U.S. Department of Education

DOCUMENT RESUME

ED 451 429 CG 030 784

TITLE Prescription Drugs: Abuse and Addiction. Research ReportSeries.

INSTITUTION National Inst. on Drug Abuse (DHHS/PHS), Rockville, MD.REPORT NO NIH-01-4881PUB DATE 2001-04-00NOTE 14p.AVAILABLE FROM National Clearinghouse for Alcohol and Drug Information,

P.O. Box 2345, Rockville, MD 20847. Tel: 800-729-6686 (TollFree); Tel: 800-487-4899 (TTD); Web site:http://www.health.org.

PUB TYPE Information Analyses (070)EDRS PRICE MF01/PC01 Plus Postage.DESCRIPTORS Adolescents; Adults; Drug Education; *Drug Use; Health

Services; Medical Services; Pharmacists; Prevention; Role;Sex Differences; *Substance Abuse

IDENTIFIERS *Prescription Drugs

ABSTRACTThis publication answers questions about the consequences of

abusing commonly prescribed medications including opioids, central nervoussystem depressants, and stimulants. In addition to offering information onwhat research says about how certain medications affect the brain and body,this publication also discusses treatment options. It examines prescriptiondrug abuse in older adults as well as in adolescents and young adults, anddiscusses sex differences in this abuse. The roles of health care providers,pharmacists, and patients in the prevention and detection of prescriptiondrug abuse are presented. This publication was developed to help health careproviders discuss the consequences of prescription drug abuse with theirpatients. According to a recent national survey of primary care physiciansand patients regarding substance abuse, 46.6% of physicians find it difficultto discuss prescription drug abuse with their patients. (MKA)

Reproductions supplied by EDRS are the best that can be madefrom the original document.

National Institute on Drug AbuseResearch Report Series

Prescription Drugs: Abuse and Addiction

U.S. DEPARTMENT OF EDUCATIONOffice of Educational Research and Improvement

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

This document has been reproduced asreceived from the person or organizationoriginating it.Minor changes have been made toimprove reproduction quality.

Points of view or opinions stated in thisdocument do not necessarily representofficial OERI position or policy.

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NATIONAL INSTITUTE ON DRUG ABUSE

Most people who take prescriptionmedications take them responsibly;however, the nonmedical use orabuse of prescription drugs remainsa serious public health concern.Certain prescription drugsopioids,central nervous system (CNS) depres-sants, and stimulantswhen abused,can alter the brain's activity andlead to dependence and possiblyaddiction.

An estimated 4 million peopleaged 12 and older used prescriptiondrugs for nonmedical reasons in1999 almost half of that numberreported using prescription drugsnonmedically for the first time in theprevious year. We would like to reversethis trend by increasing awarenessand promoting additional researchon this topic.

The National Institute on DrugAbuse (NIDA) has developed this pub-lication to answer questions aboutthe consequences of abusing com-monly prescribed medications. Inaddition to offering information onwhat research has taught us abouthow certain medications affect thebrain and body, this publication alsodiscusses treatment options.

This publication was developed tohelp health care providers discuss theconsequences of prescription drugabuse with their patients. Accordingto a recent national survey of primarycare physicians and patients regard-ing substance abuse, 46.6 percent ofphysicians find it difficult to discussprescription drug abuse with theirpatients.

Prescription drug abuse is not anew problem, but one that deservesrenewed attention. We hope thisscientific report is useful to the public,particularly to individuals workingwith the elderly, who because of thenumber of medications they may take

for various medical conditions, maybe more vulnerable to misuse orabuse of prescribed medications.

Alan I. Leshner, Ph.D.DirectorNational Institute on Drug Abuse

rch ReportSERIES

Abuseand Addiction

What are someof the commonlyabused prescriptiondrugs?

Although many pre-scription drugs canbe abused or misused,

there are three classes ofprescription drugs that aremost commonly abused:

Opioids, which are mostoften prescribed to treatpain;CNS depressants, whichare used to treat anxietyand sleep disorders;

U.S. Department of Health and Human Services

Stimulants, which areprescribed to treat thesleep disorder narcolepsy,attention-deficit hyper-activity disorder (ADHD),and obesity.

OpioidsWhat are opioids?

Opioids are commonlyprescribed because oftheir effective analgesic,

or pain-relieving, properties.Medications that fall withinthis classsometimes referredto as narcoticsinclude mor-phine, codeine, and relateddrugs. Morphine, for example,is often used before or aftersurgery to alleviate severepain. Codeine, because it isless efficacious than morphine,is used for milder pain. Otherexamples of opioids that canbe prescribed to alleviate paininclude oxycodone (OxyContin),propoxyphene (Darvon),hydrocodone (Vicodin), andhydromorphone (Dilaudid),

National Institutes3

of Health rAC9)

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3.0

2.5

2.0

1.5

10

Sedatives andTranquilizers

Pain Relievers

Source:, Office of Applied Studies, Substance Abuse and Mental Health Services Administration.

