**Substance Abuse Treatment**

**Advisory**

***News for the Treatment Field***

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

**May 2006, Volume 5, Issue 2**

**PRESCRIPTION MEDICATIONS: MISUSE, ABUSE, DEPENDENCE, AND ADDICTION**

**How serious are prescription medication use problems?**

Development and increased availability of prescription drugs have
significantly improved treatment of pain, mental disorders, anxiety, and
other conditions. Millions of Americans use prescription medications
safely and responsibly. However, increased availability and variety of
medications with psychoactive effects (see Table 1) have contributed to
prescription misuse, abuse, dependence, and addiction. In 2004,[^1] the
number of Americans reporting abuse[^2] of prescription medications was
higher than the combined total of those reporting abuse of cocaine,
hallucinogens, inhalants, and heroin. More than 14.5 million persons
reported having used prescription medications nonmedically within the
past year. Of this 14.5 million, more than 2 million were between ages
12 and 17.

Older adults are particularly vulnerable to misuse and abuse of
prescription medications. Persons ages 65 and older make up only 13
percent of the population but account for one-third of all medications
prescribed,[^3] and many of these prescriptions are for psychoactive
medications with high abuse and addiction liability.[^4] Data from the
NSDUH indicate that nonmedical use of prescription medications was the
second most common form of substance abuse among adults older than
55.[^5]

Use of prescription medications in ways other than prescribed can have a
variety of adverse health consequences, including overdose, toxic
reactions, and serious drug interactions leading to life-threatening
conditions, such as respiratory depression, hypertension or hypotension,
seizures, cardiovascular collapse, and death.[^6]

+-------------+---------------------+----------------------------------+
| **Table 1:  |                     |                                  |
| Drug        |                     |                                  |
| Classes,    |                     |                                  |
| Medical     |                     |                                  |
| Uses, and   |                     |                                  |
| Examples of |                     |                                  |
| Commonly    |                     |                                  |
| Prescribed  |                     |                                  |
| Me          |                     |                                  |
| dications** |                     |                                  |
+-------------+---------------------+----------------------------------+
| **Drug      | **Legitimate        | **Examples of Medications**      |
| Class**     | Medical Uses**      |                                  |
+-------------+---------------------+----------------------------------+
| Opioid      | Management of acute | Codeine (Empirin^®^ , Tylenol 1, |
| analgesics  | or chronic pain,    | 2, 3), Hydrocodone (Vicodin^®^), |
|             | relief of coughs,   | Hydromorphone (Dilaudid^®^),     |
|             | antidiarrheal       | Meperidine (Demerol^®^),         |
|             |                     | Methadone (Dolophine^®^),        |
|             |                     | Morphine, Oxycodone              |
|             |                     | (OxyContin^®^, Percodan^®^),     |
|             |                     | Propoxyphene (Darvon^®^)         |
+-------------+---------------------+----------------------------------+
| Sedative    | Anxiety and panic   | Alprazolam (Xanax^®^),           |
| -hypnotics: | disorders, acute    | Chlordiazepoxide HCL             |
|             | stress reactions    | (Librium^®^), Clonazepam         |
| *Benzo      |                     | (Klonopin^®^), Diazepam          |
| diazepines* |                     | (Valium^®^), Lorazepam           |
|             |                     | (Ativan^®^)                      |
+-------------+---------------------+----------------------------------+
| Sedative    | Insomnia, anxiety,  | Butalbital (Fiorinal^®^),        |
| -hypnotics: | seizure control     | Meprobamate (Miltown^®^),        |
|             |                     | Pentobarbital sodium             |
| *Ba         |                     | (Nembutal^®^), Phenobarbital,    |
| rbiturates* |                     | Secobarbital (Seconal^®^)        |
+-------------+---------------------+----------------------------------+
| Stimulants  | Attention deficit   | Amphetamine-dextroamphetamine    |
|             | disorder and        | (Adderall^®^), Dextroamphetamine |
|             | attention           | (Dexedrine^®^), Methylphenidate  |
|             | de                  | (Ritalin^®^),                    |
|             | ficit/hyperactivity | [Sibutramine](http://w           |
|             | disorder (ADD,      | ww.drugs.com/mtm/m/meridia.html) |
|             | AD/HD), narcolepsy, | (Meridia^®^)                     |
|             | weight loss,        |                                  |
|             | depression (rarely) |                                  |
+-------------+---------------------+----------------------------------+

