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Drug Abuse
Substance abuse
A maladaptive pattern of use of a substance
Compulsive, excessive, and self-damaging use of
drugs or substances
Excessive use from a harmful drug (Overuse)
psychoactive drugs or performance enhancing
drugs for a non-therapeutic or non-medical

Drug Misuse
A term used commonly for prescription
medications with clinical efficacy but
abuse potential and known adverse
effects linked to improper use, such as
psychiatric medications with sedative,

What Prescriptions Drugs Get

opioids (main focus of this module)
Most common: hydrocodone (Vicodin), oxycodone
(Oxycontin): relief of pain

Anxiolytics: benzodiazepines (Xanax,

Valium), barbiturates (butalbital, Fiorecet):
reduce anxiety, insomnia
Stimulants: amphetamine (Adderall),
methylphenidate (Ritalin): attention deficit
disorder, Narcolepsy

Epidemiology of Prescription Drug

Misuse and Abuse

It is generally believed that

the broad availability of
prescription drugs (e.g., via
the medicine cabinet, the
Internet, and physicians) and
misperceptions about their
safety make prescription
medications particularly prone
to abuse.
Among those who abuse

Epidemiology of Prescription
Drug Misuse and Abuse
Most commonly abused classes of
prescription drugs
Opioids, such as OxyContin and Vicodin, which
are most often prescribed to treat pain;
Central nervous system (CNS)
depressants, such as Valium and Xanax,
which are used to treat anxiety and sleep
disorders; and
Stimulants, which are prescribed to treat
certain sleep disorders and attention deficit
hyperactivity disorder (ADHD), and include
drugs such as Ritalin and Adderall.

In 1932, the American Psychiatric Association:

as a general rule, we reserve the term drug abuse to apply to

the illegal, nonmedical use of a limited number of substances,
most of them drugs.

In 1966, the American Medical Association's Committee

on Alcoholism and Addiction:

Misuse applies to the physician's role in initiating a potentially

dangerous course of therapy; and 'abuse' refers to selfadministration of these drugs without medical supervision and
particularly in large doses that may lead to psychological
dependency, tolerance and abnormal behavior.

In 1973 the National Commission on Marijuana and Drug


...drug abuse may refer to any type of drug or chemical without

regard to its pharmacologic actions.

Recreational Drug Use

The use of a drug, usually psychoactive,
with the intention of creating or enhancing
recreational experience.
Often being considered to be also drug
abuse, and it is often illegal.
Also, it may overlap with other uses, such
as medicinal (including self medication),
entheogenic (spiritual).

Responsible Drug Use

A harm reduction strategy
based on a belief that illegal
recreational drug use can be
reduced or eliminated risk of
negative impact on the lives
of both the user and others.

If You Decide that Opioid Therapy

for Chronic Nonmalignant Pain is
Indicated for Your Patient

Have a Treatment Plan/Informed

Consent (documentation of
risk/benefit) on the chart
Treatment Agreement (use for those
at high risk for abuse/addiction)

If You Decide that Opioid Therapy

for Chronic Nonmalignant Pain is
Indicated for Your Patient

One physician/one pharmacy

Agreement to return for pill count when asked to do so
Medication Levels
Number/frequency of all refills
Reason for discontinuation (violation of agreement,
misuse of medication, abuse of other substances)

Informed Consent
SPECIFIC RISKS OF THE TREATMENT (longterm opioid use):

Side effects (short and long term)

Physical dependence, tolerance
Risk of drug interactions or combinations
(respiratory depression)
Risk of unintentional or intentional misuse
(abuse, addiction, death)
Legal responsibilities (disposing, sharing, selling)

If You Decide that Opioid Therapy for Chronic

Nonmalignant Pain is Indicated for Your

Check urine drug screen initially and

periodically to show:
Illicit drug use highly correlated with opioid
Confirm use of the drug youre prescribing
If patient disputes result/becomes
angry/defensive: send to lab for UDS(urine
drug screening) with MS confirmation
(more expensive and will take longer, but
most accurate (gold standard)