`.National Household Survey on Drug Abuse, 1999.

as well as meperidine(Demerol), which is usedless often because of its sideeffects. In addition to theirpain-relieving properties, someof these drugsfor example,codeine and diphenoxylate(Lomotil)can be used torelieve coughs and diarrhea.

Now do cjiioids affectthe brain and body?Opioids act by attaching tospecific proteins called opioidreceptors, which are found inthe brain, spinal cord, andgastrointestinal tract. Whenthese drugs attach to certainopioid receptors, they canblock the transmission of painmessages to the brain. Inaddition, opioids can producedrowsiness, cause constipa-tion, and, depending upon

the amount of drug taken,depress respiration. Opioiddrugs also can cause euphoriaby affecting the brain regionsthat mediate what we perceiveas pleasure.

What are the possibleconsequences of opioiduse and abuse?Chronic use of opioids canresult in tolerance for thedrugs, which means that usersmust take higher doses toachieve the same initial effects.Long-term use also can leadto physical dependence andaddictionthe body adapts tothe presence of the drug, andwithdrawal symptoms occurif use is reduced or stopped.Symptoms of withdrawalinclude restlessness, muscleand bone pain, insomnia,

4

diarrhea, vomiting, cold flasheswith goose bumps ("coldturkey"), and involuntary legmovements. Finally, taking alarge single dose of an opioidcould cause severe respiratorydepression that can lead todeath. Many studies haveshown, however, that properlymanaged medical use of opi-oid analgesic drugs is safe andrarely causes clinical addiction,defined as compulsive, oftenuncontrollable use of drugs.Taken exactly as prescribed,opioids can be used to man-age pain effectively.

Is it safe to useopioid drugs withother medications?Opioids are safe to usewith other drugs only undera physician's supervision.Typically, they should not beused with other substancesthat depress the centralnervous system, such asalcohol, antihistamines,barbiturates, benzodiazepines,or general anesthetics, assuch a combination increasesthe risk of life-threateningrespiratory depression.

CNS depressantsWhat are CNS depressants?

CNS depressants aresubstances that can slownormal brain function.

Because of this property, someCNS depressants are useful inthe treatment of anxiety andsleep disorders. Among themedications that are commonly


prescribed for these purposesare the following:

m Barbiturates, such asmephobarbital (Mebaral)and pentobarbital sodium(Nembutal), which areused to treat anxiety, ten-sion, and sleep disorders.Benzodiazepines, suchas diazepam (Valium),chlordiazepoxide HC1(Librium), and alprazolam(Xanax), which can beprescribed to treat anxiety,acute stress reactions, andpanic attacks; the moresedating benzodiazepines,such as triazolam (Halcion)and estazolam (ProSom)can be prescribed forshort-term treatment ofsleep disorders.

In higher doses, some CNSdepressants can be used asgeneral anesthetics.

How do CNS depressantsaffect the brain and body?There are numerous CNSdepressants; most act on thebrain by affecting the neuro-transmitter gamma-aminobutyricacid (GABA). Neurotransmittersare brain chemicals that facili-tate communication betweenbrain cells. GABA works bydecreasing brain activity.Although the different classesof CNS depressants work inunique ways, ultimately itis through their ability toincrease GABA activity thatthey produce a drowsy orcalming effect that is beneficial

to those suffering from anxietyor sleep disorders.

What are the possibleconsequences of GISdepressant use and abuse?Despite their many beneficialeffects, barbiturates and ben-zodiazepines have the poten-tial for abuse and should beused only as prescribed.During the first few days oftaking a prescribed CNSdepressant, a person usuallyfeels sleepy and uncoordinat-ed, but as the body becomesaccustomed to the effects ofthe drug, these feelings beginto disappear. If one uses thesedrugs long term, the body willdevelop tolerance for thedrugs, and larger doses will beneeded to achieve the sameinitial effects. In addition, con-tinued use can lead to physi-cal dependence andwhenuse is reduced or stoppedwithdrawal. Because all CNSdepressants work by slowingthe brain's activity, when anindividual stops taking them,the brain's activity can reboundand race out of control, possi-bly leading to seizures andother harmful consequences.Although withdrawal frombenzodiazepines can be prob-lematic, it is rarely life threat-ening, whereas withdrawalfrom prolonged use of otherCNS depressants can havelife-threatening complications.Therefore, someone who isthinking about discontinuingCNS-depressant therapy orwho is suffering withdrawal

5

from a CNS depressant shouldspeak with a physician or seekmedical treatment.

