Articles on Prescription Drugs from the ATTC

In January of 2006, the Addiction Technology Transfer Center National Office published an informative version of The ATTC Networker, which explored the complexities of prescription drug abuse in America. Many national leaders from different fields were interviewed, and tools and resources were highlighted throughout the publication. Key articles from this newsletter are available to read below, or you may view the newsletter in it’s entirely, by clicking here.

Prescription Drug Abuse/Misuse Is a Growing Public Health Crisis: Policymakers Are Taking Action

Prescription Drug Abuse: A Profile of the Problem

Prescription Drug Monitoring Programs Combat Illegal Diversion of Prescription Drugs

Unscrupulous Internet Pharmacies Are Fueling Prescription Drug Abuse Crisis

Community Pain Management Project in Massachusetts Encourages Partnership

Adolescents Say Prescription Drugs Are Accessible and Seem Less Dangerous Than Illicit Street Drugs

Misuse of Prescription Drugs by Older Adults Is Especially Dangerous

 

Prescription Drug Abuse/Misuse Is a Growing Public Health Crisis: Policymakers Are Taking Action


In October 2006, the Substance Abuse and Mental Health Services Administration (SAMHSA), released a report that indicates the misuse of prescription drugs is second only to marijuana as the nation’s most prevalent drug problem. Abuse of pharmaceuticals has grown steadily since the 1990’s; a trend that has local, state and Federal officials taking notice. Misuse of Prescription Drugs: Data from the 2002, 2003 and 2004 National Surveys on Drug Use and Health (SAMHSA’s Misuse of Prescription Drugs), is the first NSDUH report to focus solely on the misuse of prescription medications. It showed that the annual average number of people using pain relievers nonmedically for the first time exceeded the number of new marijuana users.

A 2005 publication from the National Center on Addiction and Substance Abuse at Columbia University (CASA), called Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. (CASA’s Under the Counter), shows that nearly 15.1 million Americans report abusing prescriptions. This number is up from 7.8 million in 1992 revealing that prescription drug abuse has nearly doubled in 13 years. This is more than the combined number of people who admit to abusing cocaine, hallucinogens, inhalants and heroin. Clearly, there is a prescription drug abuse epidemic in America.

Concern over this growing epidemic is leading to new policies and initiatives. During testimony before a subcommittee of the U.S. House of Representatives in July 2006, staff from the Office of National Drug Control Policy, stated, “The Administration is concerned about the increase in the abuse of controlled substance prescription drugs. In response to the data, the Administration released its first-ever Synthetic Drug Control Strategy (Synthetics Strategy) in June 2006, which focuses on methamphetamine and prescription drug abuse. With respect to prescription drug abuse, the Synthetics Strategy calls for a 15 percent reduction in the illicit use of prescription drugs over three years.”

Some of the ways the Administration intends to combat prescription drug abuse is by supporting prescription drug monitoring programs, conducting investigations of rogue Internet pharmacy Web sites, and convening a conference of leading medical associations to focus on providing addiction-related medical education.

In July 2006, Nora Volkow, MD, National Institute on Drug Abuse (NIDA) Director outlined NIDA’s action plan to combat prescription drug abuse. She says NIDA is: 1) working to develop prescription medications that are not addictive; 2) developing protocols through the Clinical Trials Network (CTN) to address individuals who experience pain, but are addicted to commonly used medications; and 3) creating outreach efforts to inform the public about the dangers of the nonmedical use of prescription drugs.

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Prescription Drug Abuse: A Profile of the Problem


The Unique Difficulties of This Issue

In a recent interview, Nathaniel Katz, MD, MS, Tufts University School of Medicine Adjunct Assistant Professor of Anesthesia and a national authority on pain management issues, discussed some of the difficult challenges presented by prescription drug misuse/abuse. “When used appropriately, prescription medications help ease the pain and suffering of people who need them for legitimate medical reasons,” he said. “In fighting the illegal misuse of these drugs, we must not hinder patients’ access to beneficial medical treatments. However, we also must not ignore the fact that prescription drugs are potent and must be managed and monitored appropriately. There is an equilibrium that must be achieved.”

