Substance Abuse Treatment

Substance Abuse Treatment
May 2006
Volume 5
Issue 2
ADVISORY
News for the Treatment Field
Prescription Medications: Misuse, Abuse,
Dependence, and Addiction
How serious are prescription
medications with high abuse and addiction liability.4
medication use problems?
Data from the National Survey on Drug Use and Health
indicate that nonmedical use of prescription medications
Development and increased availability of prescription
was the second most common form of substance abuse
drugs have significantly improved treatment of pain,
among adults older than 55.5
mental disorders, anxiety, and other conditions. Millions
Use of prescription medications in ways other than
of Americans use prescription medications safely and
prescribed can have a variety of adverse health conse-
responsibly. However, increased availability and variety
quences, including overdose, toxic reactions, and serious
of medications with psychoactive effects (see Table 1)
drug interactions leading to life-threatening conditions,
have contributed to prescription misuse, abuse, depen-
such as respiratory depression, hypertension or hypoten-
dence, and addiction. In 2004,1 the number of
sion, seizures, cardiovascular collapse, and death.6
Americans reporting abuse2 of prescription medications
was higher than the combined total of those reporting
What are the differences among non-
abuse of cocaine, hallucinogens, inhalants, and heroin.
medical use of prescriptions, misuse,
More than 14.5 million persons reported having used
abuse, physiological dependence,
prescription medications nonmedically within the past
year. Of this 14.5 million, more than 2 million were
psychological dependence (addiction),
between ages 12 and 17.
and pseudoaddiction?
Older adults are particularly vulnerable to misuse and
The Diagnostic and Statistical Manual of Mental
abuse of prescription medications. Persons ages 65 and
Disorders, 4th Edition, Text Revision (DSM-IV-TR),7 pro-
older make up only 13 percent of the population but
vides diagnostic criteria for substance abuse and substance
account for one-third of all medications prescribed,3
dependence. Counselors working with clients who use
and many of these prescriptions are for psychoactive
prescription medications, however, need to distinguish
Table 1: Drug Classes, Medical Uses, and Examples of Commonly Prescribed Medications
Drug Class
Legitimate Medical Uses
Examples of Medications
Opioid analgesics
Management of acute or chronic pain, relief
Codeine (Empirin®, Tylenol 1, 2, 3), Hydrocodone
of coughs, antidiarrheal
(Vicodin®), Hydromorphone (Dilaudid®), Meperidine
(Demerol®), Methadone (Dolophine®), Morphine, Oxycodone
(OxyContin®, Percodan®), Propoxyphene (Darvon®)
Sedative-
Anxiety and panic disorders, acute stress
Alprazolam (Xanax®), Chlordiazepoxide HCL (Librium®),
hypnotics:
reactions
Clonazepam (Klonopin®), Diazepam (Valium®), Lorazepam
Benzodiazepines
(Ativan®)
Sedative-
Insomnia, anxiety, seizure control
Butalbital (Fiorinal®), Meprobamate (Miltown®),
hypnotics:
Pentobarbital sodium (Nembutal®), Phenobarbital,
Barbiturates
Secobarbital (Seconal®)
Stimulants
Attention deficit disorder and attention deficit/ Amphetamine-dextroamphetamine (Adderall®),
hyperactivity disorder (ADD, AD/HD),
Dextroamphetamine (Dexedrine®), Methylphenidate
narcolepsy, weight loss, depression (rarely)
(Ritalin®), Sibutramine (Meridia®)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
continued on reverse...
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov

