Substance Abuse News

Individuals addicted to prescription painkillers are more likely to succeed in treatment with the aid of the medication buprenorphine-naloxone (Suboxone), report McLean Hospital and Harvard Medical School researchers in today’s online edition of the Archives of General Psychiatry.

“Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” is the first large-scale study to address treatment of prescription opioid addiction.

Addicted to Painkillers

According to lead author Roger Weiss, MD, Chief of the Division of Alcohol and Drug Abuse at McLean Hospital, most studies examining treatments for opioid dependence have been done with heroin-dependent patients at methadone clinics, resulting in the lack of data on treatment for patients addicted to prescription painkillers, especially in the offices of primary care doctors.

“Despite the tremendous increase in the prevalence of addiction to prescription painkillers, little research has focused on this patient population,” said Weiss, a professor of Psychiatry at Harvard Medical School. “This is notable because recent data tell us that the use of prescription painkillers for non-medical reasons is 20 times more common than heroin and 50 percent more people seek treatment for prescription drug abuse than for heroin.”

600 Patients Studied

Part of the National Institute on Drug Abuse (NIDA) Clinical Trials Network, this is the first randomized large scale clinical trial for the treatment of prescription opioid abuse, involving 10 sites nationwide and more than 600 treatment-seeking outpatients dependent on prescription opioids and either taking more than prescribed or using them illicitly. Each participant received Suboxone—a combination of buprenorphine, which alleviates opioid withdrawal and craving, and naloxone, which prevents abuse if the drug is not taken orally as prescribed—in conjunction with Standard Medical Management, in which physicians evaluated treatment effectiveness and recommended abstinence and self-help participation. Fifty percent of study participants also received additional more intensive individual addiction counseling.

According to Weiss, 49 percent of patients benefitted from Suboxone during a 12-week course of the medication. However, once the medication was discontinued, patients had a high rate of relapse. Monitored in four week increments, individuals showed an increasing rate of relapse the longer they remained off Suboxone. Another interesting finding, noted Weiss was that neither having chronic pain, nor participation in intensive addiction counseling affected the participant’s success rate.

Suboxone and Recovery

“We were surprised by some of these findings because there was an overall assumption that this population—those who have had little to no exposure to heroin—would do better in terms of not needing long-term medication intervention,” said Weiss. “It is clear that given the prescription drug abuse epidemic, we need to continue to look at the viability of longer-term use of Suboxone and whether it can continue to provide sustained recovery from addiction to pain medications.”

According to the National Survey on Drug Use and Health, an estimated 1.9 million people in the United States meet abuse or dependence criteria for prescription pain relievers. In addition, the Centers for Disease Control and Prevention report that annually, more people die from prescription painkiller overdoses than from heroin and cocaine combined.

ncreasing access to rogue online pharmacies – those which dispense medications without a doctor’s prescription – may be an important factor behind the rapid increase in the abuse of prescription drugs. In a report in the journal Health Affairs, investigators from Massachusetts General Hospital (MGH) and the University of Southern California (USC) find that states with the greatest expansion in high-speed Internet access from 2000 to 2007 also had the largest increase in admissions for treatment of prescription drug abuse.

Internet Growth a Factor

“We know we face a growing problem with prescription drug abuse in the United States. One need only look at statistics for college campuses, where prescription drugs are fast replacing illegal substances, to see the magnitude of the problem,” says Dana Goldman, PhD, director of the Schaeffer Center for Health Policy and Economics at USC, the study’s senior author. “Our findings suggest that Internet growth may partly explain the increase in prescription drug abuse, since it is well known that these drugs are easily available online.” Goldman is also the Norman Topping/National Medical Enterprises Chair in Medicine and Public Policy at USC.

In their report, Goldman and lead author Anupam B. Jena, MD, PhD, of the MGH Department of Medicine, note that the recent marked rise in the abuse of prescription narcotic painkillers – drugs like Percocet and Oxycontin – corresponds with an increase in the presence of online pharmacies, many of which do not adhere to regulations requiring a physician’s prescription. Drugs that are frequently abused – painkillers, stimulants, sedatives and tranquilizers – often can be purchased from rogue sites that may be located outside the U.S. The current study was designed to examine the potential link between online availability and prescription drug abuse, an association that has been suspected but not investigated in depth.