**What are the differences among nonmedical use of prescriptions,
misuse, abuse, physiological dependence, psychological dependence
(addiction), and pseudoaddiction?**

The *Diagnostic and Statistical Manual of Mental Disorders,* 4th
Edition, Text Revision (DSM-IV-TR),[^7] provides diagnostic criteria for
substance abuse and substance dependence. Counselors working with
clients who use prescription medications, however, need to distinguish
among nonmedical use of substances, substance misuse, abuse,
physiological dependence, psychological dependence (also known as
"addiction"), and pseudoaddiction. Prescription medications that are on
the Drug Enforcement Administration's list of controlled substances have
high abuse potential and can lead to physiological or psychological
dependence, or both, in some patients.

*Nonmedical use:* Use of prescription drugs that were not prescribed by
a medical professional (i.e., obtained illicitly) or use for the
experience or feeling a drug causes.

*Misuse:* Incorrect use of a medication by patients, who may use a drug
for a purpose other than that for which it was prescribed, take too
little or too much of a drug, take it too often, or take it for too long
(misuse does not apply to off-label prescribing \[prescribing a
medication for a condition other than the conditions for which the Food
and Drug Administration approved the medication\] when such use is
supported by common medical practice, research, or rational
pharmacology).

*Abuse:* A maladaptive pattern of substance use, leading to clinically
significant impairment or distress as manifested by one or more
behaviorally based criteria.^7^

*Physiological dependence:* Increasing tolerance for a drug, withdrawal
signs and symptoms when a drug is discontinued, or the continued use of
a substance to avoid withdrawal.

*Psychological dependence (addiction):* A set of psychological symptoms
that demonstrate overall loss of control or obsessive-compulsive
drug-seeking and continued use of a substance in spite of clearly
adverse consequences. Symptoms *may* include specific physiological
signs of dependence such as increasing tolerance or withdrawal signs and
symptoms when the drug is discontinued.

*Pseudoaddiction:* Drug-seeking and other behavior that is consistent
with addiction but actually results from inadequate pain relief. Once
the pain is adequately treated, the person no longer abuses the
medication.[^8]

**How do people become dependent on prescription medications?**

Within the context of good medical care, substance misuse, abuse,
physiological dependence, and dependence/addiction are potential
treatment complications. For example, physiological dependence is an
expected outcome of long-term use of opioid medications for pain. A
minority of patients may have predisposing factors that lead to problems
of psychological dependence (addiction). Drug use may quickly escalate
to unintended and initially unanticipated levels beyond the initial
intended use, alarming both the patient and treatment provider.

Some people obtain prescription medications illicitly and experiment
with their effects. Others may find that a particular drug helps them
self-medicate undiagnosed or undertreated disorders (e.g., anxiety,
depression, ADD).

**How can prescription medication abuse or dependence be treated
effectively?**

People treated with any controlled medication should be monitored
closely for the development of a substance use disorder. Physiological
dependence may be the first symptom of a potential problem. While
physiologically dependent, people may also develop symptoms of abuse or
psychological dependence. When the decision is made to stop medication
therapy, a patient who is physiologically dependent should be expected
to develop withdrawal symptoms unless care is taken to slowly taper the
drug using a standard detoxification or withdrawal protocol. During the
detoxification or withdrawal period, symptoms of abuse or psychological
dependence may emerge.

Detoxification alone is not sufficient for a person who meets DSM-IV-TR
criteria for abuse or dependence. Providers should use evidence-based
brief interventions such as motivational enhancement,
cognitive--behavioral therapy, or 12-Step facilitation, along with
referrals to an addiction medicine/psychiatry specialist for patients
with more severe drug dependence.

