In the United States, medical drugs are developed and produced by pharmaceutical companies and legally classified in two categories: prescription and nonprescription (also called over-the-counter). The Durham-Humphrey Act of 1951, an amendment to the Federal Food, Drug, and Cosmetic Act of 1938, gave the U.S. Food and Drug Administration (FDA) authority to limit certain drugs to prescription-only status if they cannot be used safely without medical supervision. The abuse of prescription drugs refers to a range of inappropriate drug-taking behaviors, from patient nonadherence with medication regimens to compulsive drug use due to dependency. Whether a specific pattern of use is called misuse, abuse, or addiction, the nonmedical use of prescription drugs has become the fastest growing drug problem over the past two decades. Attendant to this increase in nonmedical use are increases in toxic reactions, overdoses, dependency, and death. The risk of harm from nonmedical prescription drug use varies by type of drug, how it is taken, and the reasons for use.
Nonmedical use primarily means taking a prescription drug without a prescription and medical supervision. The most popular types of prescription drugs that are used nonmedically include: opiates (e.g., oxycodone, hydrocodone, meperedine, fentanyl, methadone, and codeine); central nervous system (CNS) stimulants (e.g., amphetamines and methylphenidate); and CNS depressants (e.g., benzodiazepine tranquilizers, zolpidem, barbiturates, and other sedatives). But in reality almost any prescription drug, especially those that have psychoactive properties, can be used nonmedically and misused, and these would include antidepressants, anabolic and related steroids, human growth hormone, and many other medications.
A good indicator of which drug products are currently being used nonmedically is the Top 50 list of most prescribed medical drugs in a specific year. In 2008, among the Top 50, which include antibiotics, heart drugs, and many other types of medications, were the following prescription psychoactive drugs, which also are controlled substances: Vicodin (acetaminophen and hydrocodone), Xanax (alprazolam), Adderall XR (amphetamine and dextroamphetamine), Ambien (zolpidem), and OxyContin (oxycodone). As the number of prescriptions for certain drugs increases, the number of patients using them and number of dosages available increases, and thus more drug can be diverted to or shared with other people who do not have a prescription.
Various federal agencies support and perform regular, usually annual, surveys of illicit drug use. Occurrence of use is defined as within a lifetime (even if used only once), the past year, or the past month (all in terms of prior to the date of the survey). Past month illicit drug use of any substance, except alcohol and tobacco, in 2008 involved 20.1 million people, of which 15.2 million used marijuana, 6.2 million used prescription medications illicitly, 1.9 million used cocaine, and 0.2 million used heroin. For most illicit substances, and for alcohol and tobacco, the prevalence of use has remained relatively constant or decreased over the past decade. The prevalence of nonmedical use of prescription drugs, however, has more than doubled over the same time. The prescription drug abuse is most prevalent in the 18-25 age group. Although males are more likely than females to have misused a prescription drug at some point in their lives, differences in annual use between men and women are less pronounced, and differences in past month use are negligible.
Rates of prevalence of nonmedical prescription drug use also vary by race/ethnicity, with whites more likely than African Americans to have misused prescription drugs at least once in their life, in the past year, and in the past month. The illegal use of prescription drugs also varies by geographic regions across the country, as some prescription drugs are more popular in certain parts of the country.
The sources of supply of prescription drugs are different than for other illicit substances. Opportunities to obtain prescription drugs illegally include: valid prescriptions that are shared; theft from pharmacies; forged prescriptions; doctor shopping (for multiple prescriptions); and fraudulent practices of physicians and pharmacists. The Internet has recently become an important source of supply for obtaining prescription drugs. Many Websites offer a variety of prescription-controlled substances that can be obtained without a prescription.
In a 2007 study, specific sources of prescription opiate medications for illicit use consisted of: 70 percent obtained from relatives or friends; 19 percent obtained from a physician; 7 percent from other sources including the Internet; and only 4 percent obtained from a drug dealer. First-time illicit drug use by drug in 2008 showed that while marijuana was the most popular illicit drug for first-time users of any illicit drug (56.6 percent of all first-time users), prescription medications were the second most popular drug of choice when a person began using illicit drugs, accounting for 29.5 percent of first-time users. Inhalants (9.7 percent) and cocaine (0.8 percent) were far less popular as drugs for initiation into illicit drug use.
Emergency room (ER) visits for acute problems from nonmedical use of prescription drugs increased greatly from 2004 to 2008. In 2004 there were approximately 1.6 million ER visits due to all substances including alcohol, for a rate of 55.3 visits per 100,000 population. In 2008 the number of ER visits due to all substances increased to nearly 2 million (65.8 per 100,000). Of those visits in 2004, the number due to illicit drug use (including alcohol) was approximately 1.28 million (43.8 per 100,000), while in 2008, there were approximately 1.34 million ER visits (43.9 per 100,000).
The vast majority of the increase seen in ER visits for all substances was due specifically to prescription medications being used nonmedically. In 2004 there were 581,897 ER visits (16.1 per 100,000) and in 2008 there were 987,945 ER visits (27.6 per 100,000) for an increase over those four years of almost 70 percent. Regarding deaths due to use of a drug, as reported in the Drug Abuse Warning Network (DAWN) system, the top five drugs implicated in deaths for most cities in order from most prevalent were opiates (mostly prescription narcotics, not heroin), cocaine, alcohol, tranquilizers, and antidepressants. Thus three of the top-five drug entities identified most often in drug-related deaths were prescription medications.
