Tag Archives: prescription drug abuse

03/22/22

Hardwiring Young Brains

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The U.S. Department of Health and Human Services published a report in 2009, “Addressing Prescription Drug Abuse in the United States”, that noted a significant milestone was surpassed with prescription drugs. “For the first time in the U.S., drug overdose deaths outnumbered deaths due to motor vehicle crashes.” In 1999, opioids were involved in 30% of drug overdose deaths. By 2010, this had risen to 60%. Prescription opioid-related overdose deaths then outnumbered overdose deaths from all illicit drugs such as heroin and cocaine.

Opioids are getting the most attention as result of their potential to lead to an overdose, but other classes of psychotherapeutic drugs are also misused. The 2020 National Survey on Drug Use and Health (NSDUH), showed that prescription stimulants, tranquilizers or sedatives such as benzodiazepines are also misused. The 2020 NSDUH defined the misuse of prescription drugs as “use in any way not directed by a doctor, including use without a prescription of one’s own; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor.” Among people 12 and older 5.8% (16.1 million people) misused prescription psychotherapeutic drugs in 2020.

The 16.1 million people in 2020 who misused prescription psychotherapeutic drugs in the past year included 9.3 million people who misused prescription pain relievers, 6.2 million people who misused prescription tranquilizers or sedatives (including 4.8 million past year misusers of benzodiazepines), and 5.1 million people who misused prescription stimulants.

Surprisingly, the most recent information on the top abused prescription drugs was from 2016 by Statistica and 2017 by GEN, Genetic Engineering & Biotechnology News. GEN listed the top 20 abused drugs ranked by sales data, as did Statistica. The rankings according to revenue are almost identical. Not only have Statistica and GEN failed to continue their monitoring of prescription drugs in this way, I could find no other agency or organization that had done so. I wonder if the pharmaceutical companies had anything to do with this failure.

Statistica put their findings in handy chart (see above) but GEN did not. However, there was added information in the GEN article. This included a brief observation that fifteen of the top twenty drugs showed reduced overall sales from the previous year, likely from the lower prices of generics. Gen said that according to GlobalData, sales for ADHD drugs like Adderall and Concerta were projected to more than double by 2024, from $6.1 billion in 2014 to $13.9 billion. See the chart below which is composed of information in the GEN article.Eight of the listed drugs were opioids. All but five were scheduled as Controlled Substances by the DEA, meaning they have an addictive potential. Methylphenidate, an ADHD stimulant found in Ritalin, Concerta and Daytrana, was in three different drugs on the list as well as the generic drug. Zoloft (sertraline), an antidepressant SSRI, made the list in two different drug forms. Celecoxib, an arthritis treatment, was found in three drugs. Ironically, buprenorphine, one of only three drugs approved for the treatment of opioid misuse, was itself on the list of most abused prescription drugs, with only OxyContin listed ahead of it in pain reliever sales.

Reflecting on the implications of this information for drug treatment, a few questions arise. Are individuals (or parents in the case of ADHD medications) cautioned about the potential for developing an addiction when they or their children are first prescribed any of these drugs? Does the presence of medications like sertraline (Zoloft) and celecoxib on these lists point to a conundrum when they demonstrate a misuse potential but were not listed as controlled substances by the DEA? Does the reality of these medications being abused raise concerns for other medications in the same drug class?

According to ClinCalc, Zoloft was the 12th most prescribed drug, with 7.7 million patients and 37.2 prescriptions. Forbes said it was often a first line medication for depression, anxiety and PTSD. None of the above abused drugs had more total prescriptions. Zoloft and other antidepressants like it are beginning to be viewed as addictive, so we may see more SSRIs on future most abused prescription drug lists. Long-term users seem to go through withdrawal when stopped too abruptly. See “Are Antidepressants Worth the Risk?”

Misuse of Prescription Drugs by Class

Returning to the 2020 NSDUH, the report also gave information on the misuse of prescription stimulants, tranquilizer or sedative misuse, benzodiazepine misuse and pain reliever misuse.

Prescription stimulant misuse included amphetamine (i.e., Adderall XR) and methylphenidate (i.e., Ritalin, Concerta, Daytrana) products. Among people aged 12 and older, 1.8 percent of the population (or 5.1 million people) misused prescription stimulants in the past year. The percentage was highest among young adults aged 18 to 25 at 4.8% (or 1.6 million people). All other age categories hovered between 1 and 2 percent.

For the most part, prescription stimulants to treat ADHD are Schedule II controlled substances. To what extent does their use as the child’s brain develops lead to substance abuse disorders in later years? See the figure below.

Tranquilizer or sedative misuse included benzodiazepine tranquilizers such as alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin) or diazepam (Valium), and muscle relaxants. Among people aged 12 and older, 2.2% (or 6.2 million people) misused tranquilizers or sedatives in the past year. Again, young adults had the highest percentage of misusers with 3.7% (or 1.2 million people).

