Prescription Pain and Other Medications

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Prescription Pain and Other Medications

http://www.nida.nih.gov/Infofax/PainMed.html

Prescription medications such as pain relievers, tranquilizers,

stimulants, and sedatives are very useful treatment tools but sometimes

people do not take them as directed and may become addicted. Pain

relievers make surgery possible, and enable many individuals with

chronic pain to lead productive lives. Most people who take prescription

medications use them responsibly. However, the inappropriate or

nonmedical use of prescription medications is a serious public health

concern. Nonmedical use of prescription medications like opioids,

central nervous system (CNS) depressants, and stimulants can lead to

abuse and addiction, characterized by compulsive drug seeking and use.

Patients, healthcare professionals, and pharmacists all have roles in

preventing misuse and addiction to prescription medications. For

example, when a doctor prescribes a pain relief medication, CNS

depressant, or stimulant, the patient should follow the directions for

use carefully, learn what effects the medication could have, and

determine any potential interactions with other medications. The patient

should read all information provided by the pharmacist. Physicians and

other healthcare providers should screen for any type of substance abuse

during routine history-taking, with questions about which prescriptions

and over-thecounter medicines the patient is taking and why. Over time,

providers should note any rapid increases in the amount of a medication

needed—which may indicate the development of tolerance—or frequent

requests for refills before the quantity prescribed should have been

used.

Commonly Abused Prescription Drugs

While many prescription drugs can be abused or misused, these three

classes are most commonly abused:

Opioids - often prescribed to treat pain.

CNS Depressants - used to treat anxiety and sleep disorders.

Stimulants - prescribed to treat narcolepsy and attention

deficit/hyperactivity disorder.

Opioids

Opioids are commonly prescribed because of their effective analgesic, or

pain relieving, properties. Many studies have shown that properly

managed Prescription Pain and Other Medications medical use of opioid

analgesic compounds is safe and rarely causes addiction, which is

defined as compulsive, often uncontrollable use. Taken exactly as

prescribed, opioids can be used to manage pain effectively.

Among the compounds that fall within this class—sometimes referred to as

narcotics—are morphine, codeine, and related medications. Morphine is

often used before or after surgery to alleviate severe pain. Codeine is

used for milder pain. Other examples of opioids that can be prescribed

to alleviate pain include oxycodone (OxyContin—an oral, controlled

release form of the drug); propoxyphene (Darvon); hydrocodone (Vicodin);

hydromorphone (Dilaudid); and meperidine (Demerol), which is used less

often because of side effects. In addition to their effective pain

relieving properties, some of these medications can be used to relieve

severe diarrhea (Lomotil, for example, which is diphenoxylate) or severe

coughs (codeine).

Opioids act by attaching to specific proteins called opioid receptors,

which are found in the brain, spinal cord, and gastrointestinal tract.

When these compounds attach to certain opioid receptors in the brain and

spinal cord, they can effectively change the way a person experiences

pain.

In addition, opioid medications can affect regions of the brain that

mediate what we perceive as pleasure, resulting in the initial euphoria

that many opioids produce. They can also produce drowsiness, cause

constipation, and, depending upon the amount taken, depress breathing.

Taking a large single dose could cause severe respiratory depression or

death.

Opioids may interact with other medications and are only safe to use

with other medications under a physician’s supervision. Typically, they

should not be used with substances such as alcohol, antihistamines,

barbiturates, or benzodiazepines. Since these substances slow breathing,

their combined effects could lead to lifethreatening respiratory

depression.

Chronic use of opioids can result in tolerance to the medications so

that higher doses must be taken to obtain the same initial effects.

Long-term use also can lead to physical dependence—the body adapts to

the presence of the substance and withdrawal symptoms occur if use is

reduced abruptly. Individuals taking prescribed opioid medications

should not only be given these medications under appropriate medical

supervision, but also should be medically supervised when stopping use

in order to reduce or avoid withdrawal symptoms. Symptoms of withdrawal

can include restlessness, muscle and bone pain, insomnia, diarrhea,

vomiting, cold flashes with goose bumps (“cold turkey”), and involuntary

leg movements.

