Psychiatric Annals

Feature Article 

A Federal Perspective on the Abuse of Prescription Stimulants

H.Westley Clark, MD, JD, MPH, FASAM; Anton C. Bizzell, MD

Abstract

Prescription medications are misused and abused by a significant number of young people and adults. Even though such nonmedical use represents a relatively small percentage of all use of these medications, as recent indicators suggest, the misuse and abuse of prescription drugs is rising in the United STates, making it a significant national health issue.

The Substance Abuse and Mental Health Services Administration (SAMHSA) 2003 National Survey on Drug Use and Health (NSDUH) surveyed people 12 or older to report their illicit drug use, including their nonmedical use of prescription drugs (ie, pain relievers, tranquilizers, stimulants, sedatives). Nonmedical use is defined as the use of prescription-type drugs not prescribed for the respondent by a physician or used for the experience or feeling they caused. Nonmedical use does not include over-the-counter drugs.1

In 2003, the NSDUH estimates that 31.2 million people 12 or older (13%) had used prescription pain relievers non-medically at least once in their lifetime.1 According to SAMHSA, the number of people in 2003 who used prescription pain medications non-medically in the previous month was approximately 4.7 million; this was followed by tranquilizers (1.8 million), stimulants (1.2 million), and sedatives (0.3 million). The past-month use of stimulants increased from 761,000 in 2002 to 1.8 million in 2003, representing a 136.5% increase.1

The NSDUH further reports that in 2003, 20.8 million Americans 12 or older had used prescription-type stimulants nonmedically at least once in their lifetime. This estimate includes 4.0% of those 12 to 17 (more than 1 million people), 10.8% of those ages 18 to 25 (3.4 million people), and 9.0% people 26 or older (16.4 million people). An estimated 1.2 million people 12 or older reported past-month stimulant use in 2003. In 2003, an estimated 378,000 people in the US met the diagnostic criteria for dependence on or abuse of stimulants in the past year. Past-year dependence on or abuse of stimulants was most prevalent among people 12 to 17 and 18 to 25 (0.4% in each age group).1

Such nontherapeutic use and abuse is associated with a variety of adverse health and social consequences. As measured by SAMHSA's Drug Abuse Warning Network, overdoses and toxic reactions are the most often cited reasons for drug-related emergency department visits. Other medical emergencies arise from the interactions of multiple drugs (prescribed or illicit) used concurrently. Such interactions can produce life-threatening conditions, including respiratory depression, hypertension or hypotension, seizures, cardiovascular collapse, and death.

The fact that a small portion of prescription medications are prescribed inappropriately by physicians and misused or abused by patients and others raises an important policy dilemma. How can we make such medications readily available for therapeutic use while limiting access for nontherapeutic misuse or abuse?2 Such a dilemma poses challenges very different from those raised by illicit drugs, because control of prescription drugs must be achieved without impeding patients' access to needed medical care.

In pursuit of these dual objectives, SAMHSA is examining several possible strategies to improve the therapeutic use of drugs with abuse potential and to reduce the nontherapeutic use of these important medications.

At a policy level, SAMHSA works to ensure that science, rather than ideology or anecdote, forms the foundation for the addiction treatment system in the United States. SAMHSA and its component centers serve health professionals and the public by disseminating scientifically sound, clinically relevant information on best practices in the treatment of addictive disorders, and by working to enhance public acceptance of that treatment.

While medication misuse or abuse potentially is a problem for anyone who takes a prescription medication, it is of greatest concern for several groups identified by SAMHSA…

Prescription medications are misused and abused by a significant number of young people and adults. Even though such nonmedical use represents a relatively small percentage of all use of these medications, as recent indicators suggest, the misuse and abuse of prescription drugs is rising in the United STates, making it a significant national health issue.

The Substance Abuse and Mental Health Services Administration (SAMHSA) 2003 National Survey on Drug Use and Health (NSDUH) surveyed people 12 or older to report their illicit drug use, including their nonmedical use of prescription drugs (ie, pain relievers, tranquilizers, stimulants, sedatives). Nonmedical use is defined as the use of prescription-type drugs not prescribed for the respondent by a physician or used for the experience or feeling they caused. Nonmedical use does not include over-the-counter drugs.1

In 2003, the NSDUH estimates that 31.2 million people 12 or older (13%) had used prescription pain relievers non-medically at least once in their lifetime.1 According to SAMHSA, the number of people in 2003 who used prescription pain medications non-medically in the previous month was approximately 4.7 million; this was followed by tranquilizers (1.8 million), stimulants (1.2 million), and sedatives (0.3 million). The past-month use of stimulants increased from 761,000 in 2002 to 1.8 million in 2003, representing a 136.5% increase.1

The NSDUH further reports that in 2003, 20.8 million Americans 12 or older had used prescription-type stimulants nonmedically at least once in their lifetime. This estimate includes 4.0% of those 12 to 17 (more than 1 million people), 10.8% of those ages 18 to 25 (3.4 million people), and 9.0% people 26 or older (16.4 million people). An estimated 1.2 million people 12 or older reported past-month stimulant use in 2003. In 2003, an estimated 378,000 people in the US met the diagnostic criteria for dependence on or abuse of stimulants in the past year. Past-year dependence on or abuse of stimulants was most prevalent among people 12 to 17 and 18 to 25 (0.4% in each age group).1

Such nontherapeutic use and abuse is associated with a variety of adverse health and social consequences. As measured by SAMHSA's Drug Abuse Warning Network, overdoses and toxic reactions are the most often cited reasons for drug-related emergency department visits. Other medical emergencies arise from the interactions of multiple drugs (prescribed or illicit) used concurrently. Such interactions can produce life-threatening conditions, including respiratory depression, hypertension or hypotension, seizures, cardiovascular collapse, and death.