Is it safe to use CNSdepressants with othermedications?CNS depressants should beused with other medicationsonly under a physician'ssupervision. Typically, theyshould not be combined withany other medication or sub-stance that causes CNS depres-sion, including prescriptionpain medicines, some over-the-counter cold and allergymedications, or alcohol. UsingCNS depressants with theseother substancesparticularlyalcoholcan slow breathing,or slow both the heart andrespiration, and possibly leadto death.

StimulantsWhat are stimulants?

As the name suggests,stimulants are a class ofdrugs that enhance brain

activitythey cause an increasein alertness, attention, andenergy that is accompanied byelevated blood pressure andincreased heart rate and respi-ration. Stimulants were usedhistorically to treat asthma andother respiratory problems,obesity, neurological disorders,and a variety of other ailments.But as their potential for abuseand addiction became apparent,the medical use of stimulantsbegan to wane. Now, stimulants


are prescribed for the treatmentof only a few health conditions,including narcolepsy, attention-deficit hyperactivity disorder,and depression that has notresponded to other treatments.Stimulants may be used asappetite suppressants for short-term treatment of obesity, andthey also may be used forpatients with asthma who do notrespond to other medications.

EM do stimulants affectthe brain and body?Stimulants, such as dextroam-phetamine (Dexedrine) andmethylphenidate (Rita lin),have chemical structures thatare similar to a family of keybrain neurotransmitters calledmonoamines, which includenorepinephrine and dopamine.Stimulants increase the amountof these chemicals in the brain.This, in turn, increases bloodpressure and heart rate, con-stricts blood vessels, increasesblood glucose, and opensup the pathways of the respi-ratory system. In addition,the increase in dopamine isassociated with a sense ofeuphoria that can accompanythe use of these drugs.

What are the possibleconsequences of stimu-lant use and abuse?The consequences of stimu-lant abuse can be dangerous.Although their use may notlead to physical dependenceand risk of withdrawal, stimu-lants can be addictive in thatindividuals begin to use them

compulsively. Taking high dosesof some stimulants repeatedlyover a short time can lead tofeelings of hostility or para-noia. Additionally, taking highdoses of a stimulant may resultin dangerously high bodytemperatures and an irregularheartbeat. There is also thepotential for cardiovascularfailure or lethal seizures.

Is it safe to use stimulantswith other medic basis?Stimulants should be usedwith other medications onlywhen the patient is under aphysician's supervision. Forexample, a stimulant may beprescribed to a patient takingan antidepressant. However,health care providers andpatients should be mindfulthat antidepressants enhancethe effects of a stimulant.Patients also should be awarethat stimulants should not bemixed with over-the-countercold medicines that containdecongestants, as this com-bination may cause bloodpressure to become danger-ously high or lead to irregularheart rhythms.

Trends inprescriptiondrug abuse

prescription drug abuse ison the rise in the UnitedStates. According to the

1999 National HouseholdSurvey on Drug Abuse, in1998, an estimated 1.6 million

6

Americans used prescriptionpain relievers nonmedicallyfor the first time. This repre-sents a significant increasesince the 1980s, when therewere generally fewer than500,000 first-time users peryear. From 1990 to 1998, thenumber of new users of painrelievers increased by 181 per-cent; the number of individualswho initiated tranquilizer useincreased by 132 percent; thenumber of new sedative usersincreased by 90 percent; andthe number of people initiat-ing stimulant use increased by165 percent. In total, in 1999,an estimated 4 million peoplealmost 2 percent of the popula-tion aged 12 and olderwereusing certain prescriptiondrugs nonmedically: painrelievers (2.6 million users),sedatives and tranquilizers(1.3 million users), and stimu-lants (0.9 million users).

Although prescription drugabuse affects many Americans,some trends of concern canbe seen among older adults,adolescents, and women. Inaddition, health care profes-sionalsincluding physicians,nurses, pharmacists, dentists,anesthesiologists, and veteri-nariansmay be at increasedrisk of prescription drug abusebecause of ease of access, aswell as their ability to self-prescribe drugs. In spite ofthis increased risk, recent sur-veys and research in the early1990s indicate that health careproviders probably suffer fromsubstance abuse, including,

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OPIOIDS (Morphine Derivatives)Oxycodone (OxyCantin)Propoxyphene (Darvon)Hydrocodone (Vioodin)Hydromorphone (Dilaudid)Meperidine (Demerol)Diphenoxylate (Lomobi)

CNS DEPRESSANTSBarbiturates

Mephobarbital (Mebard)Pentobarbital sodium (Nembutal)

BenzodiazepinesDiazepam (Valium)Chlordiazepoxide hydrochloride (1thrium)Alprazolam (Xanax)Triazolam (Haldon)Estazolam (ProSom)

STIMULANTSDextromphetamine (Dexedrine)Methylphenidate (Ritahn)Sibutromine hydrochloride monohydrate (Meridia)

Generally Prescribed forPostsurgical Uain reliefManagement of acute or chronic painRelief of coughs and diarrhea

In the, bodyOpioids attach to opiaid receptors in the brainand spinal cord, blocking the transmission of painmessages to the brain.