Individuals who become addicted to prescription medications can be

treated. Options for effectively treating addiction to prescription

opioids are drawn from research on treating heroin addiction. Some

pharmacological examples of available treatments follow:

Methadone, a synthetic opioid that blocks the effects of heroin and

other opioids, eliminates withdrawal symptoms and relieves craving. It

has been used for over 30 years to successfully treat people addicted to

opioids.

Naltrexone is a long-acting opioid blocker often used with highly

motivated individuals in treatment programs promoting complete

abstinence. Naltrexone also is used to prevent relapse.

Buprenorphine, another synthetic opioid, is a recent addition to the

arsenal of medications for treating addiction to heroin and other

opiates.

Naloxone counteracts the effects of opioids and is used to treat

overdoses.

Central Nervous System (CNS) Depressants

CNS depressants slow normal brain function. In higher doses, some CNS

depressants can become general anesthetics. Tranquilizers and sedatives

are examples of CNS depressants. CNS depressants can be divided into two

groups, based on their chemistry and pharmacology:

Barbiturates, such as mephobarbital (Mebaral) and pentobarbitalsodium

(Nembutal), which are used to treat anxiety, tension, and sleep

disorders.

Benzodiazepines, such as diazepam (Valium), chlordiazepoxide HCl

(Librium), and alprazolam (Xanax), which can be prescribed to treat

anxiety, acute stress reactions, and panic attacks. Benzodiazepines that

have a more sedating effect, such as estazolam (ProSom), can be

prescribed for short-term treatment of sleep disorders.

There are many CNS depressants, and most act on the brain similarly—they

affect the neurotransmitter gamma-aminobutyric acid (GABA).

Neurotransmitters are brain chemicals that facilitate communication

between brain cells. GABA works by decreasing brain activity. Although

different classes of CNS depressants work in unique ways, ultimately it

is their ability to increase GABA activity that produces a drowsy or

calming effect. Despite these beneficial effects for people suffering

from anxiety or sleep disorders, barbiturates and benzodiazepines can be

addictive and should be used only as prescribed.

CNS depressants should not be combined with any medication or substance

that causes sleepiness, including prescription pain medicines, certain

over-the-counter cold and allergy medications, or alcohol. If combined,

they can slow breathing, or slow both the heart and respiration, which

can be fatal.

Discontinuing prolonged use of high doses of CNS depressants can lead to

withdrawal. Because they work by slowing the brain’s activity, a

potential consequence of abuse is that when one stops taking a CNS

depressant, the brain’s activity can rebound to the point that seizures

can occur. Someone thinking about ending their use of a CNS depressant,

or who has stopped and is suffering withdrawal, should speak with a

physician and seek medical treatment.

In addition to medical supervision, counseling in an in-patient or

out-patient setting can help people who are overcoming addiction to CNS

depressants. For example, cognitive-behavioral therapy has been used

successfully to help individuals in treatment for abuse of

benzodiazepines. This type of therapy focuses on modifying a patient’s

thinking, expectations, and behaviors while simultaneously increasing

their skills for coping with various life stressors.

Often the abuse of CNS depressants occurs in conjunction with the abuse

of another substance or drug, such as alcohol or cocaine. In these cases

of polydrug abuse, the treatment approach should address the multiple

addictions.

Stimulants

Stimulants increase alertness, attention, and energy, which are

accompanied by increases in blood pressure, heart rate, and respiration.

Historically, stimulants were used to treat asthma and other respiratory

problems, obesity, neurological disorders, and a variety of other

ailments. As their potential for abuse and addiction became apparent,

the use of stimulants began to wane. Now, stimulants are prescribed for

treating only a few health conditions, including narcolepsy,

attention-deficit hyperactivity disorder (ADHD), and depression that has

not responded to other treatments. Stimulants may also be used for

short-term treatment of obesity and for patients with asthma.

Stimulants such as dextroamphetamine (Dexedrine) and methylphenidate

(Ritalin) have chemical structures that are similar to key brain

neurotransmitters called monoamines, which include norepinephrine and

dopamine. Stimulants increase the levels of these chemicals in the brain

and body. This, in turn, increases blood pressure and heart rate,

constricts blood vessels, increases blood glucose, and opens up the

pathways of the respiratory system. In addition, the increase in

dopamine is associated with a sense of euphoria that can accompany the

use of stimulants.