In July 2006, NIDA Director, Nora Volkow, MD, in testimony before a U.S. House of Representatives subcommittee, explained the situation. “Prescription drugs are powerful allies in our quest to alleviate human suffering.  And psychotherapeutics – those drugs that target the central nervous system (CNS) – are responsible for remarkable advances in our ability to understand and reduce the burden of mental illness and physical pain. However, as is often the case with beneficial technologies, there is a negative side, too. Because some of the psychotherapeutic drugs act, either directly or indirectly, upon the same brain systems affected by addictive drugs, their nonmedical use carries a substantial abuse liability.”

Two Interconnected Epidemics

There are actually two epidemics that intersect around prescription drugs: prescription opioid abuse and unrelieved pain. Kathryn Weiner, PhD, director of the American Academy of Pain Management, underscores the problem of chronic pain in the publication, Pain Issues: Pain Is An Epidemic. She states, “An estimated 50 million Americans live with chronic pain caused by disease, disorder or accident. An additional 25 million people suffer acute pain. ...The loss of productivity and daily activity due to pain is substantial.”

The Federation of State Medical Boards finds the most common barriers to the adequate management of pain are lack of understanding in the medical community about treating pain and fear among physicians that they will be investigated, or even arrested, for prescribing controlled substances for pain.

The Role of Patients

A research report from NIDA called Prescription Drugs: Abuse and Addiction (NIDA’s Prescription Drugs), explains that patients can prevent prescription drug misuse in the following ways. Patients should provide doctors with a complete medical history and detailed description of their medical complaint to ensure that the doctor accurately understands their problem. Patients should also follow medication directions carefully, learn about the possible side effects of prescriptions, and be aware of potential interactions with other drugs by reading all drug information provided by their pharmacist. Patients should not abruptly stop taking a medication or change a dosage without consulting their doctor, and finally, they should never use another person’s medicine.

In addition, Katz urges medical providers to educate their patients. He says that patients need to understand that sharing controlled medications is a felony; medications should be secured as if they are cash (possibly in a lock box) because burglars and others target prescription drugs; and that misrepresenting oneself to obtain prescription opioids, such as withholding pertinent information from a doctor, is a crime.

The Role of Health Care Providers

Doctors and nurses, among other medical professionals, play a key role in addressing prescription drug abuse. NIDA’s Prescription Drugs report indicates that 70 percent of Americans visit a medical professional at least once every two years. “Health care providers are in a unique position not only to prescribe needed medications appropriately, but also to identify prescription drug abuse when it exists, help the patient recognize the problem, set goals for recovery, and seek appropriate treatment when necessary,” the report explains.

CASA’s Under the Counter report shows that only 53.8 percent of physicians ask about prescription drug abuse when taking a patient’s health history, and only 54.5 percent of physicians (all or most of the time) call or obtain records from a patient’s previous physician before prescribing controlled drugs on a long-term basis.

David Loxterkamp, MD, in a 2006 article for the Annals of Family Medicine called Helping ‘Them’: Our Role in Recovery from Opioid Dependence, called on physicians to examine their roles in this complicated issue, and implement new strategies to monitor the prescriptions they write. He states, “At the very least, doctors must be savvy about pain prescriptions. More than one week’s course of narcotics (including hydrocodone) should require a drug contract. Contracts must be enforced; enforcement requires urine testing. All physicians should have the capacity to perform qualitative drug screening tests in their office and be willing to exercise it.”

Katz says there are a number of ways physicians can help. “Physicians should all use tamper- and copy-proof prescription pads, preferably serialized, which are now available from several pharmaceutical companies and several states,” he notes. “These should be locked in the office like cash. In states where prescription monitoring data is available, this should be reviewed on all patients at every visit, and each doctor should review all prescriptions attributed to him/her regularly to make sure nobody is filling fraudulent prescriptions in his/her name. Finally, all patients on long-term opioid therapy should have a quantitative urine toxicology screen performed on every visit.”