Nonmedical use of prescription drugs implies use without medical supervision, for effects perhaps not approved by the FDA, and at doses and frequency of dosing greater than intended medically. Common examples of prescription drug misuse in the medical realm include: patient nonadherence with prescription directions; use of duplicate medications that produce the same effects; combining drugs with alcohol; continuing use after the original symptom or condition no longer exists; and self-medication (self-directed use of prescription medications). Beyond these examples are types of nonmedical use specifically for psychoactive effects and other reasons more pertinent to abuse and addiction.
There are many reasons for the nonmedical use of prescription drugs. The primary reason for most users is the drug's effects, knowledge of which is based on either curiosity or past experiences. Non-medical use of prescription drugs is perceived by users and society to involve less risk of harm and to produce fewer, less severe side effects. Other factors that motivate nonmedical use are: information about drug effects (from other users, mass media, and advertising); drug accessibility and availability (from increased prescribing, sharing among relatives and friends, and Internet access to “drug store” sites); a perceived lack of concern on the part of authority figures (e.g., less shame is attached to being identified as a user, and limited understanding of the legal status and implications of nonmedical use); and the influence of a media-based culture that often seems to encourage, promote, or even glorify this type of behavior. Social networks are instrumental in disseminating information and ideas about specific drug effects, supporting group use, and supplying actual drug products.
A typology of drug use, developed by the National Commission on Marihuana and Drug Abuse in 1972, is helpful in understanding the nature of prescription drug use and how and why use becomes misuse and addiction. Five types of drug-taking behaviors were described: experimental, social/recreational, circumstantial/situational, intensified, and compulsive. Experimental use is defined as short-term, nonpatterned, trial use of a drug. It is motivated by curiosity about the drug's effects. Risk to the user and society is very low and problems are few in nature and limited to acute events. Social/recreational use is patterned (but not daily) use typically occurring in a social setting.
It is considered a voluntary act, done for the drug's effects and group acceptance. Risk to the user and society is low to moderate (depending on the specific drug used, dose, and frequency of dosing), and problems can range from a low to moderate level of harmful outcomes. Circumstantial/situational use is self-limiting, patterned use for achievement of an effect (to cope with symptoms, a problem, or situation). It usually is an individual act, with a low to moderate risk to the user and society and limited problems as use ceases once the symptom or problem has been resolved.
This type of drug use is similar to self-medication practices, though with prescription drugs, self-medication occurs without medical supervision. Intensified use is long-term, patterned, daily use, in moderate to high doses, for achievement of relief from symptoms, conditions, or dependency. This type of use poses moderate to high risk to the user and society, and there is the potential for many problems. The drug and drug use become a part of the user's everyday life. In addition to abuse and addiction as examples, this type of use also represents medication use for chronic diseases (e.g., diabetes, heart disease, human immunodeficiency virus and acquired immune deficiency syndrome [HIV/AIDS]). The distinction is that intensified use under medical supervision will prevent or limit most of the risk of harm that would occur. Compulsive use is long-term, patterned, daily use, at high doses and frequency of dosing. Use is due to dependence and loss of functioning. The risks to the user and society are high and many problems likely will occur. The drug and drug use have become the central focus of the user's life.
The self-medication hypothesis, proposed by Edward Khantzian, suggests that most prescription drug users who misuse their drugs and develop dependencies initially begin use with a medical reason in mind—to treat a symptom, illness, or perceived medical problem. Use is or becomes self-directed. As a drug user's behavior escalates from the circumstantial-situational type of use (self-medication) to intensified and compulsive use, the original intent of treating a medical problem evolves into maintaining an addiction and preventing withdrawal symptoms. In addition to the general guidelines provided by the typology of drug-taking behaviors showing how less problematic use becomes abuse and addiction, there are specific indicators that can suggest or predict that a growing problem is occurring for a prescription drug user. A summary of these include the following: (1) a change in the pattern of use, typically with greater doses and increasing dosing frequencies and duration of use; (2) a shift to employing unreliable and illegal sources of supply of drug products; (3) use with a prescription that is self-directed (self-medication ignoring or without supervision) or use without a prescription; (4) development of tolerance and psychological and physical dependence; (5) a decrease or loss of beneficial effects experienced during initial, early use; and (6) use that continues after the original medical problem has been resolved.
Given the extent of prescription drug abuse and motivations to use medications for nonmedical reasons, reducing prescription drug abuse requires a comprehensive, multi-modal approach. Programs already have been developed that focus on: business outreach and consumer protection, primarily through information and awareness programs; risk management and comprehensive patient assessment programs in healthcare settings; the monitoring of Internet Websites for illegal activity and efforts with Internet service providers to control such sites; investigation of criminal activity and enforcement of current laws and regulations regarding the illegal possession and use of prescription drugs; identification and prosecution of suppliers, including unscrupulous physicians and pharmacists (primarily by implementing at the state level a Prescription Monitoring Program); education and training of health professional students and practitioners; and treatment programs designed to address the unique aspects of addiction to prescription medications.
Prescription drug abuse is recognized as a problem in American society exceeded only by the abuse of alcohol, tobacco, and marijuana. Health professional and public recognition of this still growing problem has begun to encourage rational responses to preventing or limiting nonmedical use and resulting harms. As with many types of drug “epidemics,” prescription drug abuse will decline in the future, but likely with a shift in favor of other types of drugs.
Barbiturates, Drug Abuse Warning Network, Drug Enforcement Administration, Food and Drug Administration, Policies Regulating Pharmaceutical Drugs, U.S.
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