Research indicates that people with ADHD do not become addicted to

stimulant medications, such as Ritalin, when taken in the form and

dosage prescribed.1 However, when misused, stimulants can be addictive.

The consequences of stimulant abuse can be extremely dangerous. Taking

high doses of a stimulant can result in an irregular heartbeat,

dangerously high body temperatures, and/or the potential for

cardiovascular failure or seizures. Taking high doses of some stimulants

repeatedly over a short period of time can lead to hostility or feelings

of paranoia in some individuals.

Stimulants should not be mixed with antidepressants or over-the-counter

cold medicines containing decongestants. Antidepressants may enhance the

effects of a stimulant, and stimulants in combination with decongestants

may cause blood pressure to become dangerously high or lead to irregular

heart rhythms.

Treatment of addiction to prescription stimulants, such as

methylphenidate and amphetamines, is based on behavioral therapies

proven effective for treating cocaine or methamphetamine addiction. At

this time, there are no proven medications for the treatment of

stimulant addiction. Antidepressants, however, may be used to manage the

symptoms of depression that can accompany early abstinence from

stimulants.

Depending on the patient’s situation, the first step in treating

prescription stimulant addiction may be to slowly decrease the drug’s

dose and attempt to treat withdrawal symptoms. This process of

detoxification could then be followed with one of many behavioral

therapies. Contingency management, for example, improves treatment

outcomes by enabling patients to earn vouchers for drug-free urine

tests; the vouchers can be exchanged for items that promote healthy

living. Cognitivebehavioral therapies, which teach patients skills to

recognize risky situations, avoid drug use, and cope more effectively

with problems, are proving beneficial. Recovery support groups may also

be effective in conjunction with a behavioral therapy.

Trends in Prescription Medication Abuse

2003 Monitoring the Future Survey (MTF)*

MTF assesses the extent and perceptions of drug use among 8th, 10th, and

12th grade students nationwide. The 2003 survey showed that the

lifetime, annual, and 30-day** use of tranquilizers declined

significantly from 2002 to 2003 for 10th- and 12th-graders. This is the

first year of decline for 12th-graders after a decade of gradual

increase; past year use went from 7.7 percent in 2002 to 6.7 percent in

2003. For 10th-graders, it is the second year of decline for annual use,

down from 7.3 percent in 2001 to 5.3 percent in 2003. In general,

8th-graders’ rates of reported tranquilizer use have been considerably

lower (about 2.7 percent for annual use) than those observed in the

upper grades.

Like tranquilizers, sedative use had shown a decade-long rise among high

school seniors before leveling at 9.5 percent in 2002 and 8.8 percent in

2003.

Only 12th grade data are reported for abuse of narcotics other than

heroin in the MTF. The annual prevalence of this class of drugs had

risen considerably from 3.3 percent in 1992 to 7 percent in 2000 and 6.7

percent in 2001. In 2002, the survey item was changed to incorporate two

new specific pain relievers, OxyContin (a controlled-release form of

oxycodone that can cause severe health consequences if crushed and

ingested) and Vicodin (hydrocodone), and separate items asking about use

of these drugs also were introduced. Following the change in the other

narcotics item, past year use was reported by 9.4 percent of seniors in

2002 and 9.3 percent in 2003.

Although not significantly higher than in 2002, annual OxyContin use was

reported in 2003 by 4.5 percent of 12th graders, 3.6 percent of

10th-graders, and 1.7 percent of 8th-graders. The annual prevalence rate

for Vicodin was considerably higher than for OxyContin, at 10.5 percent

in 12th-graders, 7.2 percent in 10th-graders, and 2.8 percent in

8th-graders in 2003. Considering the addictive potential of oxycodone

and hydrocodone, these are disturbingly high rates of use—contrasting

with an annual prevalence of less than 1 percent in all three grades for

heroin, for instance.

2002 National Survey on Drug Use and Health (NSDUH)***

According to the 2002 NSDUH, an estimated 6.2 million persons, or 2.6

percent of the population, age 12 and older had used prescription

medications nonmedically in the month prior to being surveyed. This

includes 4.4 million using pain relievers, 1.8 million using

tranquilizers, 1.2 million using stimulants, and 0.4 million using

sedatives. While prescription drug abuse affects many Americans, some

trends of particular concern can be seen among older adults,

adolescents, and women.

