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The problem of prescription drug abuse is growing on a daily basis. It is more prevalent than one suspects, and must be dealt with on a case by case basis, with careful assessment and compassion.
First, we must define what we mean by prescription drug abuse: it is the compulsive and potentially destructive use of prescription drugs, despite adverse medical and social consequences, which may lead to physical need (addiction), and/or psychological need (dependence). By definition we eliminate from our discussion the abused drugs that are not available by prescription. These include cocaine, heroin, alcohol, nicotine, PCP, LSD, marijuana, and methamphetamine.
The fact remains that 12 of the top 20 abused drugs of all types are prescription drugs. Based on my 36 years as a registered pharmacist and my extensive study of the use of psychoactive drugs over the last 13 years at Saint Luke Institute, I would list the "Abused Top Ten" as follows:
Hydrocodone Combinations: Vicodin, Lorcet, Lortab, Norco, Hydro-Apap, etc.
Oxycodone Derivatives: Percodan, Percocet, Tylox, Roxicet, etc.
Codeine Combinations: Tylenol #3 & #4, Apap with Codeine, etc.
Alprazolam (Xanax)
Diazepam (Valium)
Methadone
Lorazepam (Ativan)
Propoxyphene HCL and N, Propacet, Darvocet
Temazepam (Restoril)
Chlordiazepoxide (Librium)
We live in a society that overestimates the benefits and safety of prescription drugs and underestimates the dangers and the potential for abuse. It is estimated that 28% of all prescriptions written in the United States for controlled substances are abused. We have patients that visit 10-12 doctors and 30-40 pharmacies to satisfy their cravings and serve their addiction. They steal prescription blanks from the doctor's office, then they forge prescriptions and try to have them filled at several pharmacies. Figures from the Mental Health Services Administration show that the causative agent in 30-50% of the patients treated in emergency rooms for overdose was prescription drugs. This outnumbers the emergency room treatment for heroin overdoses by a ratio of six to one.
The solution to this problem involves the education of both the public and the providers. We all know what we would think if at a party someone pulled a vial of cocaine from their coat and snorted some. But, what would we say if they opened a vial of Xanax and took one or two "just to get over"? This attitude is a large part of the problem. We must always be aware of the need for constant review and evaluation of patients' medications. Also, be aware of the signs and symptoms of drug abuse and react immediately to any signs of a problem.
The most commonly observable symptoms of prescription drug abuse are:
a change in mood--either to one of mild euphoria or to one of chronic belligerence;
a false sense of self-confidence;
statements of "being free from anxiety;"
reports of experiencing increased sensitivity to light and sound or of having hallucinations.
complaints of feeling very unpleasant and out of sorts when they either cut back or run out of their medication;
Reports of extreme behavior such as sleeping for 12-14 hours at a time to cleaning the house at 3:30 AM.
Many people abusing prescription pain killers started out as legitimate patients. Because of poor pain management by the physician, previous drug abuse or a genetic predisposition, they continue to use the medication long after it is medically needed. These persons then move from the status of being treated for a medical condition to being treated for or maintained in an addictive state.
The chronic pain patient who has no further surgical or medical options is often incorrectly placed in this class. These legitimate chronic pain patients are not addicts! Their only addiction is to not wanting to exist in a constant state of intractable pain. The saddest situation that I face in my work as a pharmacy consultant to hospices is dealing with physicians with no hospice experience, who refuse to order sufficient pain medications for terminal patients because "they might get hooked". This is patient abuse, not drug abuse.
The importance of assessing each situation on a case-by-case basis is essential. Sometimes it may be a case of the wrong drug, a mis-dosage or confusion, especially among the elderly, about taking drugs. Pay attention to what is happening with the people in your care. If you suspect prescription drug abuse express your concerns to the individual. If this does not lead to clarification or improvement a next step might be to ask for a joint consultation with the prescribing physician. The worst thing you can do is to do nothing.
Jon Johnson is the Pharmacy Consultant for Saint Luke Institute.
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