The Role of Pharmacists

NIDA’s Prescription Drugs report notes that pharmacists are in a unique position to contribute as well. “Pharmacists can play a key role in preventing prescription drug misuse and abuse by providing clear information and advice about how to take a medication appropriately, about the effects the medication may have, and about any possible drug interactions,” it says. “Pharmacists can help prevent prescription fraud or diversion by looking for false or altered prescription forms. Many pharmacies have developed ‘hotlines’ to alert other pharmacies in the region when a fraud is detected.”

The Role of PDMPs

Prescription Drug Monitoring Programs (PDMPs), funded by the Bureau of Justice Assistance (BJA), Office of Justice Programs, U.S. Department of Justice, are in place to assist law enforcement, regulatory agencies, and health professionals in the fight against the misuse and diversion of prescription drugs. Currently, 26 states have operational PDMPs. Several other states have authorizing legislation to create a PDMP, but the programs are not yet operational. PDMPs differ for each state, but each provides data and analysis to state law enforcement and regulatory agencies in order to assist in identifying and investigating activities potentially related to the illegal prescribing, dispensing and procuring of controlled substances. States that have implemented prescription monitoring programs have the capability to collect and analyze prescription data much more efficiently than states without such programs. Some PDMPs allow physicians to access data and review patients’ prescription drug histories. Providing the medical community access to this data allows physicians to work together to eliminate doctor shopping.

The Role of State Treatment Systems

State substance abuse treatment systems play an important role in fighting prescription drug abuse also. These programs help people reclaim their lives and become contributing members of society. Providing drug abuse treatment improves life for everyone by making our communities safer and reducing society’s financial burden of caring for people with an addiction. Successful treatment may need to incorporate several components including detoxification, various types of counseling, and pharmacological therapies. Treatment must also take into account the type of drug used and the needs of each individual. It is important to remember that multiple courses of treatment are often needed for a patient to fully recover. 

What’s Next?

Many of the stakeholder groups involved in this issue agree that several different fields must come together to tackle this difficult problem. Education, information sharing, data collection, clinical trials and partnering are just some of the steps that experts in the field recommend.

Education may be the answer to empowering physicians says Kim Johnson, MSED, MBA, director of the Office of Substance Abuse for the Department of Health and Human Services in Maine. “Physicians don’t have enough information about how to access the treatment system in their communities; nor are they receiving adequate education about addiction. Physicians need to know how to get their patients (substance abuse) treatment if they suspect a problem.”

Katz explained that physicians need more specific instructions about treating people with comorbid pain and addiction. “There are no practical guidelines for physicians about how and when to prescribe opiate therapy,” he notes. “We need some information from clinical trials about the long-term risks and benefits of opioid therapy so physicians will have validated methods of performing a risk-benefit analysis before they prescribe these medications. Patients also need more education about prescription pain medications – how to take them and dispose of them safely. They need to understand what their responsibilities are, and that they are breaking the law if they don’t use these drugs as they are prescribed.” 

Sherry Green, executive director of the National Alliance for Model State Drug Laws (NAMSDL) agrees. “We have to help physicians understand how to link with the local treatment system,” she says. “Often they are told that the patient has to initiate treatment on his/her own, so doctors feel like they can’t help. All of the groups involved need to come together – from a very practical standpoint – and talk about how to handle these issues. A detailed plan needs to be created with very specific steps about how these groups can link and work together.”

Johnson believes that data sharing can be mutually beneficial to all the parties involved. “Maine is the only state where the substance abuse treatment system and the PDMP are housed within the same agency. By giving physicians access to data collected by the PDMP, they are better equipped to make practical decisions when they are suspicious about a patient’s intentions. Working together everyday is the only way we will really make progress.”

Finally, Katz called on NIDA to conduct more clinical research, the FDA to require pharmaceutical companies to study the important risks and benefits of their medications, the DEA and law enforcement agencies to systematically evaluate their practices relating to eliminating drug diversion, and Congress to enact a “major legislative program” that would provide incentives for all the stakeholders involved to join together to tackle prescription drug abuse in a collaborative manner.