Benzodiazepines are chemically similar regardless of whether they are prescribed as a sedative or a tranquilizer. Xanax, which is prescribed as a tranquilizer, has an average half-life of 11.2 hours (the length of time for half the dosage to be metabolized). Halcion, a benzodiazepine prescribed as a sedative, has a short half-life of between 1.5 and 5.5 hours. Research had shown that benzodiazepines with a short half-life have a greater dependency potential. Young adults once again had the highest percent of misusers 3.3% (or 1.1 million people).

Digging deeper into pain reliever misuse, the 2020 NSDUH asked respondents to identify specific pain relievers they used over the past year, and then categorized them into subtypes, such as hydrocodone or oxycodone products. Hydrocodone products such as Vicodin, Lortab, Norco, Zohydro ER and generic hydrocodone were the most commonly misused. Among people 12 and older, 1.7% (or 4.7 million people) misused them. There were 1.1% (or 3.2 million people) who misused oxycodone products such as OxyContin, Percocet, Percodan, Roxicodone and generic oxycodone.

No surprise, young adults aged 18 to 25 had the highest percentage of misuse with 4.1% (or 1.4 million people), followed by adults 26 and older with 3.4% (or 7.5 million people). A question arises at this point with regard to young adults. Given the evident pattern with young adults having the greatest potential to develop problems of misuse with stimulants, tranquilizers benzodiazepines and pain relievers, are they cautioned of this potential when they are first prescribed the medications?

Another way of looking at pain reliever misuse noted .1% of people 12 and older misused prescription fentanyl products. This will likely underrepresent people who used and misused illicitly manufactured fentanyl (IMF) from illegal laboratories; and will not include those who used IMF mixed with heroin or sold as heroin (but only contained IMF). The following figure compares past year pain reliever misuse among people 12 and older by the selected pain reliever subtype.

The 2020 NSDUH researchers presented the above data, and then stated that while prescription pain relievers were the second most common form of illicit drug use in 2020, “most past year users of prescription pain relievers did not misuse them in the past year.” They singled out buprenorphine, a Schedule III opioid used as an FDA approved medication for opioid misuse. Then they said the 26.5% of people who reported misusing buprenorphine over the past year meant: “Almost three fourths of past year users of buprenorphine products did not misuse them in that period.”

Another way to present this data is to say that of the .2% of people who go to a doctor for a buprenorphine prescription, supposedly to help them manage or stop their opioid misuse disorder, over 25% reported they misused their buprenorphine in the past year. There is a higher percentage of people admitting they misused buprenorphine than any of the other pain reliever subtypes.

Or you can sort the pain reliever subtypes according to their DEA scheduling as controlled substances.  See the chart below. Misuse with Schedule II pain relievers ranges from 8.9% with morphine to 16.6% with hydromorphone. Schedule IV or Schedule V pain relievers, codeine, at 12.2% and tramadol at 9.0% have noticeably lower misuse percentages, while buprenorphine significantly stands above them all with 26.5% misusing it. Remember it was 4th or 5th in the above noted lists of the most abused drugs in 2016 and 2017. What’s going on?

Despite buprenorphine being a Controlled Substance, it is a prescription drug used to treat opioid misuse disorder. This means it activates the same opioid receptors in the brain that the other opioid drugs above do. The effects may not be the same as with OxyContin or heroin, but it’s still an opioid. The people using buprenorphine for medication-assisted treatment (MAT) already have a history of abusing opioids. Apparently more than 25% of them can’t resist the temptation to abuse the very drug they’re supposed to be using to stop their addictive use of opioids.

Future NSDUH surveys will need to monitor this conundrum with buprenorphine, but the above review of the 2020 NSDUH revealed a concerning age-related problem with prescription drugs. There was a pattern of young adults having the highest frequency of prescription drug misuse with all categories—stimulants, pain relievers, benzodiazepines and tranquilizers. SAMHSA (Substance Abuse and Mental Health Services Administration) stated that the fastest growing drug-related problem with teenagers was prescription drugs. This has the potential to result in life-long challenges with addiction.

Our brains continue to develop until we reach our early- to mid-twenties. During adolescence, the pre-frontal cortex further develops to enable us to set priorities, formulate strategies, allocate attention, and control impulses. The outer mantle of the brain also experiences a burst of development, helping us to become more sophisticated at processing abstract information and understanding rules, laws, and codes of social conduct. Drug use impacts perception—a skill adolescent brains are actively trying to cultivate—and can fracture developing neural pathways. Additionally, as our brains are becoming hardwired during adolescence, the pathways being reinforced are the ones that stick. If those pathways include addiction, the impact may lead to life-long challenges.