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May 2006, Volume 5, Issue 2
ADVISORY
Substance Abuse Treatment
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among nonmedical use of substances, substance misuse, abuse,
Some people obtain prescription medications illicitly and
physiological dependence, psychological dependence (also known
experiment with their effects. Others may find that a particular
as “addiction”), and pseudoaddiction. Prescription medications
drug helps them self-medicate undiagnosed or undertreated dis-
that are on the Drug Enforcement Administration’s list of con-
orders (e.g., anxiety, depression, ADD).
trolled substances have high abuse potential and can lead to physi-
How can prescription medication abuse or
ological or psychological dependence, or both, in some patients.
dependence be treated effectively?
Nonmedical use: Use of prescription drugs that were not
prescribed by a medical professional (i.e., obtained illicitly) or
People treated with any controlled medication should be moni-
use for the experience or feeling a drug causes.
tored closely for the development of a substance use disorder.
Misuse: Incorrect use of a medication by patients, who may
Physiological dependence may be the first symptom of a poten-
use a drug for a purpose other than that for which it was pre-
tial problem. While physiologically dependent, people may also
scribed, take too little or too much of a drug, take it too often,
develop symptoms of abuse or psychological dependence.
or take it for too long (misuse does not apply to off-label pre-
When the decision is made to stop medication therapy, a patient
scribing [prescribing a medication for a condition other than the
who is physiologically dependent should be expected to develop
conditions for which the Food and Drug Administration
withdrawal symptoms unless care is taken to slowly taper the
approved the medication] when such use is supported by com-
drug using a standard detoxification or withdrawal protocol.
mon medical practice, research, or rational pharmacology).
During the detoxification or withdrawal period, symptoms
Abuse: A maladaptive pattern of substance use, leading to
of abuse or psychological dependence may emerge.
clinically significant impairment or distress as manifested by
Detoxification alone is not sufficient for a person who meets
one or more behaviorally based criteria.7
DSM-IV-TR criteria for abuse or dependence. Providers should
Physiological dependence: Increasing tolerance for a drug,
use evidence-based brief interventions such as motivational
withdrawal signs and symptoms when a drug is discontinued, or
enhancement, cognitive–behavioral therapy, or 12-Step facilita-
the continued use of a substance to avoid withdrawal.
tion, along with referrals to an addiction medicine/psychiatry
Psychological dependence (addiction): A set of psychological
specialist for patients with more severe drug dependence.
symptoms that demonstrate overall loss of control or obsessive-
Patients found to be drug dependent should be assessed for
compulsive drug-seeking and continued use of a substance in spite
the correct level of care for both detoxification and treatment
of clearly adverse consequences. Symptoms may include specific
according to standards such as the American Society of
physiological signs of dependence such as increasing tolerance or
Addiction Medicine’s patient placement criteria.9 These patients
withdrawal signs and symptoms when the drug is discontinued.
also should be considered for appropriate medication-assisted
Pseudoaddiction: Drug-seeking and other behavior that is
therapy by qualified, licensed providers, such as opioid treatment
consistent with addiction but actually results from inadequate
programs or physicians with buprenorphine waivers. Recom-
pain relief. Once the pain is adequately treated, the person no
mendations for effective treatment of substance use disorders do
longer abuses the medication.8
not differentiate between prescription drug and illicit drug use
How do people become dependent on
prescription medications?
Chronic pain may complicate substance abuse treatment
Within the context of good medical care, substance misuse,
by10—
abuse, physiological dependence, and dependence/addiction are
• Motivating drug-seeking behavior.
potential treatment complications. For example, physiological
• Decreasing clients’ quality of life, which may increase
dependence is an expected outcome of long-term use of opioid
their attraction to any drug that produces euphoria.
medications for pain. A minority of patients may have predispos-
• Creating psychiatric problems, such as depression and
ing factors that lead to problems of psychological dependence
anxiety. Clients whose pain is the result of trauma may
(addiction). Drug use may quickly escalate to unintended and
have symptoms of posttraumatic stress disorder (PTSD).
initially unanticipated levels beyond the initial intended use,
• Creating functional and social disability that can impede
alarming both the patient and treatment provider.
participation and success in treatment.
2

