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Mixed message on prescription drug abuse

by Brian Vastag, JAMA, 5/2/2001; 285 (17), 2183-2184. Originally posted 6/9/2004; Revised 6/10/2004

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The National Institute on Drug Abuse (NIDA) broadened its focus in April by launching a campaign against abuse of legally prescribed drugs. According to NIDA, 4 million people aged 12 years and older misused pain relievers, sedatives, tranquilizers, and stimulants in 1999.

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WASHINGTON-The National Institute on Drug Abuse (NIDA) broadened its focus in April by launching a campaign against abuse of legally prescribed drugs. According to NIDA, 4 million people aged 12 years and older misused pain relievers, sedatives, tranquilizers, and stimulants in 1999.

At a press conference announcing the effort to raise awareness about the dangers of these drugs, representatives from pharmacies and drug manufacturers joined NIDA director Alan 1. Leshner, PhD, at the podium. All offered obligatory support for the endeavor, which at the moment amounts to a collection of pamphlets, Web sites, and other educational materials. Lacking any fixed agenda-other than drawing the attention of the Washington media-the parade of spokespersons balked at questions about the true scope of the problem and how to remedy it.

"Determining illegitimate use is challenging," said Thomas Menighan, RPh, president of the American Pharmaceutical Association. "We can't view every patient as a potential abuser." Leshner himself seemed to undermine the message of the rally by forcefully stating, "Very, very few people who use prescription drugs develop addiction."

So what exactly is the problem? Leshner said he is alarmed by the increasing number of people who use prescription drugs nonmedically. Data from the National Household Survey on Drug Abuse, administered by the Substance Abuse and Mental Health Administration, show the number of new abusers of prescription drugs is on the rise. In 1998, an estimated 1.6 million Americans used prescription pain relievers nonmedically for the first time. In the 1980s, the survey reported there were generally fewer than 500000 first time users each year. "We're pretty confident the increase is real" and not an artifact of data collection, said Lucinda Miner, PhD, chief of science policy at NIDA.

But teasing out precise trends is difficult. The 1999 survey incorporated major changes that make it incompatible with earlier surveys, said Jim Colliver, PhD, a NIDA statistician. Colliver also said there is confusion about the figures presented at the press conference. Leshner stated that 4 million people used prescription drugs nonmedically during 1999, while the survey report actually places that figure at 93 million. The 4 million figure refers to past-month, not past-year, usage, said Colliver.

In any case, the survey does a poor job of tracking the severity of abuse, as the 1999 report does not distinguish between fleeting and chronic users. Of the 4 million-or 9.3 million, depending on the time frame, prescription drug abusers it is unclear how many used pills once, 10 times, or 100 times. [For a full examination of this issue, see Hurwitz; "The Challenge of Prescription Drug Misuse" ..alex...]

For solutions to the ill-defined problem, the press conference organizers presented a variety of views. Leshner said that he hoped "raising awareness" would lead to a decrease in prescription drug abuse and an increase in research into the issue. Other participants want better physician, patient, and pharmacist education. Ray Bullman, of the National Council for Patient Information and Education, called for the development of the "medical education team" concept, with physicians and pharmacists working together to help patients better understand their medications. Bert Spillker, MD, PhD, of the Pharmaceutical Research and Manufacturers Association, said that drug companies are committed to developing products, such as slow-release drugs, with less potential for abuse.

While some of these long-acting drugs are already on the market, they do not eliminate the potential for abuse. Front-line responders, namely pharmacists, are the ones who confront the problem most directly. They are trained to spot the signals of abuse, such as a patient filling prescriptions from multiple physicians, said Edith Rosato, RPh, of the National Association of Chain Drug Stores. But Menighan added that pharmacists need better ways to help potential abusers. "Despite our best efforts to balance our roles as health care providers and gatekeepers, we struggle with the lack of a formal process for dealing with incidents of suspected abuse," he said.

At the same time that NIDA is raising alarm bells about abuse potential, new studies point to chronic underprescribing of appropriate pain relief and a low risk of addiction to prescription drugs. At a scientific symposium following the press conference, pain management experts presented their case. "There is widespread acknowledgment that acute pain and cancer pain have been undertreated," said Richard Brown, MD, MPH, associate professor of family medicine at the University of Wisconsin Medical School. He said that upward of 17% of Americans have serious chronic pain and that many go untreated.

To gauge the extent of the problem, Brown and his colleagues developed a survey (unpublished as yet) that measured physicians' prescribing tendencies for benzodiazepines and opioids. The survey presented several variations of a single case and compared physicians' prescription decisions with recommendations from a panel of pain management experts. In all cases, the physicians underprescribed.

The most egregious underprescribing occurred with idiopathic back pain, the most common kind. While the expert panel recommended that virtually all patients with such pain-and who do not respond to other treatments-be given an opioid analgesic, only 20% of physicians said they would actually write that prescription. Orthopedic surgeons were the most prescription-averse, while oncologists were quicker with the pen. "It suggests there's a lot of unnecessary suffering," said Brown. To combat the problem, he called for increasing the amount of medical school education devoted to pain management, from the typical 2 to 4 hours to 16 or 20. Brown added that there have been strides toward greater acceptance of pain management, particularly for patients with cancer. About 95% of surveyed physicians said they would give an opioid for cancer-related pain. "That's much better than 5 or 10 years ago," he said.

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The second presentation focused on the frequency of abuse among patients taking pain relievers. In contrast to myths of yore, codeine, morphine, and their chemical cousins rarely drive patients into the ever-tightening grip of tolerance and dependency, said Steven Passik, PhD, director of Community Cancer Care Inc, Indianapolis.

A major issue, said Passik, is sorting out truly abusive or addictive behavior from borderline cases. "There is tremendous misunderstanding about the risk of addiction," he said. Preliminary data from a survey of physicians who treat chronic pain suggest that the frequency of abuse and addiction among those taking prescription drugs is the same as in the general population-about 6%.

His survey also showed that, on average, patients had 58% of their pain relieved by opioid analgesics. "They're not a panacea, but a lot of patients would take 58% to the bank," he said. And the physicians he surveyed said that they saw real improvements in overall functioning in about 80% of such patients.

With these real gains in quality of life available, putting the prescription drug abuse issue into perspective becomes a matter of numbers. NIDA says that somewhere between 4 and 9 million people misuse prescription drugs. According to Wisconsin's Brown, the number of people who could benefit from the drugs, but never get the chance to, could be even higher.



Dr. DeLuca's Addiction, Pain, and Public Health Website

Alexander DeLuca, M.D.

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Originally posted:  2004-06-09

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