The fact that a small portion of prescription medications are prescribed inappropriately by physicians and misused or abused by patients and others raises an important policy dilemma. How can we make such medications readily available for therapeutic use while limiting access for nontherapeutic misuse or abuse?2 Such a dilemma poses challenges very different from those raised by illicit drugs, because control of prescription drugs must be achieved without impeding patients' access to needed medical care.

In pursuit of these dual objectives, SAMHSA is examining several possible strategies to improve the therapeutic use of drugs with abuse potential and to reduce the nontherapeutic use of these important medications.

Prescription Drug Initiative

At a policy level, SAMHSA works to ensure that science, rather than ideology or anecdote, forms the foundation for the addiction treatment system in the United States. SAMHSA and its component centers serve health professionals and the public by disseminating scientifically sound, clinically relevant information on best practices in the treatment of addictive disorders, and by working to enhance public acceptance of that treatment.

While medication misuse or abuse potentially is a problem for anyone who takes a prescription medication, it is of greatest concern for several groups identified by SAMHSA as high-priority populations — older adults, people with cooccurring disorders (including attention-deficit/hyperactivity disorder), pregnant and parenting women, and adolescents. Each of these groups would benefit from a full continuum of programs on medication misuse and abuse, involving prevention, intervention, treatment, and recovery support services.

The dilemma in crafting programs to prevent prescription drug misuse and abuse is that the same substance can be both a very effective medicine and a dangerous addictive drug. In designing its initiative on prescription drugs, SAMHSA draws on more than 35 years of research and practice in developing prevention and intervention efforts at the federal, state, and local levels.

The framework most widely used today was developed by the Institute of Medicine (IOM). The IOM system classifies approaches according to the populations they affect, and helps planners match the needs of targeted groups with specific program objectives and formats. In essence, the IOM system can be used to provide both a conceptual and an organizational scheme for identifying risk groups, designing programs, and targeting outcomes. These IOM categories are applicable to interventions that address the therapeutic and nontherapeutic uses of prescription drugs:

  • Universal interventions target general populations without regard to those who may be at particular risk. All youth and adults — not just specific individuals or groups within a community — would benefit from a universal intervention such as a media campaign urging young people not to share prescribed medications.
  • Selective interventions target population groups who are at greater-than-average risk. Planners can identify targeted groups on the basis of the nature and number of risk factors to which a group may be exposed. For example, research on risk and protective factors among adolescents suggests those who lack a stable family environment, or who are performing poorly in school, may be at higher-than-average risk for problems with prescription stimulants and other drugs (including alcohol).
  • Indicated interventions are aimed at individuals who already display early signs of problems. They are designed to prevent escalation in the severity and consequences of the problem. For example, indicators of high-risk behaviors are seen in adolescents who make early requests for refills or report “lost” medications, and those who use prescribed medications in combination with illicit drugs or alcohol.

Principles Guiding Federal Response

In May 2003, SAMHSA responded to reports of increasing abuse of a particular prescription medication (methadone) by convening a multidisciplinary group of more than 70 experts, including representatives of various federal and state agencies, researchers, epidemiologists, pathologists, toxicologists, medical examiners, coroners, pain management specialists, addiction medicine experts, and others, to conduct a national assessment.5 Participants presented and carefully reviewed the available data on the drug's formulation, distribution, and patterns of prescribing and dispensing, as well as the relevant data on drug toxicology and drug-associated morbidity and mortality.

Based on their examination, they arrived at consensus on a number of important recommendations to address the problem. While directed specifically at methadone, these recommendations have resonance for SAMHSA's approach to the broader problem of prescription drug misuse and abuse. The recommendations are listed in the Sidebar.

Sidebar.

SAMHSA Recommendations for Approaching Prescription Drug Misuse and Abuse

Uniform Definitions Should Be Established. Professional organizations need to agree on a uniform nomenclature that clearly distinguishes between the expected consequences of physiologic dependence and drug tolerance (which occur with many commonly used medications) and the phenomenon of addiction (which is a chronic, relapsing, neurobiological disorder with behavioral manifestations).

More Useful Data Are Needed. Overall, more flexibility is needed in the design of data sets and the conduct of data analyses, as are better methods of integrating data from multiple collection systems.