Effects of short-term useBlocked pain messagesDrowsinessConstipationDepressed respiration(depending on dose)

Effects of long-term usePotential for tolerance, physicaldependence, withdrawal, and/or addiction

Possible negative effectsSevere respiratory depression or deathfollowing a large single dose

Should not be used withOther substances that cause CNS depression, including

AlcoholAntihistaminesBarbituratesBenzodiazepinesGeneral anesthetics

Generally prescribed forAnxietyTension

Panic attacksAcute stress reactionsSleep disordersAnesthesia (at high doses)

In the bodyCNS depressants slow brain activity throughactions on the GABA system and, therefore, producea calming effect.

Effects of short-term useA -sleepy" and uncoordinated feelingduring the first few days, as the bodybecomes accustomedtolerantto theeffects, these feelings diminish.

Effects of long-term usePotential for tolerance, physicaldependence, withdrawal, and/or addiction

Possible negative effectsSeizures following a rebound in brainactivity after reducing or discontinuing use

Should not be used withOther substances that cause CNS depression, inducting

Alcohol

Prescription opioid pain medicinesSome over-the-counter cold and allergymedications

Generally prescribed forNarcolepsyAttention-deficit hyperactivity disorder (ADHD)Depression that does not respond to other treatmentShod-term treatment of obesityAsthma that does not respond to other treatment

In the bodyStimulants enhance brain activity, causing an increasein alertness, attention, and energy.

Effects of short-term useElevated blood pressureIncreased heart rateIncreased respirationSuppressed appetiteSleep deprivation

Effects of long-term usePotential for addiction

Possible negative effectsDangerously high body temperaturesor an irregular heartbeat after takinghigh dosesCardiovascular failure or lethal seizuresFor some stimulants, hostility or feelingsof paranoia after taking high dosesrepeatedly over a short period of time

Should not be used withOver-the-counter cold medicines containingdecongestantsAntidepressants, unless supervised bya physidonSome asthma medications

6NIDA RESEARCH REPORT SERIESalcohol and drugs, at a ratesimilar to rates in society asa whole, in the range of 8 to12 percent.

Older calultsData suggest that up to 17 per-cent of adults aged 60 or oldermay be affected by prescriptiondrug abuse. Elderly personsuse prescription medicationsapproximately three times asfrequently as the general pop-ulation and have been foundto have the poorest rates ofcompliance with directions fortaking a medication. In addi-tion, data from the VeteransAffairs Hospital System suggestthat elderly patients may beprescribed inappropriatelyhigh doses of medicationssuch as benzodiazepines andmay be prescribed these med-ications for longer periodsthan are younger adults. Ingeneral, older people shouldbe prescribed lower doses ofmedications, because thebody's ability to metabolizemany medications decreaseswith age.

An association between age-related morbidity and abuse ofprescription medications likelyexists. For example, elderlypersons who take benzodi-azepines are at increased riskfor falls that cause hip andthigh fractures, as well as forvehicle accidents. Cognitiveimpairment also is associatedwith benzodiazepine use,although memory impairmentmay be reversible when thedrug is discontinued. Finally,

la MarijuanaPsychotherapeutics

Inhalants

II Hallucinogens

Age 12 Age 14

Source: Office of Applied Studies, Substance Abuse and Mental Health Services Administration.National Household Survey on Drug Abuse, 1999.

use of benzodiazepines forlonger than 4 months is notrecommended for elderlypatients because of the possi-bility of physical dependence.

Adolescents andyou adultsData from the NationalHousehold Survey on DrugAbuse indicate that the mostdramatic increase in new usersof prescription drugs for non-medical purposes occurs in12- to 17-year-olds and 18- to25-year-olds. In addition, 12-to 14-year-olds reported psy-chotherapeutics (for example,painkillers or stimulants) asone of two primary drugsused. The 1999 Monitoring theFuture Survey showed that forbarbiturates, tranquilizers, andnarcotics other than heroin,the general, long-term declinesin use among young adults in

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the 1980s leveled off in theearly 1990s, with modestincreases again in the mid-tolate 1990s. For example, theuse of methylphenidate(Ritalin) among adolescentsand young adults increasedfrom an annual prevalence(use of the drug within thepreceding year) of 0.1 percentin 1992 to an annual preva-lence of 2.8 percent in 1997before reaching a plateau.According to a recent surveyby the University of Wisconsin,one in five students had usedRitalin nonmedically.