Patients found to be drug dependent should be assessed for the correct
level of care for both detoxification and treatment according to
standards such as the American Society of Addiction Medicine's patient
placement criteria.[^9] These patients also should be considered for
appropriate medication-assisted therapy by qualified, licensed
providers, such as opioid treatment programs or physicians with
buprenorphine waivers. Recommendations for effective treatment of
substance use disorders do not differentiate between prescription drug
and illicit drug use problems. Among these patients, alcohol abuse and
dependence also are frequently involved and must be addressed.

Chronic pain may complicate substance abuse treatment by[^10]

-   Motivating drug-seeking behavior.

-   Decreasing clients' quality of life, which may increase their
    attraction to any drug that produces euphoria.

-   Creating psychiatric problems, such as depression and anxiety.
    Clients whose pain is the result of trauma may have symptoms of
    posttraumatic stress disorder (PTSD).

-   Creating functional and social disability that can impede
    participation and success in treatment.

The first step toward effective treatment of a substance use disorder is
screening and comprehensive assessment, including

-   Evaluation of how the person began using prescription medication

-   Medical history and evaluation to determine underlying medical
    issues

-   Screening for and, when indicated, assessment of mental health
    issues

Frequently, a problem that begins as prescription drug misuse is
complicated by illicit use of that same drug or illicit use of another
drug. Sometimes, a patient's use of an illicit drug may evolve into
dependence on a drug that is subsequently prescribed for him or her.

Effective counseling and medication-assisted treatments apply to all
patients identified with any substance use disorder. However, to ensure
treatment effectiveness, clients with ongoing pain and those with
underlying anxiety disorders, ADD, AD/HD, and other mental disorders
will need services beyond standard addiction counseling. *Not* providing
these services ensures treatment failure.

In summary, programs or counselors treating individuals with
prescription medication-related problems must use their established
approaches and resources, modified or expanded to address the specific
issues identified in this *Advisory.*

Programs treating clients with addictions to prescription medications
need to ensure that they have access to the following resources or
professionals, either on site or through appropriate referral sources:

-   Appropriate dose-tapering or other detoxification services

-   Physicians, physician's assistants, or nurse practitioners with
    expertise in pain management and/or pain clinics

-   Psychiatrists with expertise in addiction treatment and psychotropic
    medication management

-   Addiction counselors, social workers, and/or psychiatric nurses with
    experience and training in providing cognitive--behavioral therapy
    and other approaches for treating anxiety and panic disorders, PTSD,
    ADD, AD/HD, and eating disorders

Programs also need to ensure that clients in recovery have adequate
information about working with physicians if and when pain or other
psychoactive prescription medications are needed.

**Resources for Additional Information**

*Substance Abuse and Mental Health Services Administration (SAMHSA)*

1 Choke Cherry Road

Room 8-1054

Rockville, MD 20857

Phone: 240-276-2130 (Office of Communications)

Web: www.samhsa.gov

*SAMHSA's National Clearinghouse for Alcohol and Drug Information
(NCADI)*

Phone: 800-729-6686

Español: 877-767-8432

TDD: 800-487-4889

Web: www.ncadi.samhsa.gov

*National Institute on Drug Abuse (NIDA)*

6001 Executive Boulevard

Bethesda, MD 20892-9561

Phone: 301-443-1124

Web: www.nida.nih.gov

*U.S. Food and Drug Administration (FDA)*

5600 Fishers Lane

Rockville, MD 20857-0001

Phone: 888-INFO-FDA (888-463-6332)

Web: www.fda.gov

*SAMHSA/FDA Comprehensive Prescription Drug Campaign*

Web: www.rx.samhsa.gov/main.htm

***Substance Abuse Treatment Advisory***

*Substance Abuse Treatment Advisory*published on an as-needed basis for
treatment providerswas written and produced under contract number
270-04-7049 by the Knowledge Application Program (KAP), a Joint Venture
of JBS International, Inc., and The CDM Group, Inc., for the Center for
Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health
Services Administration (SAMHSA), U.S. Department of Health and Human
Services (HHS). The content of this publication does not necessarily
reflect the views or policies of SAMHSA or HHS.