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Prescription Drug Monitoring Programs Combat Illegal Diversion of Prescription Drugs


BJA administers a unique program designed to combat the illegal diversion of prescription drugs called the Harold Rogers Prescription Drug Monitoring Program (PDMP). Currently, 26 states have operational PDMPs. Several other states have authorizing legislation to create a PDMP, but the programs are not yet operational. Program objectives include building a data collection and analysis system at the state level, enhancing existing programs¹ ability to analyze and use collected data, facilitating the exchange of collected prescription data among states, and assessing the efficiency and effectiveness of the programs funded under this initiative.

Each state’s PDMP is different, but the primary purpose of these programs is to prevent and detect the illegal diversion of prescription drugs. PDMPs all provide data and analysis to state law enforcement and regulatory agencies. States that have implemented prescription monitoring programs have the capability to collect and analyze prescription data much more efficiently than states without such programs, where the collection of prescription information requires the manual review of pharmacy files, a time-consuming and invasive process,” says the BJA Web site.

The National Alliance for Model State Drug Laws (NAMSDL) provides technical assistance to states that either have a PDMP or intend to establish one. Sherry Green, executive director of NAMSDL, believes that ultimately each state will have a PDMP. “We (NAMSDL) speak to policymakers and help states strengthen their policies and create more cooperative programs. We are beginning to see positive results with the PDMPs in general. I think this will be a continuing trend, and eventually each state will develop a program.”

Some PDMPs authorizing statutes allow physicians access to the data that is collected so they can monitor “doctor shopping” by reviewing patients’ prescription drug histories. “Information sharing will be an important component in the success of these programs,” says Green. “By giving the medical and treatment communities access to the information that is collected, early intervention is more likely. I think in the future it will also be important to share information across state lines to effectively combat the (prescription drug) problem.” For more information about the PDMPs, visit www.ojp.usdoj.gov/BJA/grant/prescripdrugs.html.

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Unscrupulous Internet Pharmacies Are Fueling Prescription Drug Abuse Crisis


The ease of making purchases on the Internet is one of the reasons experts say misuse of prescription drugs continues to grow around the world. A computer and a credit card are often all that are needed to buy these medications. Many sites selling pharmaceuticals don’t require prescriptions or consultations with physicians, nor do they have any provisions in place to prevent children from making purchases. 

According to a study from the National Center on Addiction and Substance Abuse at Columbia University (CASA), during a one-week period in February 2006, researchers found 344 Web sites either advertising or selling Schedule II-V controlled prescription drugs. CASA’s study, You’ve Got Drugs! Prescription Drug Pushers on the Internet: 2006 Update, found that 89 percent of sites selling controlled prescription drugs don’t have prescription requirements, a decrease from the 94 percent that did in 2004. “The striking fact is that despite increasing public attention to this issue and concern at the state and Federal levels of government, there has been a steady increase over three years in the number of sites we found selling controlled prescription drugs online,” says Susan Foster, CASA’s Vice President and Director of the Division of Policy Research and Analysis. “We are not getting a handle on this problem and those selling drugs online are becoming more sophisticated in the ways they offer and sell drugs.”

To get around the prescription requirement, Internet pharmacies have begun offering “online consultations” for patients. This means that a patient completes a questionnaire, which is evaluated by a physician affiliated with the online pharmacy – without benefit of a face-to-face meeting, phone conversation, medical exam, medical records, tests or any follow up. This is in direct opposition to a number of medical organizations, including the Federation of State Medical Boards, the National Association of Boards of Pharmacy, the Drug Enforcement Administration and the American Medical Association. 

There are steps being taken to curb this growing trend. In 2005, the DEA, the Federal Bureau of Investigation, the Internal Revenue Service, the Food and Drug Administration, and the U.S. Attorney’s Office jointly conducted Operation CYBERx, which targeted more than 22 rogue Internet pharmacies and resulted in 18 arrests.

