Substance Abuse Treatment

ADVISORY

News for the Treatment Field

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 abuse2 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 National Survey on Drug Use and Health 

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 Medications

Drug Class Legitimate Medical Uses Examples of Medications

Opioid analgesics Management of acute or chronic pain, relief 

of coughs, antidiarrheal

Codeine (Empirin®, Tylenol 1, 2, 3), Hydrocodone 

(Vicodin®), Hydromorphone (Dilaudid®), Meperidine 

(Demerol®), Methadone (Dolophine®), Morphine, Oxycodone 

(OxyContin®, Percodan®), Propoxyphene (Darvon®) 

Sedativehypnotics: 

Benzodiazepines

Anxiety and panic disorders, acute stress 

reactions

Alprazolam (Xanax®), Chlordiazepoxide HCL (Librium®), 

Clonazepam (Klonopin®), Diazepam (Valium®), Lorazepam 

(Ativan®) 

Sedativehypnotics: 

Barbiturates

Insomnia, anxiety, seizure control Butalbital (Fiorinal®), Meprobamate (Miltown®), Pentobarbital 

sodium (Nembutal®), Phenobarbital, Secobarbital (Seconal®)

Stimulants Attention deficit disorder and attention deficit/ 

hyperactivity disorder (ADD, AD/HD),

narcolepsy, weight loss, depression (rarely)

Amphetamine-dextroamphetamine (Adderall®), 

Dextroamphetamine (Dexedrine®), Methylphenidate 

(Ritalin®), Sibutramine (Meridia®) 
 

 

 

 

 

 

May 2006, Volume 5, Issue 2 

Substance Abuse Treatment

ADVISORY .............................................................................. 
 

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 obsessivecompulsive 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 

Chronic pain may complicate substance abuse treatment 

by9— 

• 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. 

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Prescription Medications 

Substance Abuse Treatment

ADVISORY .............................................................................. 
 

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.10 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. 

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; and
 

• 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, 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. 

Resources for Additional Information 

Substance Abuse and Mental Health Services

 Administration (SAMHSA) 

http://www.samhsa.gov 

SAMHSA: Prevent Prescription Drug Abuse 

http://www.samhsa.gov/rxsafety 

National Institute on Drug Abuse (NIDA) 

http://www.nida.nih.gov 

U.S. Food and Drug Administration (FDA) Safe Use Initiative 

http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/default.htm 

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. 

3 
Substance Abuse Treatment Advisory

Prescription Medications: Misuse, Abuse, Dependence, and Addiction

Notes

1Office 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.

2The 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.)

3National Institute on Drug Abuse. Prescription Drugs: Abuse 

and Addiction. NIDA Research Report Series, NIH Publication No. 

05-4881. Printed 2001, revised August 2005.

4Blow, 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.

5Office of Applied Studies. The NSDUH Report: Substance Use 

Among Older Adults—2002 and 2003 Update. Rockville, MD: 

Substance Abuse and Mental Health Services Administration, 

November 2005.

6Clark, H.W., and Bizzell, A. A federal perspective on the abuse of 

prescription stimulants. Psychiatric Annals 35(3):254–256, 2005.

7American Psychiatric Association. Diagnostic and Statistical 

Manual of Mental Disorders, 4th Edition, Text Revision. Washington, 

DC: American Psychiatric Association, 2000.

8Savage, 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.

9Trafton, 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 72:23–31, 2004

10Mee-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.

Substance Abuse Treatment Advisory

Substance Abuse Treatment Advisory was written and produced under contract number 270-04-7049 by the Knowledge 

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Recommended Citation: Center for Substance Abuse Treatment. Prescription medications: Misuse, abuse, dependence, and 

addiction. Substance Abuse Treatment Advisory. Volume 5, Issue 2, May 2006.

Substance Abuse Treatment

ADVISORY ..............................................................................

May 2006, Volume 5, Issue 2

HHS Publication No. (SMA) 12–4175

First printed 2006

Revised 2009 and 2012