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Prescription Medications
ADVISORY
Substance Abuse Treatment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
problems. Among these patients, alcohol abuse and dependence
Programs treating clients with addictions to prescription
also are frequently involved and must be addressed.
medications need to ensure that they have access to the fol-
The first step toward effective treatment of a substance use
lowing resources or professionals, either on site or through
disorder is screening and comprehensive assessment, including—
appropriate referral sources:
• Evaluation of how the person began using prescription
• Appropriate dose-tapering or other detoxification
medication;
services
• Medical history and evaluation to determine underlying
• Physicians, physician’s assistants, or nurse practitioners
medical issues; and
with expertise in pain management and/or pain clinics
• Screening for and, when indicated, assessment of mental
• Psychiatrists with expertise in addiction treatment and
health issues.
psychotropic medication management
Frequently, a problem that begins as prescription drug misuse
• Addiction counselors, social workers, and/or psychiatric
is complicated by illicit use of that same drug or illicit use of
nurses with experience and training in providing
another drug. Sometimes, a patient’s use of an illicit drug may
cognitive–behavioral therapy and other approaches for
evolve into dependence on a drug that is subsequently pre-
treating anxiety and panic disorders, PTSD, ADD,
scribed for him or her.
AD/HD, and eating disorders
Effective counseling and medication-assisted treatments apply
Programs also need to ensure that clients in recovery have
to all patients identified with any substance use disorder.
adequate information about working with physicians if and
However, to ensure treatment effectiveness, clients with on-
when pain or other psychoactive prescription medications
going pain and those with underlying anxiety disorders, ADD,
are needed.
AD/HD, and other mental disorders will need services beyond
standard addiction counseling. Not providing these services
ensures treatment failure.
8Savage, S.R. Opioid medications in the management of pain. In: Graham,
In summary, counselors treating individuals with prescription
A.W., Schultz, T.K., Mayo-Smith, M.F., Ries, R.K., and Wilford, B.B., eds.
Principles of Addiction Medicine, 3d Edition. Chevy Chase, MD: American
medication-related problems must use their established approaches
Society of Addiction Medicine, Inc., 2003, pp. 1451–1463.
and resources, modified or expanded to address the specific issues
9 Mee-Lee, D., ed. ASAM PPC-2R: ASAM Patient Placement Criteria for the
identified in this Advisory.
Treatment of Substance-Related Disorders, 2d Edition. Chevy Chase, MD:
American Society of Addiction Medicine, 2001.
Notes
10Trafton, J.A., Oliva, E.M., Horst, D.A., Minkel, J.D., and Humphreys, K.
1
Treatment needs associated with pain in substance use disorder patients: Impli-
Office of Applied Studies. Results from the 2004 National Survey on Drug
cations for concurrent treatment. Drug and Alcohol Dependence 72:23–31, 2004.
Use and Health: National Findings. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2005.
2
Resources for Additional Information
The National Survey on Drug Use and Health (NSDUH) defines prescription
drug abuse as using “any prescription (pain reliever, sedative, stimulant, tran-
Substance Abuse and Mental Health Services
quilizer) that was not prescribed for you or that you took only for the experience
Administration (SAMHSA)
or feeling it caused.” (See note 1.)
3National Institute on Drug Abuse. Prescription Drugs: Abuse and Addiction.
1 Choke Cherry Road
NIDA Research Report Series, NIH Publication No. 05-4881. Printed 2001,
Room 8-1054
revised August 2005. www.nida.nih.gov/ResearchReports/Prescription/
Rockville, MD 20857
prescription.html [accessed November 3, 2005].
4
Phone: 240-276-2130 (Office of Communications)
Blow, F.C. Special issues in treatment: Older adults. In: Graham, A.W.,
Schultz, T.K., Mayo-Smith, M.F., Ries, R.K., and Wilford, B.B., eds. Principles
Web: www.samhsa.gov
of Addiction Medicine, 3d Edition. Chevy Chase, MD: American Society of
Addiction Medicine, Inc., 2003, pp. 581–607.
SAMHSA’s National Clearinghouse for Alcohol
5Office of Applied Studies. The NSDUH Report: Substance Use Among Older
and Drug Information (NCADI)
Adults—2002 and 2003 Update. Rockville, MD: Substance Abuse and Mental
Phone: 800-729-6686
Health Services Administration, November 2005.
6Clark, H.W., and Bizzell, A. A federal perspective on the abuse of prescrip-
Español: 877-767-8432
tion stimulants. Psychiatric Annals 35(3):254–256, 2005.
TDD: 800-487-4889
7American Psychiatric Association. Diagnostic and Statistical Manual of
Web: www.ncadi.samhsa.gov
Mental Disorders, 4th Edition, Text Revision. Washington, DC: American
Psychiatric Association, 2000.
3

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May 2006, Volume 5, Issue 2
Substance Abuse Treatment
ADVISORY
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
National Institute on Drug Abuse (NIDA)
6001 Executive Boulevard
Substance Abuse Treatment Advisory
Bethesda, MD 20892-9561
Substance Abuse Treatment Advisory was written and produced under contract number
Phone: 301-443-1124
270-04-7049 by the Knowledge Application Program (KAP), a Joint Venture of JBS
Web: www.nida.nih.gov
International, Inc., and The CDM Group, Inc., for the Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental Health Services Administration
U.S. Food and Drug Administration (FDA)
(SAMHSA), U.S. Department of Health and Human Services (HHS). The content of this
5600 Fishers Lane
publication does not necessarily reflect the views or policies of SAMHSA or HHS.
Rockville, MD 20857-0001
Phone: 888-INFO-FDA (888-463-6332)
Public Domain Notice: All material appearing in this report is in the public domain
and may be reproduced or copied without permission; citation of the source is appreci-
Web: www.fda.gov
ated. However, this publication may not be reproduced or distributed for a fee without
SAMHSA/FDA Comprehensive Prescription
the specific, written authorization of the Office of Communications, SAMHSA, HHS.
Drug Campaign
Electronic Access and Copies of Publication: This publication can be accessed
Web: www.rx.samhsa.gov/main.htm
electronically through the Internet at www.kap.samhsa.gov. Additional free print copies
can be ordered from SAMHSA’s NCADI at 800-729-6686.
Recommended Citation: Center for Substance Abuse Treatment. Prescription
medications: Misuse, abuse, dependence, and addiction. Substance Abuse Treatment
Advisory. Volume 5, Issue 2, May 2006.
National Clearinghouse for Alcohol and Drug Information
PRSRT STD
Substance Abuse and Mental Health Services Administration
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PERMIT NO. 259
DHHS Publication No. (SMA) 06–4175
Substance Abuse Treatment Advisory
Printed 2006
Prescription Medications: Misuse, Abuse, Dependence, and Addiction

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