It also appears that collegestudents' nonmedical use ofpain relievers such as oxy-codone with aspirin (Percodan)and hydrocodone (Vicodin)is on the rise. The 1999 DrugAbuse Warning Network,which collects data on drug-related episodes in hospital

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NIDA RESEARCH REPORT SERIES 7emergency departments,reported that mentions ofhydrocodone as a cause forvisiting an emergency roomincreased by 37 percentamong all age groups from1997 to 1999. Mentions of thebenzodiazepine clonazepam(Klonopin) increased by 102percent since 1992.

Gendea. differencesStudies suggest that womenare more likely than men touse an abusable prescriptiondrug, particularly narcotics andanti-anxiety drugsin somecases 48 percent more likely.This may be in part becausewomen are two to three timesmore likely to be diagnosedwith depression and thusare more often treated withpsychotherapeutic drugs.

Overall, men and womenhave roughly similar rates ofnonmedical use of prescrip-

tion drugs. An exception isfound among 12- to 17-year-olds: In this age group, youngwomen are more likely thanyoung men to use psychother-apeutic drugs nonmedically.In addition, research hasshown that women and menwho use prescription opioidsare equally likely to becomeaddicted. However, amongwomen and men who usesedatives, anti-anxiety drugs,and hypnotics, women arealmost two times more likelyto become addicted.

Preventing anddetecting prescrip-tion drug abuse

Although most patientsuse medications asdirected, abuse of and

addiction to prescription drugsare public health problems for

,

Have you ever felt the need to Cut down on your use ofprescription drugs?Have you ever felt. Annoyed by remarks your friends orloved ones made about your use of prescription drugs?Have you ever felt Guilty or remorseful about your useof prescription drugs?Have you Ever used prescription drugs as a way to"get going" or to "calm down?"

Adapted from Ewing, J.A. "Detecting Alcoholism: The CAGE Questionnaire."Journal of the American Medical Association 252(141:1905-1907, 1984.

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many Americans. However,addiction rarely occurs amongthose who use pain relievers,CNS depressants, or stimulantsas prescribed; the risk foraddiction exists when thesemedications are used in waysother than as prescribed.Health care providers suchas primary care physicians,nurse practitioners, and phar-macists as well as patients canall play a role in preventingand detecting prescriptiondrug abuse.

Role of health careprovidersAbout 70 percent ofAmericansapproximately191 million peoplevisit ahealth care provider, such asa primary care physician, atleast once every 2 years. Thus,health care providers are in aunique position not only toprescribe needed medicationsappropriately, but also toidentify prescription drugabuse when it exists and helpthe patient recognize theproblem, set goals for recov-ery, and seek appropriatetreatment when necessary.Screening for any type ofsubstance abuse can beincorporated into routinehistory taking with questionsabout what prescriptions andover-the-counter medicinesthe patient is taking andwhy. Screening also can beperformed if a patient presentswith specific symptoms associ-ated with problem use of asubstance.


'It is estimated that more than 50 million Americanssuffer fromchronic pain. When treating pain, heath carei:prthiders Piave

long wrestled with a dilemma: Hot,tia.acreilluateljr refer apatient's suffering while avoidinathpotentiar kir Teriftobecome addicted to pain medication?"

Many health care providers undetprescribe painkillers becausethey overestimate the potential for patients to become addictedto medications such as morphine and codeine. Although thesedrugs carry a heightened risk of addiction. research has shownthat providers' concerns that patients will become addicted topain medication are largely unfounded. This fear of prescribingopioid pain medications is known as ..opiophobia.-

Most patients who are prescribed opioids for pain, even thoseundergoing long-term therapy, do not become addicted to thedrugs. The few patients who do develop rapid and markedtolerance for and addiction to opioids usually have a historyof psychological problems or prior substance abuse. In fact,studies have shown that abuse potential of opioid medicationsis generally low in healthy, nortdrucjobusing volunteers. Onestudy found that only 4 out of morel.than 12,000 patients whowere given opioids for ocutepairitiecame addicted. In a studyof 38 chronic pain patients, most of whom received opioids for4 to 7 years, only 2 patients became addicted, and both hada.history ofdrug..abuse.

The:issues of underprescription of opioids and the suffering ofmilli8ns of patients who do not receive adequate pain reliefhas led to the development of 'guidelines for pain treatment.11i4se guidelines may help.bting an end to underprescribing,but alternative forms of-OCtin control are still needed. NIDA-funded scientists continue to search for new ways to controlpain and to develop new pain medications that are effectivebut do not have the potential for addiction.

Over time, providers shouldnote any rapid increases inthe amount of a medication

neededwhich may indicatethe development of toleranceor frequent requests for refills

before the quantity prescribedshould have been used. Theyshould also be alert to thefact that those addicted toprescription medications mayengage in "doctor shopping,"moving from provider toprovider in an effort to getmultiple prescriptions forthe drug they abuse.