If You Decide that Opioid Therapy for Chronic

Nonmalignant Pain is Indicated for Your Patient

Pill counts should be part of

Should be done by licensed
personnel only
May be most useful early in
treatment and can be combined with
urine toxicology at a nursing or
pharmacist visit

If You Decide that Opioid Therapy for Chronic

Nonmalignant Pain is Indicated for Your

Periodic review:

Evidence of analgesia
Treat side effects
Enhanced social/employment functioning
Overall improved quality of life
Family assessment
Unsatisfactory: review other options

You can always get a consultation:

Pain specialists
Psychiatrist (co-occurring mental illness is
Addiction specialist

Risks/Concerns of Chronic Opioid Therapy

Causing Addiction in persons without abuse or

dependence history with opioids
Feeding an existing addiction
Causing a relapse in a patient in stable
Diversion of medication by a patient with or
without pain

None of these risks are adequately quantified for

any patient population, but they are not

Identification of Prescription
Opioid Abusers
Deterioration in
Resistance to
changes in therapy
Use of drug by
injection or nasal
Early refills
Doctor shopping

Prescription forgery
Abuse of other
Frequent retail visits
Unauthorized dose
Nonmedical use
Refuses UDS/referral
to specialist

Approaching Patient with Aberrant Medication-Taking


Take non-judgmental stance

Use open-ended questions

State your concerns about the behavior

Examine the patient for signs of flexibility

Is the patient more focused on specific opioid

or pain relief?

Approach as if they have a relative

contraindication to controlled drugs (if not
absolute contraindication)

What to do if Your Patient Develops a

Substance Use Disorder with Prescribed Opioids

Therapeutic Options:
Combination of medication treatment
plus psychosocial/psychotherapeutic
Inpatient (usually detoxification; short
term pharmacotherapy) followed by:
Intensive outpatient
Individual/Group Drug Counseling
+/- Maintenance pharmacotherapy

Know the options in your community

Treatment for Opioid

Pharmacotherapy Options (following medical
Antagonist Treatment (naltrexone)
Opioid Assisted Therapy
1. Methadone
2. Buprenorphine

Psychotherapies (motivational interviewing,

Relapse Prevention, educational groups,
substance abuse group therapy; individual
drug counseling, 12-Step)

Medical Withdrawal: Should not

be Used Alone
Use of medications to gradually
reduce physical dependence
Taper off of opioids
High relapse rate without ongoing
treatment (>90% within 1 year)

Maintenance Medications
Antagonist treatment: Naltrexone 50
mg/d (oral)
Blocks opiate agonist effects
Infrequently used:

Physician lack of knowledge of treatment

Poor acceptance by patients

Has been shown to be effective in motivated

groups (health care professionals, those in
criminal justice system)
Formulations: tablet, once a month injectable
(alcohol indication currently)
Could be difficult to implement if patient has a
pain syndrome, but could be considered if
other analgesic interventions were provided

Maintenance Medications
Most widely utilized pharmacotherapy for
opioid dependence
Schedule D drug
Specialized treatment programs must be used if
patient has opioid addiction
Restricted numbers of take-home doses
Induces tolerance to acute dose of opioid
Does not induce full tolerance to all opioid
effects (e.g. sedation at peak plasma
Reduced crime, increased employment,
improved health, decreased risk related to
diseases common to drug users (HIV, Hep C)

Maintenance Medications
Opioid partial agonist
Lower abuse liability
Schedule D
Available by prescription
Waiver needed for physician to be
able to prescribe
Allows for office-based treatment
of opioid dependence

Prescription narcotic abuse and associated
addiction increasing
Consider non-opioid treatment options for chronic
If chronic opioids are to be used:
Treatment Agreement/Informed Consent
Good documentation of treatment plan and responses
Get releases at outset for other treatment providers,
family member(s) important to therapy

Know the options for referral in your community

Effective pharmacotherapies and psychotherapies
available for substance use disorders
Some available treatments make it possible to
treat medical/mental disorders and opioid
dependence (i.e.: buprenorphine)

Thank You !