Lifetime prevalence of pain reliever abuse among youth aged 12 to 17

increased from 9.6 percent in 2001 to 11.2 percent in 2002, continuing

an increasing trend from 1989 (1.2 percent). Among young adults aged 18

to 25, the rate increased from 19.4 percent in 2001 to 22.1 percent in

2002; the young adult rate was 6.8 percent in 1992.

In 2002, approximately 1.9 million people aged 12 and older had used

OxyContin nonmedically at least once in their lifetimes. An estimated

360,000 Americans received treatment for pain reliever abuse in the past

year. The number of new pain reliever users increased from 628,000 in

1990 to 2.4 million in 2001; over half (52 percent) of the new users in

2001 were female.

Lifetime nonmedical use of stimulants increased steadily from 1990 to

2002 for youth aged 12 to 17 (0.7 percent to 4.3 percent). Rates

increased between 2001 and 2002 for both youth (3.8 percent to 4.3

percent) and young adults (10.2 percent to 10.8 percent).

2002 Drug Abuse Warning Network (DAWN)****

DAWN collects data on drug-related hospital emergency department (ED)

episodes. The latest DAWN findings indicate that drug abuse-related ED

episodes involving certain prescription drugs, particularly the

benzodiazepines and narcotic analgesics (pain relievers), continued to

rise between 1995 and 2002. ED mentions of benzodiazepines increased 38

percent, and mentions of narcotic analgesics/combinations increased from

45,000 to nearly 120,000. By the end of 2002, ED mentions of

benzodiazepines and narcotic analgesics/combinations were about as

frequent as mentions of heroin or marijuana but ranked below cocaine and

alcohol.

Long-term findings indicate that ED mentions of unspecified narcotics,

as well as those containing hydrocodone, oxycodone, and methadone rose

substantially from 1995 to 2002, increasing 160 percent for hydrocodone

combinations, 176 percent for methadone, 341 percent for unspecified

narcotic analgesics, and 560 percent for oxycodone/combinations. ED

mentions of oxycodone/combinations doubled from 2000 to 2002.

From 2001 to 2002, ED mentions of narcotic analgesics/combinations rose

20 percent. From 2000 to 2002, the increase was 45 percent, and over the

8-year period from 1995 to 2002, ED mentions rose 163 percent. Overall,

narcotic analgesics/ combinations comprised 10 percent of total ED

mentions in the United States in 2002.

In 2002, there were 105,752 mentions of benzodiazepines in hospital EDs,

an increase of 16 percent from 2000. Mentions of alprazolam (Xanax) rose

25 percent during that period.

For more information on addiction to prescription medications, visit

http://www.drugabuse.gov/drugpages/prescription.html.

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1 Nora Volkow, et al., Dopamine Transporter Occupancies in the Human

Brain Induced by Therapeutic Doses of Oral Methylphenidate, Am J

Psychiatry 155:1325–1331, October 1998.

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* These data are from the 2003 Monitoring the Future Survey, funded by

the National Institute on Drug Abuse, National Institutes of Health,

DHHS, and conducted by the University of Michigan’s Institute for Social

Research. The survey has tracked 12th-graders’ illicit drug use and

related attitudes since 1975; in 1991, 8th- and 10th-graders were added

to the study. The latest data are online at www.drugabuse.gov.

** “Lifetime” refers to use at least once during a respondent’s

lifetime. “Annual” refers to use at least once during the year preceding

an individual’s response to the survey. “30-day” refers to use at least

once during the 30 days preceding an individual’s response to the

survey.

*** NSDUH (formerly known as the National Household Survey on Drug

Abuse) is an annual survey conducted by the Substance Abuse and Mental

Health Services Administration. Copies of the latest survey are

available at www.samhsa.gov.

**** These data are from the annual Drug Abuse Warning Network, funded

by the Substance Abuse and Mental Health Services Administration, DHHS.

The survey provides information about emergency department visits that

are induced by or related to the use of an illicit drug or the

nonmedical use of a legal drug. The latest data (2002) are at

www.samhsa.gov.