Preventing or stoppingprescription drug abuse isan important part of patientcare. However, health careproviders should not avoidprescribing or administeringstrong CNS depressantsand painkillers, if they areneeded. (See box on painand opiophobia.)Role of pharmacistsPharmacists can play a keyrole in preventing prescriptiondrug misuse and abuse byproviding clear informationand advice about how to takea medication appropriately,about the effects the medica-tion may have, and about anypossible drug interactions.Pharmacists can help preventprescription fraud or diversionby looking for false or alteredprescription forms. Many phar-macies have developed"hotlines" to alert other phar-macies in the region when afraud is detected.

Role of patientsThere are several ways thatpatients can prevent prescrip-tion drug abuse. When visitingthe doctor, provide a complete

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NIDA RESEARCH REPORT SERIES 9medical history and a descrip-tion of the reason for the visitto ensure that the doctorunderstands the complaintand can prescribe appropriatemedication. If a doctor pre-scribes a pain medication,stimulant, or CNS depressant,follow the directions for usecarefully and learn about theeffects that the drug couldhave, especially during thefirst few days during whichthe body is adapting to themedication. Also be awareof potential interactions withother drugs by reading allinformation provided by thepharmacist. Do not increaseor decrease doses or abruptlystop taking a prescriptionwithout consulting a healthcare provider first. For exam-ple, if you are taking a painreliever for chronic pain andthe medication no longerseems to be effectively con-

trolling the pain, speak withyour physician; do not increasethe dose on your own. Finally,never use another person'sprescription.

Treatingprescriptiondrug addiction

ears of research haveshown us that addictionto any drug, illicit or

prescribed, is a brain diseasethat can, like other chronicdiseases, be effectively treated.But no single type of treatmentis appropriate for all individuals.addicted to prescription drugs.Treatment must take intoaccount the type of drug usedand the needs of the individual.To be successful, treatmentmay need to incorporateseveral components, such ascounseling in conjunction with

11

a prescribed medication, andmultiple courses of treatmentmay be needed for the patientto make a full recovery.

The two main categories ofdrug addiction treatment arebehavioral and pharmacolo-gical. Behavioral treatmentsteach people how to functionwithout drugs, how to handlecravings, how to avoid drugsand situations that could leadto drug use, how to preventrelapse, and how to handlerelapse should it occur. Whendelivered effectively, behav-ioral treatmentssuch as indi-vidual counseling, group orfamily counseling, contingencymanagement, and cognitive-behavioral therapiesalso canhelp patients improve theirpersonal relationships andability to function at workand in the community.

Some addictions, such asopioid addiction, can also betreated with medications. Thesepharmacological treatmentscounter the effects of the drugon the brain and behavior.Medications also can be usedto relieve the symptoms ofwithdrawal, to treat an over-dose, or to help overcomedrug cravings.

Although a behavioral orpharmacological approachalone may be effective fortreating drug addiction,research shows that a com-bination of both, whenavailable, is most effective.


Depression Alcohol PrescriptionAbase Drug Abuse

Over 40% of physicians report having difficulty discussingsubstance abuse, including abuse of prescription drugs,with their patients. In contrast, less than 20% have difficultydiscussing depression.

National Center on Addiction and Substance Abuse at Columbia University(CASA). Missed Opportunity: Notional Survey of Primary Care Physicians andPatients on Substance Abuse. New York: CASA, 2000.

Treating addiction toprescription apioidsSeveral options are availablefor effectively treating addic-tion to prescription opioids.These options are drawnfrom experience and researchregarding the treatment ofheroin addiction. They in-clude medications, such asmethadone and LAAM(levo-alpha-acetyl-methadol),and behavioral counselingapproaches.

A useful precursor to long-term treatment of opioidaddiction is detoxification.Detoxification in itself is not

a treatment foropioid addiction.Rather, its primaryobjective is torelieve withdrawalsymptoms whilethe patient adjuststo being drug free.To be effective,detoxification mustprecede long-termtreatment thateither requirescomplete abstinenceor incorporates, amedication, such asmethadone, intothe treatment plan.

Methadone is asynthetic opioidthat blocks theeffects of heroinand other opioids,eliminates with-drawal symptoms,and relieves drug

craving. It has been usedsuccessfully for more than30 years to treat peopleaddicted to opioids. Othermedications include LAAM,an alternative to methadonethat blocks the effects of opi-oids for up to 72 hours, andnaltrexone, an opioid blockerthat is often employed forhighly motivated individualsin treatment programs pro-moting complete abstinence.Buprenorphine, another effec-tive medication, is awaitingFood and Drug Administration(FDA) approval for treatmentof opioid addiction. Finally,

12

naloxone, which counteractsthe effects of opioids, is usedto treat overdoses.

