The Prescription Drug Misuse Epidemic: Are We Making Progress?

It's clear that the war on drugs has shifted away from the back alleys and instead on to Main Street. Abuse of prescription medication has grown to a bona fide public health crisis.

It's been almost 45 years since then-President Nixon declared a "war on drugs" and more than 30 years since the "Just Say No" anti-drug campaign of the Reagan Administration. There has been no clear winner in the war on drugs, which has simply evolved and re-emerged in new forms.

But can we say that our "tools"—the strategies that we have employed to combat drug abuse–have kept pace with the evolving face of drug abuse?

The answer is both no and yes.

Drug use and abuse is not a recent phenomenon. Marijuana, opiates, and hallucinogenic drugs have been used for centuries around the world and in the United States. As early as 1875, the San Francisco Board of Supervisors passed an ordinance regulating opium dens;1 the Harrison Narcotics Tax Act, a federal law that regulated and taxed the production, importation, and distribution of opiates, was approved in 1914.2 The federal government, recognizing the growing drug problem, created the Federal Bureau of Narcotics in the 1930s, the precursor to both the Bureau of Narcotics and Dangerous Drugs (1968) and the modern Drug Enforcement Agency. In 1971, the U.S. officially declared its "war on drugs."3

Our primary tool in this war was regulation, including the Controlled Substance Act (CSA), the federal U.S. drug policy, which regulated the manufacture, importation, possession, use, and distribution of certain substances through Schedules based on drugs' acceptable medical use and abuse or dependency potential.4 In the 1980s, anti-drug prevention programs (such as "D.A.R.E.") in schools were added to the anti-drug toolkit.5

But the drug problem continued to grow, in part due to the lack of criminal penalties for the use of drugs that were neither on federal Schedules nor FDA prescription drugs. In 1985, the proportion of Americans polled who saw drug abuse as the nation's "number one problem" was just 2-6 percent; by September 1989, it had skyrocketed to 64 percent.6 And with the exception of certain substances, such as cocaine (use of which declined) and marijuana (use of which has grown), rates of use of most "hard" drugs has not changed appreciably over the past two decades. In the general workforce, drug testing has revealed declining positivity rates among those employers conducting drug testing, from 1988 to 1996, but then those declines plateaued in more recent years.

In this first front in the drug war, prescription drug abuse and misuse was not a primary concern of drug abuse prevention advocates. That has since changed. In the 1990s, opioids—which had seldom been used for pain management due to concerns over addictive potential and diminishing therapeutic value—were increasingly prescribed for chronic pain.7 Since then, prescription opioid use has escalated dramatically and dosage has increased. In 2000, 174 million prescriptions for opioids were dispensed; by 2009, that number had increased to 257 million, an increase of 48 percent.8 From 1997 to 2007, the milligram per person use of prescription opioids in the United States increased from 74 milligrams to 369 milligrams, an increase of 402 percent.9

More worrisome than increases in the use of prescription medication is its misuse. Data indicate that, despite declines, 6.1 million people used prescription medication non-medically in the past month in 2011;10 nearly one-third of people aged 12 and over who used drugs for the first time in 2009 began by using a prescription drug non-medically;11 and non-medical use of prescription drugs among youths aged 12 to 17 in 2013 was the second most prevalent illicit drug use category, with marijuana being the first.12 Shockingly, overdose deaths from prescription painkillers have quadrupled since 1999 and now exceed deaths from heroin and cocaine combined.13

Given these dynamics, it's clear that the war on drugs has shifted away from the back alleys and instead on to Main Street. Abuse of prescription medication has grown to a bona fide public health crisis, causing the Centers for Disease Control and Prevention to classify prescription drug abuse as an epidemic.14

This classification is supported by what we have learned through our conversations with health care providers and our experience as a provider of prescription drug monitoring services: Prescription drug misuse impacts individuals in every age group, of both genders, and across a broad socioeconomic strata. Over the past three years, a series of reports have been released detailing the extent of the crisis based on our database of de-identified testing data from across the United States.15 Among the findings from the 2014 report was that the majority (55 percent) of Americans misused their prescription medications in 2013. Forms of misuse ranged from mixing prescribed medications with illicit drugs to skipping doses of prescribed medication altogether.

Prescription drug misuse is now as serious, or perhaps even more serious, than the abuse of so-called illicit drugs. To counter these trends, we should recognize that some of the tools that have worked in the past to combat the use of illicit drugs may not be the best solution to fight this new front of drug abuse.

