Prescription medication abuse

Abuse of prescription painkillers is a public health problem that needs urgent attention. Opioid-related death in Ontario in 2004 was estimated at 27.2 per million people, which is more than 3 times that of HIV (9 per million).[1] Results from qualitative reports of BC data available at the time of writing were not generalizable. According to the United States Centers for Disease Control and Prevention (US CDC) prescription drugs were involved in 14 800 overdose deaths in 2008, more than cocaine and heroin combined.[2]

Emerging addictions
Significant attention has been paid in recent decades to reducing the smoking rate in the population—among young adults in particular—to prevent the harm related to active and passive smoking. Successes in this endeavor have been achieved; however, other types of substance abuse are on the increase. These emerging addictions have been outside of our field of attention, and in some communities their use is far more prevalent than that of smoking. In Ontario, for instance, the rate of smoking among students in grades 7 to 12 was 8.7%, whereas the rate of abusing painkillers was 15.2% (opioid 14%, oxycontin 1.2%).[3] Of importance is that 19% of students indicated fairly easy or very easy access to prescription painkillers without visiting a doctor. In 2009, 0.6% of Canadians aged 15 years and older reported having used a psychoactive pharmaceutical to get high during the past year. The use of prescription opioids to get high (with annual prevalence of 0.4%) overshadows the use of heroin (annual prevalence of 0.3%), and was greater than the use of stimulants (0.1%), and sedatives and tranquilizers (0.2%).[4]

Obtaining prescription drugs
Prescription painkillers are obtained in various ways, including given by relatives/friends for free (55%), prescribed by a doctor (17.3%), bought from relatives or friends (11.4%), taken from relatives or friends without asking (4.8%), and bought from drug dealers (4.4%).[5] 

As practising physicians in addiction clinics and detoxification centres in Vancouver, we commonly hear from our patients that they buy different types of morphine on the street. We have also noted that a significant portion of urine drug screens (UDS) are positive for drugs that are not prescribed to the patient, most commonly oxycontin and benzodiazepines. Patients obtain them in several ways: they buy the drugs on the street, they get them from family members or friends, or the drugs have been added to other illicit drugs that patients are using.

Regardless of the source of the drugs, this issue has important public health and preventive medicine implications. One concern is that all of the medications originate from a prescription. Although the majority of patients given prescriptions are aware of the potential risks and take due responsibility regarding their medications, a smaller portion do not. This smaller group can be a source of drugs for their family members, intentionally or not, or they might sell their medications or divert them so as to receive their drugs of choice. To prevent this, physicians should be mindful of such possibilities, discuss the risks with individuals who are on sensitive medications, conduct random UDS to ensure patients are taking the prescribed drugs, and conduct pill counts. Issues such as patients missing medications repeatedly, asking for increased doses often, declining to give UDS for a variety of reasons, changing their pharmacy repeatedly, obtaining medications from different prescribers, asking for carries, and regularly visiting emergency rooms are considered red flags that should prompt special attention.

Working to reduce harm
Unfortunately, a national database of prescription medications does not exist. Recent findings emphasize the importance of such a resource and its role in the prevention of prescription medication abuse and potential overdose and death. Monitoring physicians’ prescribing practices through regular audits could be an important component of reducing harm related to prescription medications. In fact, 20% of prescribers in the United States prescribe 80% of prescription painkillers.[6] Introducing new approaches through CME courses, developing guidelines, incorporating shared client care, and monitoring prescriptions can go a long way toward improving the quality of pain control while ensuring safe prescription practices among clinicians.[7]

The US CDC recommends that prescription drug monitoring programs focus their resources on two areas: first on patients at highest risk in terms of prescription painkiller dosage, numbers of controlled substance prescriptions, and numbers of prescribers; and second on prescribers who clearly deviate from accepted medical practice in terms of prescription painkiller dosage, numbers of prescriptions for controlled substances, and proportion of doctor-shoppers among their patients.[8]

Red flags: Patient behavior that should prompt special attention
•    Missing medications repeatedly.
•    Asking for increased doses often.
•    Declining to give UDS for a variety of reasons.
•    Changing their pharmacy repeatedly.
•    Obtaining medications from different prescribers. 
•    Asking for carries.
•    Regularly visiting emergency rooms.

Suggested reading
Furlan, AD, Reardon, R, Weppler, C. Opioids for chronic noncancer pain: A new Canadian practice guideline. CMAJ 2010;182:923-930.

References

1.    Statistics Canada. Age-standardized mortality rates by selected causes, by sex (both sexes). Accessed 15 August 2013. www40.statcan.gc.ca/l01/cst01/health30a-eng.htm.
2.    Centers for Disease Control and Prevention. Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011;60:1487-1492.
3.    Centre for Addiction and Mental Health. Drug use among Ontario students 1977–2011. Accessed August 2013. www.camh.ca/en/research/news_and_publications/ontario-student-drug-use-a...
4.    Health Canada. Canadian alcohol and drug use monitoring survey 2008. Accessed August 2013. http://data.library.utoronto.ca/datapub/codebooks/cstdli/cadums/2008/cad....
5.    Substance Abuse and Mental Health Services Administration. Results from the 2010 national survey on drug use and health: Summary of national findings. Accessed 27 January 2014. http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16.
6.    Dhalla IA, Mamdani MM, Sivilotti ML, et al. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ 2009;181:891-896.
7.    Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med 2005;6:107-112.
8.    Centers for Disease Control and Prevention. Policy impact: Prescription Painkiller Overdoses: What’s the issue? Accessed 26 August 2013. www.cdc.gov/homeandrecreationalsafety/rxbrief.

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Dr Siavash Jafari is a specialist in public health and preventive medicine. He is currently working as an addiction and mental health physician at the Burnaby Centre for Mental Health and Addiction and in several Vancouver Coastal Health Authority clinics. Dr Ronald Joe is a practising physician with expertise in addiction medicine. He is also the associate director of addiction programs for the Vancouver Coastal Health Authority.