**Public Domain Notice:** All material appearing in this report is in
the public domain and may be reproduced or copied without permission;
citation of the source is appreciated. However, this publication may not
be reproduced or distributed for a fee without the specific, written
authorization of the Office of Communications, SAMHSA, HHS.

**Electronic Access and Copies of Publication:** This publication can be
accessed electronically through the Internet at www.kap.samhsa.gov.
Additional free print copies can be ordered from SAMHSA's NCADI at
800-729-6686.

**Recommended Citation:** Center for Substance Abuse Treatment.
Prescription medications: Misuse, abuse, dependence, and addiction.
*Substance Abuse Treatment Advisory*. [Volume 5, Issue 2, XXXX
2006.]{.mark}

National Clearinghouse for Alcohol and Drug Information

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

7079 Oakland Mills Road

Columbia, MD 21046

DHHS Publication No. (SMA) 06-[XXXX]{.mark}

Printed 2006

[^1]: Office of Applied Studies. *Results from the 2004 National Survey
    on Drug Use and Health: National Findings.* Rockville, MD: Substance
    Abuse and Mental Health Services Administration, 2005.

[^2]: The National Survey on Drug Use and Health (NSDUH) defines
    prescription drug abuse as using "any prescription (pain reliever,
    sedative, stimulant, tranquilizer) that was not prescribed for you
    or that you took only for the experience or feeling it caused." (See
    note 1.)

[^3]: National Institute on Drug Abuse. *Prescription Drugs: Abuse and
    Addiction.* NIDA Research Report Series, NIH Publication No.
    05-4881. Printed 2001, revised August 2005.
    [www.nida.nih.gov/ResearchReports/Prescription/prescription.html](http://www.nida.nih.gov/ResearchReports/Prescription/prescription.html)
    \[accessed November 3, 2005\].

[^4]: Blow, F.C. Special issues in treatment: Older adults. In: Graham,
    A.W., Schultz, T.K., Mayo-Smith, M.F., Ries, R.K., and Wilford,
    B.B., eds. *Principles of Addiction Medicine*, 3d Edition. Chevy
    Chase, MD: American Society of Addiction Medicine, Inc., 2003, pp.
    581--607.

[^5]: Office of Applied Studies. *The NHSDA Report: Substance Use Among
    Older Adults---2002 and 2003 Update.* Rockville, MD: Substance Abuse
    and Mental Health Services Administration, November 2005.

[^6]: Clark, H.W., and Bizzell, A. A federal perspective on the abuse of
    prescription stimulants. *Psychiatric Annals* 35(3):254--256, 2005.

[^7]: American Psychiatric Association. *Diagnostic and Statistical
    Manual of Mental Disorders,* 4th Edition, Text Revision. Washington,
    DC: American Psychiatric Association, 2000.

[^8]: Savage, S.R. Opioid medications in the management of pain. In:
    Graham, A.W., Schultz, T.K., Mayo-Smith, M.F., Ries, R.K., and
    Wilford, B.B., eds. *Principles of Addiction Medicine*, 3d Edition.
    Chevy Chase, MD: American Society of Addiction Medicine, Inc., 2003,
    pp. 1451--1463.

[^9]: Mee-Lee, D., ed. *ASAM PPC-2R: ASAM Patient Placement Criteria for
    the Treatment of Substance-Related Disorders*, 2d Edition. Chevy
    Chase, MD: American Society of Addiction Medicine, 2001.

[^10]: Trafton, J.A., Oliva, E.M., Horst, D.A., Minkel, J.D., and
    Humphreys, K. Treatment needs associated with pain in substance use
    disorder patients: Implications for concurrent treatment. *Drug and
    Alcohol Dependence* 73:23--31, 2004.