Emphasize Prevention Over Prosecution
Arguably, increasing statutory penalties for drug use have not brought about the desired outcome. Of the roughly 2.3 million people incarcerated in U.S. prisons, more than half a million of these individuals are incarcerated for a drug law violation,16 including countless young people, but abuse rates have not appreciably declined. So we must be cautious about stressing prosecution over prevention and focus our efforts on curbing the circumstances that promote drug abuse in the first place.

Implement Holistic Solutions Rather Than 'Silo Solutions'
Without an omnibus approach, prescription drug abuse may simply mutate to newer, more insidious forms of misuse. Already, we know that heroin use is on the rise, with many in the medical field conjecturing that it is a less expensive alternative to prescription oxycodone. Another popular new drug, "synthetic marijuana" or "spice," is highly toxic and can cause dangerous health impacts, including psychotic episodes, seizures, and death. And new, creative forms of prescription medication misuse are emerging, such as drinking prescription-strength cough syrup containing codeine and promethazine, known as "sizzurp" or "lean."

Focusing on limiting access to certain narcotics is too narrow of an approach—and, worse, may carry negative ramifications for those individuals who legitimately need medication to control pain. This is especially important because we must not demonize prescription painkillers. More than 100 million Americans suffer from pain, including those who suffer from acute, debilitating pain.17 For many individuals, prescription pain medication is a necessary and critical component in their pain management regimen.

Align Public Health Campaigns with the Reality of a Drug-Supportive Culture
"Just Say No" campaigns will no longer be as effective with youth and teens growing up in an era in which "recreational" marijuana use has been legalized in several states. Education that stresses the health dangers of inappropriate use of all types of drugs is more likely to be effective.

In fact, there are signs that suggest that current efforts may be working. Although our 2014 report showed that medication misuse remains very high, we also found that the rate of misuse, as determined by drug test results, declined by 8 percent from 2011 to 2013, suggesting that physicians may be doing a better job communicating about the importance of adherence to a prescription drug regimen and/or that patients are exercising better prescription drug compliance. This data also supports National Survey on Drug Use and Health research which shows that in 2011, illicit use of prescription drugs declined for the first time in more than two decades. Past month non-medical use of psychotherapeutic drugs (pain relievers, stimulants, tranquilizers, and sedatives) by those 12 and older dropped by 14 percent, from 7 million in 2010 to 6.1 million in 2011.

Additionally, our data showed that adolescents experienced the greatest gains in appropriate drug use. Inconsistency rates for patients ages 10-17 decreased from 70 percent in 2011 to 57 percent in 2013, an improvement of 13 percentage points in two years. Patients ages 64 years and older had the lowest rate of inappropriate drug use, at 44 percent, according to test results.

Our analysis also provided directional guidance on the types of clinical, technological, and policy strategies that can help curtail the prescription drug epidemic:

  • Invest in comprehensive, state-run prescription medication abuse prevention approaches. Research found that the five states that have implemented multi-faceted prescription drug abuse prevention programs in recent years showed the greatest rate of decline in prescription drug misuse rates nationwide. In Florida, Georgia, Kentucky, New York, and Tennessee, the average decline in misuse rates over the past three years was 10.7 percent, nearly 2.5 times higher than the average decline of 4.4 percent among other states combined.18
  • Promote data sharing via state Prescription Drug Monitoring Programs (PDMPs). In 2006, only 20 states had PDMPs. Today, 49 states have laws authorizing PDMPs, and 48 states have operational programs.19 Efforts are under way to increase data sharing with other states' systems, and many PDMP administrators are working to better integrate these systems into other health IT programs. These efforts will help all those who play a role in reducing drug abuse, from law enforcement to physicians.
  • Enhance clinical assessment of risk with objective drug tests. Too often, physicians say they can always spot a patient who is at risk of abusing drugs. This is unlikely, given research that finds all patients are at risk, regardless of socioeconomic level, gender, or age.20 And patient questionnaires and reliance on self-reporting about drug abuse are unreliable predictors of prescription medication abuse, as patients are reluctant to admit misuse or mistakenly believe they are not misusing their medications. Physicians must be prescient, ensuring that patients are not taking medications that are counter-indicated or represent a significant safety risk. This presents a great challenge for physicians who must prescribe medications that are medically indicated for their patients while serving as gatekeeper against misuse and abuse. Drug testing, which allows clinicians to ensure that patients are taking their prescription medications, can help health care providers design and safely manage a treatment program as well as discourage misuse.
  • Use “smarter” drug testing. In the 1980s, drug testing was primarily utilized by the federal government for contractors, and many times limited to immunoassay (IA) technology for "presumptive" testing, which establishes the possibility that a specific substance may be present. Although IA can be sensitive, drug detection can vary according to the drug's concentration in the urine and the assay's cutoff concentration. Any response at or above the cutoff is deemed presumptively positive and any response below the cutoff is negative, leading to the possibility of false positives and false negatives. Following a series of advances in analytical science—including confirmation testing of IA presumptive positive results by gas chromatography-mass spectrometry (GC-MS) and later, by liquid chromatography-mass spectrometry (LC-MS) or tandem mass-spectrometry (LC-MS/MS)—we are now able to get the most accurate and unequivocal results for definitive drug identification possible. But more physicians need to be aware of the differences between IA and mass spectrometry methods for these advantages to make a meaningful clinical impact.
  • Adopt regulations to reduce potential abuse. As of October 2014, more than 65 prescription medications containing hydrocodone, the most widely prescribed painkiller, were subjected to new, stricter federal prescribing rules. The new regulations recommended by the Food and Drug Administration and published by the U.S. Drug Enforcement Administration made medications that contain opioid subject to the same restrictions as other narcotics, such as oxycodone and morphine.21 This is an example of how intelligent regulations may help reduce the likelihood that patients become addicted to powerful narcotics.
  • Leverage the power of health care technology to empower better care. The industry now has mobile apps that track medications and remind individuals to take pills in accordance with clinician directives. But there is also growing utilization of more sophisticated health IT tools that help physician group administrators and health plans to identify clinicians who appear to be outside the norm in prescribing pain medications and patients who appear to have inappropriate utilization.