In addition, the National Association of Boards of Pharmacy has launched Verified Internet Pharmacy Practice Sites (VIPPS). To become VIPPS certified, a pharmacy must comply with the licensing and inspection requirements of their state and each state to which they dispense pharmaceuticals. Pharmacies displaying the VIPPS seal must also have demonstrated compliance with other VIPPS criteria, including patient rights to privacy, authentication and security of prescription orders, adherence to a recognized quality assurance policy, and provision of meaningful consultation between patients and pharmacists.

Foster says that Congressional hearings have been held and that CASA has had conversations with major shippers, credit card companies and the DEA about potential solutions. “There is interest in a national clearinghouse as a way to address this problem, but it will take Congressional action and allocation of additional resources,” she says.  To view CASA’s report, visit www.casacolumbia.org/supportcasa/item.asp?cID=12&PID=147.

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Community Pain Management Project in Massachusetts Encourages Partnership


Like communities around the country, prescription medications have become popular street drugs in Berkshire County, Massachusetts. “An insidious black market in prescription pain medication has taken root throughout the area, fueled, in significant part, through prescriptions issued by unwitting Berkshire County health care providers,” says John Rogers, vice president and general counsel for Berkshire Health Systems, Inc. To combat this growing problem, a unique new program has been established.

The Berkshire County Community Pain Management Project (BCCPMP) is a multi-disciplinary and multi-agency effort designed to help local health care providers and community agencies work together. The goal of the project is to improve the health care management of patients suffering from chronic or acute pain, and to reduce the risk of abuse and diversion of pain medication prescribed by Berkshire County physicians.

“Berkshire County health care providers face the challenge of assuring that effective and appropriate pain management remains available to those who need it, while, at the same time, combating the misuse and diversion of pain medicines,” he says. “These efforts require an efficient and timely means of sharing appropriate information among health care providers and an effective coordination of consulting and referral services.” The BCCPMP includes the expertise of a broad range of groups including physicians, pharmacists, rehabilitation specialists, behavioral health specialists and members of the law enforcement and legal communities.

As part of this project, Berkshire Health Systems developed a manual for physicians and other health care professionals. A Pain Care Resource Manual: A Practical Guide for Health Care Professionals is designed to serve as a clinical toolbox for Berkshire County practitioners, and provides best practice guidelines for the assessment and treatment of chronic pain. Forms and other resources are provided, and information about how best to respond to suspected misuse or diversion of pain medication is included. Additional tools were also developed to assist health care practitioners including tamper-proof prescription pads and cautionary office signage.

In discussing this project, Rogers says, “Several hundred members of the Berkshire County medical community have responded enthusiastically to this project, demonstrating to us that physicians and other prescribing providers in our communities recognize the difficult challenges of trying to effectively treat chronic pain and also combat abuse and diversion of pain medication. We haven’t had to convince our medical community that there is a problem that requires their immediate response. To the contrary, we have found a tremendous desire among providers for information and tools that can help them address these dual challenges.”

Every prescribing provider in Berkshire Country now receives a toolkit. Rogers says that they are also expanding the reach of their electronic medical record, so that with the help of real-time, readily accessible information, practitioners can more effectively manage patient care. “The Massachusetts Department of Public Health has been working with our project for the last several months to make available individual and aggregate data from the prescription monitoring program, so that each prescriber can better understand and manage his or her own prescribing practices,” adds Rogers. “In addition, we have been developing outcome goals and methods of data collection that describe our experience with this project in ways that are applicable and usable by other communities.” For more information about the Berkshire Health System, visit www.berkshirehealthsystems.org.

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Adolescents Say Prescription Drugs Are Accessible and Seem Less Dangerous Than Illicit Street Drugs


Research shows that many teens cite easy access to prescription drugs as a primary factor contributing to the increase in this type of substance abuse. Specifically, many teens say parents’ medicine cabinets and/or friend’s medicine cabinets are key access points. Kim Johnson, MSED, MBA, director of the Office of Substance Abuse for the Department of Health and Human Services in Maine, believes that many adolescents are under the impression that because these drugs are legal, they are safe. “Teens think taking a pill that comes from the pharmacy is less harmful than taking a drug that comes from the street. This perception has fueled the growth of prescription drug use among this age group. There is a very casual attitude among young adults and college students,” she explains.