04/14/17

An Opioid Shell Game

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Heroin sales and overdoses get a significant mount of attention, but we need to also remember that since 2002, the number of deaths related to controlled prescription drugs (CPD) have outpaced those for cocaine and heroin COMBINED. And the number of individuals who report current use of CPDs is more than those reporting use of cocaine, heroin, methamphetamine, MDMD and PCP (phencyclidine) combined. Each day, 129 individuals die from a drug overdose in the U.S. And yes, five of the seven most prescribed CPDs are opioids. The other two are amphetamine (i.e., Adderall) and methylphenidate (i.e., Ritalin and Concerta).

This information was taken from a yearly statistical summary published by the DEA called the National Drug Threat Assessment (NDTA). The 2016 NDTA Summary covers a wide range of data and classes of drugs. There’s even information on the various drug cartels operating in the U.S. This article will focus on CPDs.

The first figure (Figure 26) gives a comparison of the drug poisoning deaths for prescription drugs, cocaine and heroin from 2007 to 2014. Then Figure 29 shows the top five CPDs distributed nationwide in the BILLIONS of dosage units. Far and away from all the other CPDs, hydrocodone and oxycodone are the most prescribed drugs in the U.S. Both of these figures were taken from the 2016 NDTA Summary.

Not surprisingly, the number of admissions to publically funded treatment facilities for non-heroin opiate/synthetic abuse was 24% higher in 2013 than in 2008. The number of admissions has declined since 2011, but that has been offset by an increase in heroin use between 2011 and 2013.

Recently there has been an increase in the abuse of stimulant medications, specifically amphetamine. Between 2006 and 2011 the nonmedical use of Adderall increased by 67%.  Emergency department visits related to Adderall almost tripled between 2005 and 2010. Misuse of ADHD medications as a class resulted in a 76% increase in poison control interventions from 2005 to 2010.

Young adults 18-25 years old represent the majority of the increase in Emergency Department visits, despite children comprising the largest subset of ADHD diagnoses. Many high school and college age students display limited knowledge of either the side effects or the addictive nature of Adderall. This coincides with the popular reputation of the drug on college campuses as a study-aid to improve concentration, and not something harmful or addictive. This contributes to the increased rate of non-medical use among adults.

Looking at concerns with prescription drug use and misuse from another perspective, a report by Quest Diagnostics suggested many Americans are misusing their prescription drugs. In their 2016 Prescription Drug Monitoring Report, Quest Diagnostics found that 54% of patient specimens showed signs of prescription drug misuse. For the purposes of their analysis, a consistent result was when a patient was taking a prescribed drug appropriately. An inconsistent result meant the patient was either not taking their prescribed drug, was taking drugs in addition to those that were prescribed, or was taking drugs that hadn’t been prescribed to them. These three combined causes of “inconsistent test results” indicated potential drug misuse in the Quest report.

About 45% of the inconsistent specimens showed evidence of patients taking drugs in addition to what was prescribed to them, “suggesting the potential for dangerous drug combinations in a sizeable number of patients.” This 2015 finding was considerably higher than other years. STAT News quoted Quest’s medical affairs director as saying, ““The discovery that a growing percentage of people are combining drugs without their physician’s knowledge is deeply troubling, given the dangers.” Of particular concern is the combination of opioids and sedatives, which can lead to respiratory depression, coma and death. The following graphic was taken from the Quest Diagnostics report.

Quest also examined the drug groups associated with the highest number of inconsistencies, by age groups. Unfortunately, given their composite sense of “inconsistent test results,” it is not clear what caused the top inconsistent drug classes. For example, we can speculate that in the under age 10 category, the top two drug inconsistent classes (amphetamine and methylphenidate) were likely due to no drug found, meaning those children were prescribed, but not taking their ADHD medications. The same can be said for the various places that “marijuana metabolite” appeared. However, the inconsistent classes for benzodiazepines, opiates and oxycodone are not distinguished by cause. So while benzodiazepines are noted as the top inconsistent drug class for every age group over 25, it is not clear if that meant they were taken in addition to what was prescribed or not.

One exception to this was with heroin and benzodiazepines. Quest found 1.56% of their tests were positive for heroin. Among adults who tested positive for heroin, 28.6% were also positive for benzodiazepines. Among those who combined these two drugs, 92.3% of the benzodiazepines were not prescribed.

The Fix, an addiction and recovery website, enlisted Peter Grinspoon, the author of Free Refills: A Doctor Confronts His Addiction, to look at the study. Dr. Grinspoon observed that Quest Diagnostics is in the business of doing urine drug testing, so they are interested in promoting drug testing. He went on to say:

Drug tests simply aren’t that accurate. They’re subject to human and lab error, and are rife with both false positives and false negatives. Savvy drug users can outsmart these tests. Any drug testing needs to be interpreted in the context of who is using the drug and why they are using it.

