The nonmedical use of prescription drugs (using medication for purposes other than those prescribed) has been increasing rapidly in recent years.  In 2001, 36 million Americans (16% of people 12 or older) had used prescription-type drugs nonmedically at least once in their lifetime.¹ Most alarming is that the number of people using prescription pain relievers nonmedically for the first time increased from 600,000 in 1990 to more than 2 million in 2001.² The National Household Survey on Drug Abuse (NHSDA) data show that the initiation of nonmedical prescription drug use occurs mostly among those aged 12 to 25 and that new use has been increasing.¹ The annual number of new users of pain relievers has been increasing annually since the 1980s, from 400,000 to 2 million in 2000.¹ New users of stimulants increased from more than 200,000 in 1991 to almost 700,000 in 2000. New users of tranquilizers have been increasing since the 1980s, as well, but the largest increase has been more recent, from more than 700,00 new users in 1999 to almost 1 million in 2000.¹

Most people take prescribed medications properly, but many obtain drugs fraudulently, use more than prescribed, or take them for reasons other than medically indicated. According to the National Institute on Drug Abuse (NIDA), the misuse of prescription drugs refers to taking medication in a manner other than prescribed. Prescription drug abuse is intentional misuse of a medication outside of the normally accepted standards for its use; prescription drug dependence is characterized by compulsive use and development of tolerance and withdrawal symptoms.³

High-risk groups, drug misuse

In 2001, more than 3 million youths 12 to 17 and almost 7 million young adults aged 18 to 25 had used prescription drugs nonmedically at least once in their lifetime.¹ The most common category of prescription drugs used nonmedically by youths and young adults in the past year was pain relievers, with youths, 6%, and young adults at 10%. Pain relievers include codeine, methadone, meperidine (Demerol), Percocet, hydrocodone (Vicodin), and oxycodone (Oxycontin).¹ Additionally, young people comprise the majority of first-time nonmedical users of the prescription opioids such as hydrocodone (Vicodin, Lortab, Lorcet) and oxycodone (OxyContin), with 46% of those 12-17, 34% of those 18-25, and 20% of those 26 and older using the drug nonmedically.⁴

Among youths, females were more likely to have used prescription drugs non-medically in the past year than males (9% to 7% respectively).¹ However, among young adults, males were more likely to have used in the past year, at 14% compared to 10% for females.¹ Among those people aged 12 to 25, whites were more likely to have used prescription drugs nonmedically in the past year compared to Hispanics, blacks, or Asians (whites, 12%; Hispanics, 8%; blacks, 6%, and Asians, 5%).¹

Geographical differences are associated with prescription drug misuse. Youths in nonmetropolitan or small metropolitan areas were more likely to have used prescription drugs nonmedically in the past year (9%) than youths in large metropolitan areas (7%).¹ However, among young adults, the rate of past year nonmedical use of prescription drugs was similar among metropolitan and nonmetropolitan areas.¹ Additionally, treatment admission rates for narcotic pain reliever misuse increased by 135% in nonmetropolitan areas without cities.⁵

The route of administration among narcotic pain reliever abusers entering treatment has changed between the years 1992 and 2000. In 1992, 66% of admissions for narcotic pain reliever abuse took the drugs orally, and 25% injected them.⁵ By 2000, however, the proportion taking the drugs orally had increased to 80%, and the proportion injecting had fallen to 12%. ⁵

Women, adolescents, and older adults are at greater risk for prescription misuse, according to the National Household Survey and other studies.^6-8  One researcher indicated that being female is a significant predictor of anxiolytic (anti-anxiety drugs such as diazepam and alprazolam) and narcotic analgesic use, but this association did not occur with sedative-hypnotic drugs (sleeping pills) or stimulants.⁷ The rate of prescription drug use is higher among women, reportedly because of gender differences in coping with and expressing anxiety, a willingness to seek medical care, perception of illness and physician-prescribing bias.^7,8 Women are two to three times more likely to be diagnosed with depression and anxiety, and among 12- to 17-year-olds, girls use psychotherapeutic drugs nonmedically more often than boys.^3,7 When possible, 12- to 17-year-olds should be treated with non-benzodiazepine drugs for anxiety disorders, such as buspirone (Buspar), and SSRIs, such as sertraline (Zoloft) or fluoxetine (Prozac), for depression or anxiety, in combination with psychotherapy.⁹

