses falling in a vicious cycle

Stimulants like dextroamphetamine (Dexedrine) and methylphenidate (Ritalin) are drugs causing

an increase in alertness, attention, and energy. Stimulants are prescribed for the treatment of only

a few health conditions like narcolepsy, attention-deficit hyperactivity disorder, and recalcitrant

or severe depression. Stimulants may be used as appetite suppressants for short-term treatment of

obesity.

Steroids (Anabolic-Androgenic) like nandrolone ( Durabolin), testosterone (Testoviron depot)

are demanded by patients or prescribed by doctors to enhance performance and/or improve

physical appearance. Patients on these drugs feel good about themselves but mood swings can

also occur, including manic-like symptoms that could lead to violence. Users may also suffer

from paranoid jealousy, irritability, delusions, and impaired judgment.

Who is at risk? Although prescription drug abuse can affect anyone, older adults, adolescents,

women and we medical professional, are at highest risk. Older adults are prescribed these drugs

for their ailments like osteoarthritis, insomnia, depression, etc. In women- without dealing with

the underlying cause of the problem, we doctors prescribe anti-anxiety drugs like diazepam

(Calmpose), alprazolam (Alprax), for their anxiety and depression. And in adolescent- use of

drugs can be an experimentation, occasional recreational drugs or may provide a way of coping

with the stress of modern world and its expectations. Others are abusers, popping a pill along

with alcohol or marijuana for an added "kick". Some see prescription drugs as back-up, to be

used when their main source like of addiction drugs heroin, Ecstasy are not available or

feasible. Unlike the pills, injected drug use is common among this age group and so they are at

risk of infections like HIV, hepatitis B and C, and other problems like cellulitis,

thrombophlebitis, endocarditis, septicaemia, etc. Also, health care professionals - including

physicians, nurses, pharmacists, dentists, anesthesiologists, and veterinarians are at increased

risk of prescription drug abuse because of easy availability with self-prescription. Overall, men

and women have roughly similar rates of abuse of prescription drugs, though young women are

more likely than young men to use benzodiazepines.

W

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is our role as doctors? We are in a unique position to identify prescription drug abuse, help the

patient recognize it and then manage the problem. Screening for any type of substance abuse can

be incorporated into routine history taking. Eg. ASSIST questionnaire developed by WHO or

Drug Abuse Screening Test (DAST). Discussing and motivating our neighboring chemists about

this issue with can play a key role in preventing prescription drug abuse, as these are the places

where the drugs are procured from. They should be vigilant about false or altered prescriptions

and should not unlawfully refill prescriptions. Other alternative could be dispensing from our

clinics the drugs that can be potentially abused, instead of prescribing them.

How to treat? The two main categories of drug addiction treatment are behavioral and

pharmacological. Brief interventional therapy takes not more than few minutes and has found to

be effective. The A-FRAMES model is the core structure of a brief intervention: Assessment,

providing objective Feedback, emphasizing that Responsibility for change belongs to the patient,

How to diagnose this disorder? We need to have a high level of clinical suspicion to diagnose

prescription drug abuse disorder in our busy practice. We should take notice if a patient

demands to increase the dose these prescribed drugs or comes frequently to us for refills before

the quantity prescribed should have been used. This may indicate the development of tolerance.

We should also be aware of “doctor shoppers” patients, those moving from doctor to doctor to

get multiple prescriptions for the drug they abuse. We can also diagnosis if we are aware of

withdrawal symptoms of these abused prescription drugs. Symptoms of opiate withdrawal

include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with

goose bumps ("cold turkey"), and involuntary leg movements. Taking a large single dose of an

opoid could cause severe respiratory depression and can also lead to death. Benzodiazepines in

withdrawal state cause sleeplessness, restlessness, tremors of the hand, slurring, irritability,

vomiting, sadness, altered appetite, and abnormal behavior, even delirium in extreme cases.

Although the use of stimulants may not lead to physical dependence and risk of withdrawal,

they can be addictive in that individuals begin to use them compulsively. Taking high doses of

some stimulants repeatedly over a short time can lead to feelings of hostility or paranoia.

Withdrawal symptoms of anabolic steroids include mood swings, fatigue, restlessness, loss of

appetite, insomnia, reduced sex drive, and depression, all of which may contribute to continued

abuse.

giving clear Advice about the benefits of change, providing a Menu of options for treatment to

facilitate change, using Empathic listening, and emphasizing and encouraging Self-efficacy with

the patient.

Medications are used to relieve the symptoms of withdrawal, to treat an overdose, or to help

overcome drug cravings. For withdrawal symptoms of opioid, buprenorphine (Tidigesic) 1.2-4.0

mg or 6-12capsules of dextropropoxyphene (Proxyvon) are given initially and tapered off after

the third day. Usually, detoxification medicines are required for 2-3 weeks. Methadone

(60mg/day), or buprenorphine 4 mg and 8 mg /day) are used as maintainance therapy.

Naltrexone( Naltima) (antagonist) given three times a week(100mg on 1t and 3rd day and 150mg

on 5hday or 50mg/day), act as anti-craving agent for abstinence. In cases of mild to moderate

benzodiazepine dependence, an outpatient detoxification by tapering of the drug, with weekly

reduction in doses can be carried out. In patients with severe dependence, particularly with

dependence on short acting benzodiazepines, indoor detoxification is preferred. In indoor setting,

the drugs can be tapered off at a rate of 10% a day. In patients dependent on short or

intermediately acting benzodiazepine (oxazepam, alprazolam, etc), risk of withdrawal seizures

should be kept in mind and to prevent the seizures, detoxification is started with equivalent doses

of long acting benzodiazepines (diazepam, chlordiazepoxide ), which then should be tapered off as

usual. Usually, detoxification in indoor set-ting is over within 2 weeks. In cases where only

insomnia persists, non-benzodiazepine hypnotics like zopiclone alone should be tried. Treatment

of addiction to prescription stimulants, such as Ritalin, is often based on behavioral as there are

no proven medications for the treatment of stimulant addiction. However, antidepressants may

help manage the symptoms of depression that can accompany the early days of abstinence from

stimulants. For steroids, if withdrawal symptoms are severe or prolonged, symptomatic

medications or hospitalization may be needed.

To summarize, we as general practitioners are in a unique position to prevent, diagnose and

manage the problem of prescription drug abuse- what we need is a little awareness and

motivation!!

REF: APA Practice Guidelines: Practice Guideline for the Treatment of Patients With Substance Use

Disorders, Second Edition