Increase in High-Speed Access

Using data available from the Federal Communications Commission, the researchers first compiled statistics on access to high-speed Internet service in each state during the years studied. Since actual rates of prescription drug abuse would be difficult if not impossible to calculate, they used information on admissions to substance abuse treatment facilities from a database maintained by the U.S. Substance Abuse and Mental Health Administration.

Changes in both measures over the seven years were analyzed on a per-state basis, and treatment admissions were categorized by the particular types of abused substances involved.

No Increase in Illegal Drug Use

The analysis indicated that each 10 percent increase in the availability of high-speed Internet service in a state was accompanied by an approximately 1 percent increase in admissions for prescription drug abuse. The increases were strongest for narcotic painkillers, followed by anti-anxiety drugs, stimulants and sedatives. During the same period admissions to treat abuse of alcohol, heroin or cocaine, substances not available online, showed minimal growth or actually decreased.

“The lack of an increase in abuse of drugs not available on the Internet suggests that an overall growth in drug-seeking behavior cannot explain the rise in prescription drug abuse,” Jena says. “Further studies need to better evaluate how easily commonly abused prescription drugs can be purchased online and explore the importance to the problem of foreign Internet pharmacies, which are outside the jurisdiction of the U.S. government.”

Few primary care physicians pay adequate attention to patients taking prescription opioid drugs — despite the potential for abuse, addiction and overdose, according to a new study by researchers at Albert Einstein College of Medicine of Yeshiva University.

The study, published in the Journal of General Internal Medicine, found lax monitoring even of patients at high risk for opioid misuse, such as those with a history of drug abuse or dependence. The findings are especially concerning considering that prescription drug abuse now ranks second (after marijuana) among illicitly used drugs, with approximately 2.2 million Americans using pain relievers nonmedically for the first time in 2009, according to the National Institute on Drug Abuse (NIDA).

Missed Prevention Opportunity

“Our study highlights a missed opportunity for identifying and reducing misuse of prescribed opioids in primary care settings,” said lead author Joanna Starrels, M.D., M.S. , assistant professor of medicine at Einstein. “The finding that physicians did not increase precautions for patients at highest risk for opioid misuse should be a call for a standardized approach to monitoring.”

The researchers studied administrative and medical records of more than 1,600 primary care patients for an average of two years while they received regular prescription opioids for chronic, non-cancer pain. They looked at whether patients received urine drug testing, were seen regularly in the office, or received multiple early opioid refills.

Few Given Urine Tests

Only a small minority (8 percent) of patients were found to have undergone any urine drug testing. While such testing was more common in patients at higher risk for opioid misuse, the rate of testing among those high-risk patients was still low (24 percent). Only half of patients were seen regularly in the office, and patients at higher risk of opioid misuse were not seen more frequently than patients at lower risk. Although fewer than one-quarter (23 percent) of all patients received two or more early opioid refills, patients at greater risk for opioid misuse were more likely to receive multiple early refills.

“We were disturbed to find that patients with a drug use disorder were seen less frequently in the office and were prescribed more early refills than patients without these disorders,” said Dr. Starrels. “We hope that these findings will call attention to this important safety concern.”

Prescription Drug Misuse Problem

Prescription drug misuse is a major public health problem. In a 2004 NIDA report , it was estimated that 48 million people over the age of 12 have taken prescription drugs for nonmedical uses in their lifetime – which represents approximately 20 percent of the U.S. population. Opioids, central nervous system depressants and stimulants were the drugs most commonly abused.

“Most primary care physicians are attuned to these problems,” said Dr. Starrels, “but they haven’t put sufficient strategies in place to help reduce risks.” She and her co-authors recommend that physicians adopt the following risk-reduction strategies: standardize a plan of care for all patients on long-term opioids, which includes urine drug testing; schedule regular face-to-face office visits to evaluate patients’ response to opioids and evidence of misuse; and stick to a previously agreed-upon refill schedule.