Older people are prescribed medications about three times more often than the general population and demonstrate lower levels of compliance with directions for use.⁶ This greater exposure combined with age-related physiological changes such as decreased liver metabolism and renal excretion and alterations in brain neurotransmitters place the older person at greater risk for adverse drug effects.¹⁰ Of particular concern are oversedation, falls, motor vehicle accidents, cognitive impairment, and memory loss. The elderly often abuse tranquilizers (benzodiazepines) and sleeping pills as a result of insomnia and chronic health conditions.^9,10 Elderly patients who have symptoms of anxiety and insomnia may respond to buspirone, thereby avoiding the negative effects and addictive potential of benzodiazepines.¹¹ RNs should assess the medications elderly patients are taking, as multiple prescriptions increase the likelihood of adverse effects.

Factors associated with misuse

Several researchers have identified physician, patient, and regulatory factors associated with prescription drug misuse.^12-15 Physician factors encompass misprescribing, inappropriate prescribing in response to patient demands, and uninformed prescribing by physicians who are not fully aware of a patient’s substance abuse history.^9,12 The number of physicians charged with dishonestly prescribing drugs is small, about 1%.^13,14 Actually, physicians may underprescribe pain medication for fear of criminal or civil charges.^14,15 NIDA reports many physicians have difficulty discussing substance abuse, including prescription drug abuse, with patients, and proposes that physicians and pharmacists collaborate on patient education strategies.¹⁶

Patient factors associated with prescription drug misuse include a constellation of drug-seeking behaviors. Examples include patients’ implying that the only possible solution to a medical problem is a prescription for a controlled substance, insisting on a particular medication, reporting high tolerance levels, and describing symptoms that markedly deviate from the objective evidence or the physical examination findings. Patients also may claim that nonaddictive medications do not work; resist nonpharmacological interventions such as relaxation training or therapy; manipulate by threats, bribes, or challenging one physician’s opinion with that of another physician; and doctor-pharmacy “shop” for prescriptions (that is, going from doctor to doctor or pharmacy to pharmacy until the desired prescription is obtained).¹⁷ Patients also may use excuses for needing more medication. They may tell the physician that the bottle spilled, the prescription was lost—or even that their dog ate the medication.⁹ They may also alter or falsify prescriptions.

The federal Drug Enforcement Agency regulates record-keeping on prescription drugs.¹⁸ However, most of the actual power to control and monitor the prescribing and dispensing of prescription drugs resides with the states. Recommendations to improve regulatory processes include increasing surveillance of drugs (such as evaluating their propensity for abuse), limiting prescriptive authority, creating a peer review system to evaluate MD prescribing practices, increasing premarketing tests on drugs prescribed to the elderly, and requiring patient education inserts in drug packaging.¹²

Assessing drug misuse

Assessment of patient drug misuse involves evaluating drug-seeking behaviors and assessing the extent of drug abuse and the symptoms of withdrawal. Addicts refer to drug-seeking behaviors as “working” or “making a doctor,”¹⁷ and patients can be adept at feigning symptoms. Disorders that patients invent or exaggerate to manipulate health care providers include migraine headaches, tic douloureux (trigeminal nerve pain causing jaw and facial pain), back pain, colitis and narcolepsy.¹⁷ Patients also may use a concern about obesity to obtain the desired drugs.¹⁷

The extent of drug use usually is revealed through a patient or family report and assessment of symptoms common to psychoactive drug use or intoxication. Patients who have developed dependence on these drugs may minimize use. Deliberate minimization is related to craving and the need to maintain the physiological and psychological effects of the drug. Unintentional minimization may result from the medication’s depressant effects on the central nervous system, which may reduce memory and recall. Psychoactive effects and withdrawal symptoms of commonly abused prescription drugs are shown in the table.

