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Prescription Drug Abuse

Prescription medications are abused more commonly than cocaine, heroin and methamphetamine. Unfortunately there is a public Pillsmisperception that prescription medications are safer than and not as addictive as street drugs. THIS IS WRONG!!! The difference is that prescription drugs have accepted medical use and the benefit outweighs the risk to treat the disease. Medical practitioners must take extra measures compared to other medications to ensure their safe use.

In an address given in February by the Director of the Centers for Disease Control, Thomas Frieden, MD, MPH, illustrates the magnitude of the problem:

  • ”The rise in abuse of and deaths from prescription opioid narcotics has reached epidemic proportions…"
  • “There were more than 27,000 deaths from prescription drug overdoses in 2007, a number that has risen five-fold since 1990….”
  • “…overdose deaths from prescription opioids are exceeding deaths from heroin and cocaine overdoses combined….”
  • “Also, the overall number of drug-induced deaths -- which includes all drugs, not just prescription painkillers, although it is attributable in large part to those -- is approaching the number of deaths from motor vehicle crashes.”
  • “Drug abuse deaths have also surpassed the number of deaths from suicide, homicide, and fire arms….”

These prescription medications include opioid (synthetic opiate) painkillers such as oxycodone and hydrocodone, anti-anxiety medications like Xanax and Valium and stimulants like Dexedrine, Adderall or Ritalin commonly used for ADD and ADHD.
Before a discussion of these substances, one needs to understand the differences between physical dependence, tolerance and addiction:

  • Tolerance - this is when the body adapts to a substance being ingested needing more substance to get the same effect. This does not define addiction; we do not call a diabetic an addict for needing more insulin.
  • Physical dependence - this is another adaptation by the body to a substance resulting in a particular set of withdrawal symptoms upon reduction or cessation of a particular compound. Again, this is not addiction; when one has a headache from not having morning coffee it is not necessarily addiction.
  • Addiction - a simple definition is that it is a compulsion to use a substance despite continued adverse psychological, social and physical consequences. A good example of an addict without physical dependence would be a “binge-alcoholic”. A ‘binge alcoholic” is addicted to alcohol and continues to drink despite DWI’s, arrests, cirrhosis or other consequences yet does not develop withdrawal.

The Breakdown:

Opiates/Opioids

vicodinThese are medications based on opium derived from the poppy plant. Technically, the correct term for naturally occurring compounds such as morphine is opiates and the synthetic compounds are referred to as opioids. The medical community generally refers to all as opiates as opioids in professional discussions.

This class includes morphine, hydrocodone (e.g.-Vicodin, etc.), oxycodone (e.g.-OxyContin, Roxicodone, Percocet, etc.), fentanyl (e.g.-Duragesic, Actiq, Fentora, etc.), hydromorphone (e.g.-Dilaudid), oxymorphone (e.g.-Opana and Opana ER), methadone, Heroin (at one time a legal prescription drug.)

These are powerful pain relieving medications that work in the brain to decrease and block pain signals thus relieving the patient of suffering. When inappropriately prescribed and/or inappropriately taken, these are potentially highly addictive. They can cause euphoria (a powerful sense of well-being which may be accompanied by emotional highs and low) and they kill by causing “respiratory depression”. This is when the opioid sedates the person and then decrease the drive to breathe resulting in brain damage and likely death. As the afflicted develops greater tolerance they try to “get the original high” and they overshoot the mark resulting in sedation. An observer may note the afflicted nodding off at inappropriate times or “zoning out” during conversations (the person is awake but frequently not able to follow simple conversations coherently or stares off into space.) Please see below for further symptoms.

There are two main classes of opioid medications used for pain management, long acting and short acting. The average effective half-life of these medications is on average four to six hours but for chronic pain certain formulations have been made to allow their slow release over anywhere from eight to twenty-four hours. These are available in much higher dosages indicted for chronic pain patients that may have developed tolerance. Examples of the long-acting preparations are: OxyContin, Opana ER, Exalgo, MS-Contin, Fentanyl patch (Duragesic). When an addicted person wants to use these to get “high” they compromise the delivery system (e.g.- crush to snort, put in solution to inject, etc.). It is for this reason that the manufacturers are now required to make tamper resistant pills for all new opioid medications to try and decrease and hopefully eliminate their abuse. An example of how much more valuable the immediate release is to the afflicted, OxyContin 80 mg street price prior to January, 2010, was from $50 - $80 per tablet. In January, 2010, the pill was reformulated to turn to paste when crushed, foiling attempts to crush and snort or inject. Because of this the street value has dropped to $20 - $30 per pill from $80. Immediate release Roxicodone has supplanted OxyContin as the preferred drug for addicts and a 30mg pill of Roxicodone goes for the same price as an 80mg OxyContin.