It is true that Quest Diagnostics makes money by increasing the amount of urine testing it does; that it is interested in promoting and highlighting drug-testing. But this was the fifth Prescription Drug Monitoring Report done by Quest. Additionally, Quest provides testing services to about half of all physicians and hospitals in the U.S. So the claim in the report, that it is “well positioned to identify trends in prescription drug monitoring and misuse” is legitimate.

Further, Dr. Grinspoon’s comments on the inaccuracy of urine testing seem overstated. Yes, there are false positives and negatives; and labs can make mistakes. But he gave the impression these errors happen so often that drug testing was a questionable, unreliable procedure. The FDA, among other sources, considers laboratory testing of urine samples to be the most reliable way to confirm drugs of abuse.

He also seems to assume the testing in the Quest report included drug users given urines as part of their treatment within drug treatment programs, which is not the case. Quest specifically stated that drug rehabilitation clinics and addiction specialists were excluded from the analysis “given the higher rates of testing and potentially higher rates of inconsistency.” There is no reason for a drug user to want to outsmart a urine test done in conjunction with their ongoing medical treatment that I can imagine.

The bottom line is that I think the Quest Prescription Drug Monitoring Report still provides helpful and valuable information on the dangerous practice of combining prescription medications. But prescription drug misuse is just one third of a kind if opioid shell game. Along with heroin and fentanyl, it keeps us trying to guess where the next opioid crisis will be.

06/16/14

Killing Us Softly with Prescription Drugs

And now, the top five abused prescription drugs of 2013 are: 1) OxyContin®, 2) Suboxone®, 3) Concerta, 4) Ambien and 5) Ritalin. Rounding out the top ten are: 6) Zoloft, 7) Lunesta, 8) Adderal XR, 9) Opana® ER, and 10) Xanax.  Three of the top ten are prescribed for ADHD; two are prescribed for pain relief; another two are sleep aides. Plus there is a tranquilizer, an antidepressant and AN OPIOID MAINTENANCE DRUG! Don’t get me started about that one (Suboxone; buprenorphine). Well it’s actually too late to say that. See “Is Buprenorphine Just a New Head for the Hydra of Opiate Addiction?”

See a list of the top 17 abused prescription drugs here.

The website from which the information on the top abused prescription drugs was taken, GeneticEngineering & Biotechnology News also took a poll of its readers on whether the government should move to put limits on the availability and use of pain and mood-altering drugs. 52.7% said yes; 47.3% said no. It amazes me that the vote was so evenly split. I would have liked to see a higher percentage of yeses.  Let’s look at some further information on the abuse of prescription drugs and then ask that question again.

For several years, the nonmedical use of prescription drugs has been the second most commonly abused illicit substance after marijuana. The rankings of most frequently abused illicit drugs for 2012 are: marijuana, pain relievers, tranquilizers, cocaine, stimulants, ecstasy, methamphetamine and THEN heroin. See my “2012 National Drug Use Summary” for more information.

Let’s look at some straight up statistics from the Center for Disease Control (CDC). The drug overdose death rate per 100,000 was approximately 1.0 in 1970. By 2007 that rate had risen to 9.18. The following graphic (to the left)  is from the Office of National Drug Control Policy report on “Prescription Drug Abuse.”

There are now more unintentional overdose deaths from opioids than cocaine and heroin COMBINED, as illustrated by the additional graphic, also from the Office of National Drug Control Policy report on “Prescription Drug Abuse.” (to the right)

pd_chart2-lg

pd_chart3_lg

 

 

 

 

 

 

2000

2002

2004

2009

2010

All ages

6.2

8.2

9.4

11.9

12.3

15-24

3.7

5.1

6.6

7.7

8.2

55-64

4.2

6.0

7.8

13.7

15.0

White males

8.4

11.1

12.6

16.4

16.8

White females

4.3

6.2

7.5

10.3

10.9

Black males

10.8

11.5

11.1

10.8

10.1

Black females

4.1

5.0

5.5

5.6

5.7

Further data from the CDC on death rates from opioid analgesics indicates that in the year 2000, the death rate per 100,000 of the US population for all ages was 6.2. By 2010 the rate had increased to 12.3. Among 15-24 year olds, the death rate was 3.7 in 2000 and 8.2 in 2010.  For individuals between the ages of 55 and 64, the death rate was 4.2 in 2000 and 15.0 in 2010. White male death rates have increased from 8.4 in 2000 to 16.8 in 2010; white females from 4.3 in 200 to 10.9 in 2010. Rates for Black or African American males actually fell; Black female rates had a slight increase. See the table above for selected years and demographics. Go to the CDC report for additional information.