Treating addiction toMS depressantsPatients addicted to barbitu-rates and benzodiazepinesshould not attempt to stoptaking them on their own, aswithdrawal from these drugscan be problematic, and in thecase of certain CNS depressants,potentially life-threatening.Although no extensive bodyof research regarding the treat-ment of barbiturate and ben-zodiazepine addiction exists,patients addicted to thesemedications should undergomedically supervised detoxi-fication because the dosemust be gradually tapered off.Inpatient or outpatient coun-seling can help the individualduring this process. Cognitive-behavioral therapy also hasbeen used successfully tohelp individuals adapt to theremoval from benzodiazepines.

Often the abuse of barbitu-rates and benzodiazepinesoccurs in conjunction withthe abuse of another substanceor drug, such as alcohol orcocaine. In these cases ofpolydrug abuse, the treatmentapproach must address themultiple addictions.

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Tredting addiction toprescription stimulantsTreatment of addiction toprescription stimulants, suchas Rita lin, is often based onbehavioral therapies proveneffective for treating cocaineor methamphetamine addic-tion. At this time, there are noproven medications for thetreatment of stimulant addic-tion. However, antidepressantsmay help manage the symp-toms of depression that canaccompany the early days ofabstinence from stimulants.

Depending on the patient'ssituation, the first steps intreating prescription stimulantaddiction may be tapering offthe drug's dose and attempt-ing to treat withdrawal symp-toms. The detoxificationprocess could then be followedby one of many behavioraltherapies. Contingency man-agement, for example, uses asystem that enables patients toearn vouchers for drug-freeurine tests. The vouchers canbe exchanged for items thatpromote healthy living.

Another behavioral approachis cognitive-behavioral inter-vention, which focuses onmodifying the patient's think-ing, expectations, and behav-iors while at the same timeincreasing skills for copingwith various life stressors.

Recovery support groupsmay also be effective in con-junction with behavioraltherapy.

GlossaryAddidion: A chronic, relapsing disease,characterized by compulsive drug seekingand use and by neurochemical and molecularchanges in the brain.

Barbiturate: A type of central nervoussystem (CNS) depressant often prescribedto promote sleep.

Benzodiazepine: A type of (NS depressantprescribed to relieve anxiety; among the mostwidely prescribed medications, includingValium and Librium.

Buprenorphine: A new medication awaitingFDA approval for treatment of opiate addic-tion. It blocks the effects of opioids on thebrain.

Central nervous system (CNS): The brainand spinal cord.

CNS depressants: A class of drugs thatslow CNS function, some of which are used totreat anxiety and sleeping disorders; includesbarbiturates and benzodiazepines.

Detoxification: A process that allows thebody to rid itself of a drug while at the sametime managing the individual's symptoms ofwithdrawal; often the first step in a drugtreatment program.

Dopamine: A neurotransmitter present inregions of the brain that regulate movement,emotion, motivation, and feelings of pleasure.

LAAM (levo-alpha-acetyl-methadol):An approved medication for the treatment ofopiate addiction, taken 3 to 4 times a week.

Methadone: A long-acting syntheticmedication that is effective in treating opiateaddiction.

Narcolepsy: A disorder characterized byuncontrollable episodes of deep sleep.

Norepinephrine: A neurotransmitterpresent in some areas of the brain and theadrenal glands; decreases smooth musclecontraction and increases heart rate; oftenreleased in response to low blood pressureor stress.

Opioids: Controlled drugs or narcotics mostoften prescribed for the management of pain;natural or synthetic chemicals based on

13

opium's active componentmorphinethat work by mimicking the actions of pain-relieving chemicals produced in the body.

Opiophobia: A health care provider'sunfounded fear that patients will becomephysically dependent upon or addicted toopioids even when using them appropriately;can lead to the underprescribing of opioidsfor pain management.

Physical dependence: An adaptive physio-logical state that can occur with regular druguse and results in withdrawal when drug useis discontinued.

Polydrug abuse: The abuse of two or moredrugs at the same time, such as CNS depres-sant abuse accompanied by abuse of alcohol.

Prescription drug abuse: The intentionalmisuse of a medication outside of thenormally accepted standards of its use.

Prescription drug misuse: Taking a med-ication in a manner other than that prescribedor for a different condition than that for whichthe medication is prescribed.

Psychotherapeutics: Drugs that have aneffect on the function of the brain and thatoften are used to treat psychiatric disorders;can include opioids, CNS depressants, andstimulants.

Respiratory depression: Depression ofrespiration (breathing) that results in thereduced availability of oxygen to vital organs.

Stimulants: Drugs that enhance the activityof the brain and lead to increased heart rate,blood pressure, and respiration; used to treatonly a few disorders, such as narcolepsy andattention-deficit hyperactivity disorder.

Tolerance: A condition in which higher dosesof a drug are required to produce the sameeffect as experienced initially.

Tranquilizers: Drugs prescribed to promotesleep or reduce anxiety; this NationalHousehold Survey on Drug Abuse classificationincludes benzodiazepines, barbiturates, andother types of CNS depressants.