Some common signs of opioid addiction/abuse may be:
• Extreme mood changes – happy, sad, excited, anxious, etc.
• Sleeping a lot more or less than usual, or at different times of day or night
• Changes in energy – unexpectedly and extremely tired or energetic
• Weight loss or weight gain
• Unexpected and persistent coughs or sniffles
• Seeming unwell at certain times, and better at other times
• Pupils of the eyes seeming smaller or larger than usual
• Secretiveness • Lying
• Stealing
• Financially unpredictable (large amounts of cash at times but broke at other times)
• Changes in social groups, new and unusual friends, odd cell-phone conversations
• Repeated unexplained outings, often with a sense of urgency
• Drug paraphernalia such as unusual pipes, cigarette papers, small weighing scales, etc. • “Stashes” of drugs, often in small plastic, paper or foil packages It should be made clear that the above symptoms can be seen with addiction to any substance and often addicts abuse several drugs at the same time as part of a “cocktail”.

Symptoms of opioid withdrawal are similar to the symptoms of severe flu:
• Unbearable pain
• Cold sweats, chills
• Uncontrollable diarrhea
• Nausea and vomiting
• Aching limbs
• Severe depression
• Restlessness
• Anxiety

Benzodiazepines/Anti-anxiety medications

Benzodiazepine medications are prescribed primarily for anxiety/panic attacks. They work in the central nervous system to give a calming effect on the central nervous system hence their use not just to calm a panic attack and help with sleep but to also acutely stop seizures (the uncontrolled firing of nerve cells in the central nervous system). Examples include alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan) and temazepam (Restoril).

Their abuse will cause marked sedation and this is potentiated with the use of other sedatives such as alcohol or opioids. It is this affect that makes benzodiazepines as well as other “date-rape” drugs possible.

Muscles relaxants are listed in the same category of Sedative/Hypnotics and one in particular has developed a large following on the street, carisoprodol (Soma). This medication breaks down into meprobamate in the body. This was a benzodiazepine developed in the 1950’s called Miltown and subsequently removed from the market. It is also known as “Soma-Coma” and when taken with Xanax and Vicodin it is called “The Holy Trinity” and will give a heroin-like high.

Signs of abuse can be similar to that of opioid, marked sedation in addition to the aforementioned symptoms. Abuse can result in marked slowing of the heart rate and/or marked respiratory depression which may result in death.

Signs of withdrawal may include:
• Extremely long withdrawal compared to other drugs of abuse (as much as 2-4 months)
• Tremors
• Chills/cold sweats
• Anxiety
• Insomnia
• Nausea
• Hallucinations
• Seizures (may be fatal)

Stimulants (Cocaine, methamphetamine, amphetamine)

These medications cause a dramatic increase in central nervous system activity and are commonly called “speed”. Amphetamines include the prescription medications such as amphetamine salts (Adderall), methylphenidate (Ritalin) and dextroamphetamine (Dexedrine). These are commonly used for the treatment of ADD/ADHD, narcolepsy and severe fatigue and used as diet aids but are commonly abused by students to aid in study or to just get “high”. Cocaine and methamphetamine have similar effects just much stronger and associated with a higher rate of addiction but no accepted medical use. Overdose can include; seizures, abnormal heart rhythm and possible heart attack, shortness of breath, hallucinations, anxiety, paranoia, a form of muscle breakdown called rhabdomyolysis as well as kidney failure.

Signs of intoxication may include:
• Euphoria (increased alertness, energy, sociability or appetite)
• Increased libido or impotence
• Increased heart rate and respirations
• Bruxism (grinding of teeth)
• Chronic rhinitis (constant runny nose)
• Twitching or involuntary movements

Signs of withdrawal may include:
• Fatigue
• Insomnia
• Increased appetite
• Depression and suicidal thoughts
• Anxiety
• Craving for more stimulants
• Impaired concentration and thinking