Treatment approaches

The level of treatment is determined by the patient’s presenting physical and psychological status, the drug abused, the extent of drug abuse, and the severity of withdrawal symptoms. Treatment may range from outpatient (for low-intensity symptoms) to intensive inpatient hospitalization (for high-intensity symptoms).

Although all psychoactive drugs of abuse create some form of withdrawal symptoms, generally it is accepted that patients who have misused barbiturates (such as secobarbital) and benzodiazepines (tranquilizers such as diazepam and alprazolam) require careful medical monitoring during the withdrawal process.^9,19

Public initiatives

Because of the increase in nonmedical use of prescription drugs, NIDA has proposed a new and more comprehensive public initiative on prescription drug abuse, misuse and addiction.² As part of this effort, NIDA formed partnerships with the American Association of Retired Persons, the American Academy of Family Physicians, the American Pharmaceutical Association, the National Association of Chain Drug Stores, the National Community Pharmacists Association, the National Council on Patient Information and Education, and the Pharmaceutical Research and Manufacturers of America.  The goal is to inform the public and health care providers about the dangers of prescription drug abuse and to promote research in this area.²⁰

The NIDA initiative is not the first prescription drug abuse awareness campaign.  In 1980, the American Medical Association sponsored a White House conference on prescription drug abuse, and in 1988, the AMA’s Department of Substance Abuse called a second national conference on the abuse of these drugs.¹⁹

The American Nurses Association announced its position on the abuse of prescription drugs in 1991, stating that it “recognizes and acknowledges the abuse and misuse of prescribed drugs” and registering its concern about “over-prescription misuse of certain categories of prescribed drugs for women and teenagers and the role of the health care provider.”²¹  The ANA called for education for nurses “to ensure safe measures of the prescription and monitoring of drugs.”²¹

Nursing implications

Nurses are pivotal in detecting prescription drug misuse by identifying patients’ drug-seeking behaviors such as magnifying symptoms, relating multiple somatic complaints, and insisting that other (less addictive or over-the-counter) medications do not work.

RNs should be familiar with the general indicators of drug abuse, which include sudden, unexplained mood changes; irritability or aggression; abnormal fluctuation in concentration or energy; becoming confused; impairment of short-term memory; and loss of interest in work or usual activities.¹⁷

Specific attention to women, adolescents, and the elderly is crucial to early intervention. The RN who provides medication education should evaluate a patient’s reliability in taking a medication. Adolescents may lack the maturity to understand the consequences of drug misuse, and elderly patients may inadvertently misuse medications because of vision or memory deficits.

RNs should assess susceptibility for all patients in these at-risk populations. A prior history of substance abuse or a family history of such abuse may put patients in these categories at even greater risk.

Nurses need to take a careful prescription drug history from patients and also ask about present and past alcohol and drug use, including the use of OTC and herbal products. Studies indicate that as many as half of all patients sampled for appropriate prescription drug use deviate from prescription directions by not taking the drug, taking the medication improperly (taking the incorrect quantity per dose or the incorrect total daily dose), omitting or doubling doses, or discontinuing the medication abruptly or prematurely.⁶

Contracting with patients who are at high risk for abuse often is effective and involves entering into an agreement with patients that specifies that the provider will refuse to order refills without an office visit or will recommend patients go to the emergency room when requesting early refills.

To instruct patients, nurses should write out the times of day the medication should be taken, suggest the use of drug boxes that allow patients to organize their prescription for each day of the week, and provide clearly written drug information.  Patient information should emphasize the importance of correct use, reporting adverse reactions and the abuse potential of specific drugs. In addition, nurses should advise patients to obtain the following information for a new medication:

• The name of the medication and what it is supposed to do.
• How and when to take it and for how long.
• What foods, drinks, and other medicine or activities to avoid while taking the medication.
• Any side effects and what should be done if they occur.
• Whether the prescription will work safely with other prescription or nonprescription drugs such as vitamins, herbal remedies, or OTC medications.
• Written information on the medication.