Withdrawal: A variety of symptoms thatoccur after chronic use of some drugs isreduced or stopped.

1 2 NIDA RESEARCH REPORT SERIESOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 00000000000000000oeoccomeeeeoc000eesseeee

ReferencesAmerican Psychiatric Association. Benzodiazepine

Dependence, Toxicity, and Abuse: A TaskForce Report of the American PsychiatricAssociation. Washington, DC: AmericanPsychiatric Association, 1990.

Center for Substance Abuse Treatment (CSAT).Detoxification from Alcohol and Other Drugs,Treatment Improvement Protocol (TIP) #19.Department of Health and Human Services(DHHS) Pub. No. BK0172. Substance Abuseand Mental Health Services Administration(SAMHSA),1995.

CSAT. Substance Abuse Among Older Adults,TIP #26. DHHS Pub. No. BK0250. SAMHSA,1997.

CSAT. Substance Abuse Among Older Adults(TIP #26): Physicians Guide. DHHSPub. No. (SMA) 00-3394. SAMHSA, 2000.

Hardman, J.G.; Limbird, LE; Molinoff, P.B.;Ruddon, R.W.; and Gilman, A.G., eds.Goodman & Gilman's The PharmacologicalBasis of Therapeutics 9th Ed. New York:McGraw-Hill, 1996.

Isaacson, J.H. Preventing Prescription DrugAbuse. Cleveland Clinic Journal of Medicine67(7): 473-475, 2000.

Johnston, L.D.; O'Malley, P.M.; and Bachman,J.G. Monitoring the Future: National SurveyResults on Drug Use, 1975.1999, 2 Vols.NIH Pub. No. 00-4803. National Instituteon Drug Abuse (NIDA), NIH, DHHS, 2000.

Joransson, D.E.; Ryan, K.M.; Gilson, A.M.; andDahl, J.L. Trends in medical use and abuse ofopioid analgesics. Journal of the AmericanMedical Association 283(13):1710-1714,2000.

Longo, LP., and Johnson, B. Addiction: Part I.Benzodiazepines-side effects, abuse risk,and alternatives. American Family Physician61:2121.2131, 2000.

Longo, L.P.; Parton, T.; Johnson, B.; and Kinsey,W. Addiction: Part II. Identification andmanagement of the drugseeking patient.American Family Physician 61:2401-2408,2000.

National Center on Addiction and SubstanceAbuse at Columbia University (CASA).Missed Opportunity: National Survey ofPrimary Care Physicians and Patients onSubstance Abuse. New York: CASA, 2000.

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NIDA. Principles of Drug Addiction Treatment:A Research-Based Guide. NIH Pub.

No. 99-4180. NIDA, NIH, DHHS, 1999.

NIDA NOTES. Research eases concerns aboutuse of opioids to relieve pain, NIDA NOTES15(1):12.13, 2000.

Office of Applied Studies. Substance Use AmongWomen in the United States. DHHS Pub. No.(SMA) 97-3162. SAMHSA, 1997.

Office of Applied Studies. Summary of Findingsfrom the National Household Survey on DrugAbuse. DHHS Pub. No. (SMA) 00-3466.SAMHSA, 2000.

Office of Applied Studies. Year-End 1999Emergency Department Data from the DrugAbuse Warning Network. DHHS Pub.No.(SMA) 00-3462. SAMHSA, 2000.

Patterson, IL., and Jeste, D.V. The potentialimpact of the baby-boom generation onsubstance abuse among elderly persons.Psychiatric Services 50:1184-1188, 1999.

Phillips, D.M. JCAHO pain management stan-dards are unveiled. Journal of the AmericanMedical Association 284(4):428.429, 2000.

Simoni-Wastila, L The use of abusable prescrip-tion drugs: The role of gender. Journal ofWomen's Health and Gender-based Medicine9(3):289 -297, 2000.

Snyder, S.H. Drugs and the Brain. New York:Scientific American Library, 1996.

Wilford, B.B; Finch, J.; Czechowicz, D.J.; andWarren D. An overview of prescription drugmisuse and abuse: Defining the problem andseeking solutions. Journal of law, Medicine& Ethics 22(3):197-203, 1994.

1.4

Access informationon the NIDA web site

Information onprescription drugs andother drugs of abusePublications andcommunications(including NIDA NOTES)Calendar of eventsLinks to !VIDAorganizationill unitsFunding information(including programannouncementsand deadlines)InternationalactivitiesLinks to relatedWeb sites (access toWeb sites of manyother organizations inthe field)

NIDA Web Siteswww.drugabuse.gov

www.steroidabuse.orgwww.clubdrugs.org

National Clearinghousefor Alcohol and DrugInformation (NCADI)

Web Site: www.health.orgPhone No.: 1-800-729-6686

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