Similarly, the Office of the National Coordinator for Health Information Technology and the Substance Abuse and Mental Health Services Administration funded pilot studies that improved the integration of PDMPs into provider workflow and other health records systems. These pilot programs show great promise. The Indiana Network for Patient Care leveraged its secure hospital network to offer information from the state PDMP along with a "narcotic score" alert to emergency department doctors as part of their normal view of a patient's record. Under a pilot program in Kansas, a secure email protocol sends a PDMP report to a patient’s electronic health record when a certain threshold is met, such as when the patient sought to fill five prescriptions from five providers during one calendar quarter.22

So have our tools kept pace with the evolving face of drug misuse? We may not have turned the tide, but we are employing new strategies to help us combat the epidemic.

In President Richard Nixon's 1971 message to Congress on drug abuse prevention and control efforts, he declared, "We are not without some understanding in this matter, however . . . and we are not without the will to deal with this matter. We have the moral resources to do the job . . . but time is critical. Every day we lose compounds the tragedy which drugs inflict on individual Americans." Sadly, those words are still relevant 45 years later. But it is also true that there is much we can do to ensure that prescription drugs foster good health, not harm, for our patients.

References
1. H. H. Kane, Opium Smoking in America and China (New York, 1882), cited in Terry and Pellens, p. 73
2. http://www.cfr.org/drug-trafficking-and-control/harrison-narcotics-tax-act-1914/p27928
3. http://www.drugpolicy.org/new-solutions-drug-policy/brief-history-drug-war
4. http://www.dea.gov/druginfo/ds.shtml
5. http://www.dare.org
6. New York Times/CBS News poll, 9/6-9/8, 1989
7. Rational Use of Opioids for Management of Chronic Nonterminal Pain,  Daniel Berland, MD, and Phillip Rodgers, MD, University of Michigan Medical School, Ann Arbor, Michigan, Am Fam Physician. 2012 Aug 1;86(3):252-258
8. http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf
9. http://www.whitehouse.gov/ondcp/prescription-drug-abuse
10. http://www.drugabuse.gov/related-topics/trends-statistics/infographics/popping-pills-prescription-drug-abuse-in-america
11. http://www.whitehouse.gov/sites/default/files/ondcp/Fact_Sheets/prescription_drug_abuse_fact_sheet_4-25-11.pdf
12. http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm
13. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
14. http://www.whitehouse.gov/ondcp/prescription-drug-abuse
15. http://www.questdiagnostics.com/home/physicians/health-trends.html
16. http://www.drugpolicy.org/docUploads/FactSheet_National_War_on_Drugs.pdf
17. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.
18. http://www.questdiagnostics.com/dms/Documents/health-trends/2014_health_trends_prescription_drug_misuse.pdf
19. http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/prescriptiondrug-monitoring-factsheet.pdf
20. http://www.questdiagnostics.com/dms/Documents/health-trends/2014_health_trends_prescription_drug_misuse.pdf
21. http://www.deadiversion.usdoj.gov/drug_chem_info/hydrocodone.pdf
22. http://www.healthit.gov/sites/default/files/connecting_for_impact-final-508.pdf

This article originally appeared in the September 2015 issue of Occupational Health & Safety.

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