Rural teens appear more likely than their urban peers to use prescription drugs for non-medical purposes, according to a report posted online today that will appear in the March 2011 print issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

The non-medical use of prescription drugs is common among U.S. adolescents, with about one in eight reporting lifetime non-medical use of prescription opioids, according to background information in the article. “During adolescence, non-medical prescription drug use is particularly problematic given its association with use of other illicit drugs such as cocaine and heroin, as well as engagement in problem behaviors such as gambling, increased sexual activity and impulsivity,” the authors write. “Moreover, individuals who use prescription drugs earlier in life have a greater chance of later developing prescription drug dependence.”

Abuse Among Urban Teens

Previous studies have examined substance abuse among urban teens, but their conclusions may not apply to those from rural areas, the authors note. Jennifer R. Havens, Ph.D., M.P.H., of University of Kentucky College of Medicine, Lexington, and colleagues analyzed data from 17,872 12- to 17-year-olds participating in the 2008 National Survey on Drug Use and Health. Of these, 53.2 percent lived in urban areas, 51 percent were male and 59 percent were white.

There were no differences between urban and rural youth in rates of any illicit drug use, including marijuana, cocaine, heroin and hallucinogens. However, 13 percent of rural teens reported ever having used prescription drugs for non-medical purposes, compared with 10 percent of urban teens. When the researchers assessed specific medication types, they found rural teens were also more likely to have used pain relievers (11.5 percent vs. 10.3 percent) or tranquilizers (3.5 percent vs. 2.5 percent) non-medically.

After adjusting for sociodemographic factors, health status and the use of other substances, rural teens remained 26 percent more likely than urban adolescents to say they had used prescription drugs for non-medical purposes. “Data support that one reason for the higher prevalence of non-medical prescription drug use in rural areas may be the lack of availability of drugs such as heroin that are easily accessed in urban areas,” the authors write.

Family Involvement Important

Rural teens were more likely to misuse prescription drugs if they reported poorer health, episodes of depression or other substance abuse. “Residing in a household with two parents was associated with a 32 percent reduction in the odds of non-medical prescription drug use,” the authors write. “These results suggest that interventions aimed at family involvement may be beneficial in preventing or reducing non-medical prescription drug use.” Enrollment in school was also a protective factor.

“The cultural, structural and social realities of rural life can not only affect the prevalence of drug use but also exacerbate its consequences. The isolation and self-reliance of rural communities can negatively affect careseeking behavior, particularly regarding mental health and substance abuse services,” the authors write. “While we were able to identify potential targets for intervention such as increased access to health, mental health and substance abuse treatment, this may be difficult for rural areas where such resources are in short supply or non-existent. Research into the causal mechanisms surrounding initiation of non-medical prescription drug use in rural adolescents is necessary to develop tailored interventions for this population.”

Child abuse is a serious problem that affects nearly one million children a year in the United States alone. The American Academy of Pediatrics and the US Department of Health and Human Services classify child abuse into four categories including neglect, physical abuse, sexual abuse, and emotional abuse. None of these categories, however, clearly includes the abusive use of drugs on children. A study soon to be published in the Journal of Pediatrics investigates the malicious use of pharmaceuticals and attempts to shed light on this under-recognized problem.

Dr. Shan Yin from the University of Colorado and the Rocky Mountain Poison Drug Center at Denver Health reviewed cases of pharmaceutical abuse reported to the National Poison Data System between 2000 and 2008. Dr. Yin included reports of the malicious use of alcohol, painkillers, cough and cold medicines, sedatives and sleeping pills, and antipsychotic medicines.

Using Drugs to Subdue Children

Of the more than 1400 cases studied, nearly 14% resulted in moderate to major consequences, including death. Nearly one-half of the abused children were exposed to at least one sedative. An average of 160 cases, including two deaths, was reported each year. Motives and legal findings were unavailable for these particular cases; however, motives for the abusive use of drugs generally are varied, and can include punishment, amusement, or a wish for a break from childcare responsibilities.

This study illustrates the seriousness of the abusive use of drugs administered to children. According to Dr. Yin, “The malicious administration of pharmaceuticals should be considered an important form of child abuse.” He encourages pediatricians and emergency medical personnel to be on the watch for this form of maltreatment, and suggests the use of comprehensive drug screening during the evaluation of a child suspected to be the victim of abuse. Dr. Yin also cautions parents that the “non-therapeutic administration of pharmaceuticals to children can result in serious outcomes, including death.”