Data from SAMHSA’s new report, Misuse of Prescription Drugs: Data from the 2002, 2003 and 2004 National Surveys on Drug Use and Health, shows that young adults aged 18 to 25 have the highest rates of nonmedical use of prescriptions in the past year, followed by youths 12 to 17. The survey found that four million young adults aged 18 to 25 (12.4 percent) used prescription pain relievers such as OxyContin nonmedically within the past year in 2005. In addition, 1.7 percent of young adults met the criteria for dependence or abuse of prescription pain relievers in the past year.

Randolph Muck, MEd, CSAT Lead Public Health Advisor/Team Leader, says, “Typically, adolescents are opportunistic users; they will use what’s available. The number one abused drug by youth presenting to substance abuse treatment is marijuana followed by alcohol and then everything else. Marijuana and alcohol may be the ‘gateways’ to these drugs (prescription medications) being abused, not the other way around. Of those abusing pain relievers, 73.8 percent had used another illegal drug. With Oxycontin, 99.1 percent had used something else before.”

NIDA’s Freevibe Web site (www.freevibe.com/Drug_Facts/prescription_drugs.asp) says teens point to personal and family-related stress as major reasons why they abuse prescription drugs. Many high school students attribute their stressful feelings to: friendships; romantic relationships; difficult family life; competition for college entrance; honors courses; balancing school work, grades, and extracurricular activities; and a desire to have the “ideal” physical appearance.

Research also shows that use of prescription drugs by college students continues to rise. Like adolescents, young adults cite a variety of reasons for misusing prescription medications: getting high, staying awake and focused to study, and controlling weight are the most commonly noted. 

A troubling trend with adolescents and college students is a recent phenomena known as “pharming.” Young people have pharming parties where they trade prescription drugs, mix them with alcohol and ingest some or all of them at once, unaware of the potentially severe drug interactions. “There are so many prescriptions available and everyone shares,” notes Johnson. “There needs to be more public education about the powerful effects of these drugs. Our current prevention efforts are inadequate. Many times adults unwittingly supply kids with prescription drugs because they don’t appropriately store or get rid of these medications. We need more parent education.”

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Misuse of Prescription Drugs by Older Adults Is Especially Dangerous


Older adults are likely to have more adverse health consequences due to prescription drug misuse and abuse than younger people says a 2005 publication by NIDA called, Community Drug Alert Bulletin - Prescription Drugs. While people 65 years of age and above comprise only 13 percent of the population, they are prescribed about one-third of all medications in the United States. Comorbid illnesses, complex drug regimens, errors in dosing, and changing drug metabolism rates are all factors that can contribute to older people developing dependence or becoming addicted to prescription drugs.

Admissions for substance abuse treatment increased by 32 percent among older adults from 1995-2002 says Older Adults in Substance Abuse Treatment: Update, a 2005 report by SAMHSA. The percent of older adults with opiates as their primary substance of abuse increased from 6.8 percent to 12 percent during this time period. Opiates are the second most frequent reason for treatment admissions among older adults after alcohol. In a press release regarding SAMHSA’s report, Charles Curie, MA, ACSW, former SAMHSA Administrator, stated, “We are only beginning to realize the pervasiveness of substance abuse among older adults. We have made older adults a priority at SAMHSA and are working to advance our understanding of the relationship between aging and substance abuse.”

SAMHSA and the Food and Drug Administration have collaborated to educate older Americans about the proper use of prescription medications. The As You Age campaign warns people in this age group about the risks of mixing certain prescription drugs or prescription medications and alcohol. Do the Right Dose materials are also available, which highlight the dangers of misusing prescription drugs. Visit http://asyouage.samhsa.gov/default.aspx to access these materials. In 2004, NIDA sponsored a symposium called Drug Abuse in the 21st Century: What Problems Lie Ahead for the Baby Boomers? A number of informative presentations are available online at www.drugabuse.gov/whatsnew/meetings/bbsr/prescription.html.

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