Health Professionals Need Better Training. Physicians and other health professionals must be well-grounded in their knowledge of pharmacotherapies for all types of medical disorders. Such training should be part of the core educational curricula for all health care professionals.In particular, physicians need to understand the pharmacology and appropriate use of drugs with abuse potential, as well as specific indications and cautions to consider when deciding whether to use such medications in a particular patient.

Patients and the Public Need Accurate Information. Better information also is needed about the nature of education and prevention messages currently being communicated to and by the public, patients, and the media.Given inaccurate or incomplete information, patients may be deterred from seeking treatment for legitimate medical problems.

Public Policies Must Respond to Multiple Needs. Public policies must respond to the imperative to protect society from unfettered use of drugs that can cause illness and death, but neither public policies nor regulatory concerns should impede patients' access to medically indicated use of medications-even those with abuse potential.

SAMHSA's response also supports the President's overall drug policies. For example, in releasing the Nation's 2004 National Drug Control Strategy — the first to explicitly address the problem of prescription drug abuse — John P. Walters, director of the Office of National Drug Control Policy, noted:

“The nonmedical use of dangerous prescription substances threatens the integrity of medical practice as well as has become an important and dangerous source of addiction in this country ... Our effort is to provide a balanced approach focusing on prevention, treatment and enforcement actions that will reduce the demand, as well as the supply, of these substances for abuse ... “For diverted and abused pharmaceuticals, our prevention efforts include awareness campaigns for patients about the real risks of the nonmedical abuse of these legitimate medicines. Better warnings and labeling of medication will help reduce this risk. In addition, we are crafting education and risk management curricula to alert and educate physicians and pharmacists about proper prescribing practices and how abusers manipulate the system.”6

SAMHSA's programs to address prescription drug misuse and abuse reflect the strategy above, as well as the agency's mission to effect a full, rewarding life in the community for everyone. Consistent with this strategy is SAMHSA's involvement in a special Federal Synthetic Drug Working Group that discusses the status of current efforts in prevention, treatment, law enforcement, and regulatory measures involving prescription and synthetic drugs.

In an effort to collaborate and coordinate the President's National Synthetic Drugs Action Plan, the Department of Health and Human Services, through agencies such as SAMHSA and the National Institute on Drug Abuse, is working with multiple federal agencies, including the White House Office of National Drug Control Policy; the US Department of Justice, including the Drug Enforcement Administration; the Department of Homeland Security; the US Environmental Protection Agency; and the State Department on efforts to come up with a coherent comprehensive federal response to diverted pharmaceuticals. This effort is ongoing and will produce tangible results in the near future.

References

  1. 2003 National Survey on Drug Use and Health. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Available at: http://www.oas.samhsa.gov/nhsda.htm#NHSDAinfo. Accessed February 15, 2005.
  2. Parran TV Jr, . Prescription drug abuse: A question of balance. Alcohol and Other Substance Abuse. 1997;81(4):253–978.
  3. Methadone-Associated Mortality: Report of a National Assessment, May 8–9, 2003. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment; 2004. SAMHSA Publication No. 04-3904.
  4. The President's National Drug Control Strategy. Office of National Drug Control Policy. March2004. Available at: http://www.whitehousedrugpolicy.gov/publications/policy/ndcs04/index.html. Accessed February 7, 2005.

Sidebar.

SAMHSA Recommendations for Approaching Prescription Drug Misuse and Abuse

Uniform Definitions Should Be Established. Professional organizations need to agree on a uniform nomenclature that clearly distinguishes between the expected consequences of physiologic dependence and drug tolerance (which occur with many commonly used medications) and the phenomenon of addiction (which is a chronic, relapsing, neurobiological disorder with behavioral manifestations).

More Useful Data Are Needed. Overall, more flexibility is needed in the design of data sets and the conduct of data analyses, as are better methods of integrating data from multiple collection systems.

Health Professionals Need Better Training. Physicians and other health professionals must be well-grounded in their knowledge of pharmacotherapies for all types of medical disorders. Such training should be part of the core educational curricula for all health care professionals.In particular, physicians need to understand the pharmacology and appropriate use of drugs with abuse potential, as well as specific indications and cautions to consider when deciding whether to use such medications in a particular patient.

Patients and the Public Need Accurate Information. Better information also is needed about the nature of education and prevention messages currently being communicated to and by the public, patients, and the media.Given inaccurate or incomplete information, patients may be deterred from seeking treatment for legitimate medical problems.

Public Policies Must Respond to Multiple Needs. Public policies must respond to the imperative to protect society from unfettered use of drugs that can cause illness and death, but neither public policies nor regulatory concerns should impede patients' access to medically indicated use of medications-even those with abuse potential.

Authors

Dr. Clark is director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD. Dr.Bizzell is medical director, Division of Pharmacologic Therapies, with the Center for Substance Abuse Treatment.

Address reprint requests to: Anton C. Bizzell, MD, Center for Substance Abuse Treatment, 1 Choke Cherry Road, Room 2-1067, Rockville, MD 20857; or e-mail anton.bizzell@samhsa.hhs.gov.

10.3928/00485713-20050301-09

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