Prescription Drug Addiction When People

Prescription Drug Addiction

When people think of drug addiction, they usually picture the use of illegal drugs such as heroin or crack cocaine, but people who use prescriptions drugs for non-medical purposes -- and become dependant and preoccupied with a compulsive need for them -- have become a serious problem in the United States (Meadows, 2001).

Ukens (2005) reports that controlled prescription drug abuse nearly doubled between 1992 and 2003 -- from 7.8 million to 15.1 million. Prescription drug abuse among teenagers has risen by 212%. There has been an 81% increase in prescription drug abuse in adults over 18. The U.S. Drug Enforcement Administration reported 146 deaths attributable to OxyContin abuse in 2000 and 2001. Former U.S. Secretary of Health, Education, and Welfare, Joseph Califano, Jr. states, "Our nation is in the throes of an epidemic of controlled prescription drug abuse and addiction" (cited in Ukens, 2005, p. 8).

According to Lisa Kiebzak, the director of a substance abuse program in Florida, many people use opioids (such as Vicodin and OxyContin) "to heal psychological wounds" (cited in Sverdlik, 2005). Moreover, the Substance Abuse and Mental Health Services Administration states nearly one-quarter of Americans between the ages of 18 and 25 take painkillers recreationally. The abuse of OxyContin, for example, has jumped 40%. Among adults who are 26 and older, the jump was 60% (Sverdlik, 2005). Painkillers, obtained legally by prescription only, have great potential for abuse and addiction, but their users often think taking them is safer than abusing heroin or a "street drug." They think it's okay because it is prescription "medicine" -- so what could be the harm?

Three categories of prescription drug abuse have been identified: (1) Patients who come to the doctor with an already established dependence on a prescription drug; (2) patients who develop drug dependence during the course of taking drugs that were prescribed by a physician; and (3) patients who come to the doctor seeking drugs in order to divert them -- that is, to get drugs they intend to sell (Gerada & Ashworth, 1997). Additionally, heroin users often turn to prescription drugs when they cannot obtain heroin (Bailes, 1998).

The problem is not that potentially addictive drugs should never be prescribed or used. They have an important place, particularly in the control of severe or chronic pain. People suffering from cancer, for example, have terrible pain, and need medicine to control it. Even a history of substance abuse doesn't completely rule out using potentially addictive drugs. Some doctors are so concerned and worried about penalties for over-prescribing these substances that they fail to treat patients in pain appropriately (Meadows, 2001). According to Longo et al. (2000), "Physicians' concerns about possible legal, regulatory, licensing or other third-party sanctions related to the prescription of controlled substances may contribute significantly to the under-treatment of pain syndromes and anxiety disorders" (p. 2401). Obviously, patients who have legitimate medical problems may truly need them.

Furthermore, when drugs are taken exactly as prescribed, addiction is actually uncommon. Problems arise when patients increase the dose in hopes of gaining more relief or begin to take more sooner than prescribed instead of waiting for the first dose to work. This can lead to addiction and to addiction-related behaviors such as doctor-shopping, fraudulent prescriptions, pharmacy thefts, and various techniques addicts use, such as the use of scams to obtain drug supplies (Byrd, 2001; and Longo et all, 2000). The problem of prescription drug addiction is not simple at all. The ineffectiveness of many drug treatment programs along with social and cultural factors that complicate the issue of drug abuse make it a complex social issue.

Drug abuse can affect people from infancy to old age. The children of addicts often suffer neglect or maltreatment, and as they grow up may develop malnutrition, poor self-esteem, depression or attention deficit disorder. Conditions like these often lead to adolescent drug use, early pregnancy, and dropping out of school. If drug abuse is not identified and help forthcoming, the next generation may fall victim as well.

Doctors get investigated by State Licensing Boards more frequently for over-prescribing controlled substances than for any other allegation. Not only that, the street value of prescription drugs is more than for heroin, and second only to cocaine. Longo et al. (2000) points out, "This sets up an unfortunate paradox for physicians: the desire to relieve pain, anxiety and other discomfort must be weighed against the fear of creating addiction, of being investigated by law enforcement or licensing authorities, and of being 'scammed' by the occasional patient who abuses opioid analgesics, sedative-hypnotics or psychostimulants" (p. 2402).

Brief History of Substance Abuse

During the 19th century patented (over-the-counter) medicines often contained morphine and opium, which were used for relief of coughing, diarrhea, dysentery, and "women's pains." These drugs were the only effective remedies available to doctors for pain. They were readily available to patients from pharmacists and physicians. There were no laws to control their sale or use, and pharmaceutical companies advertised them heavily. Coca Cola, originally developed as a "health drink" and sold in drug stores, contained cocaine, but most doctors considered it a "harmless stimulant." Parke-Davis produced cocaine in forms that could be sniffed, injected, and smoked. In the U.S. The use of cocaine spread quickly and stories began to appear in newspapers about overdoses, addictions, reactions, and antisocial behavior. About the same time, morphine became a prescription drug, and its use declined as people became more aware of the possibility of addiction (Byrd, 2001).

Early in the 20th century Federal laws were enacted to control drug abuse. Specifically, the Harrison Narcotic Act of 1914 made it illegal to buy more than a small quantity of opium, morphine, heroin or cocaine unless prescribed by a doctor. Opiate abuse declined after that except among middle and upper class people, who presumably could afford to buy "under the counter." Cocaine's popularity declined except with Hollywood celebrities and underworld criminals. Marijuana came to the United States with Mexican workers during the 1920s and '30s and became popular with jazz musicians. Concern about drug abuse was at low ebb at that time, at least, comparatively (Byrd, 2001).

Concerns changed, however, after World War II when pharmaceutical companies began to design tranquilizers, sleep inducing remedies, and mind-altering drugs to treat anxiety, depression, and to help people lose weight. By the 1960s and '70s most people viewed drug addiction as a symptom of psychological problems that required hospitalization. At that time the use of psychedelic drugs became widespread among young people and "barbiturates, amphetamines, and cocaine became readily available to athletes and the wealthy" (Byrd, 2001).

The 1980s and '90s brought crack cocaine and "designer drugs." A designer drug is a synthetic derivative of a prescription drug and produced in a laboratory. But any drug that has been redesigned for easier use or greater appeal may be called a designer drug -- crack cocaine, for instance (Byrd, 2001). By 2000 prescription drug addiction had increased alarmingly.

What is Addiction?

The Merck Manual of Diagnosis and Therapy (2006) suggests there is no universally accepted definition of drug abuse, and that the term expresses society's disapproval more than the behavior associated with it. Merck goes on then to state, "It may involve experimental and recreational use of drugs, which is usually illegal; unsanctioned or illegal use of psychoactive drugs to relieve problems or symptoms; or use of drugs first for the previous two reasons but later because of dependence and the need to continue at least partially to prevent withdrawal" (p. 1683). The term drug abuse, according to Longo et al. (2000) refers to using a prescription drug in a manner that is inconsistent with the doctor's intention. Addiction "is a further evolution of this preoccupation, with loss of control and acquisition of an obsessive-compulsive pattern that takes on a life of its own as a primary illness" (p. 2409). The Merck Manual (2006) describes addiction as, "compulsive use and overwhelming involvement with a drug, including spending an increasing amount of time obtaining the drug, using the drug, or recovering from its effects..." (p. 1683).

When an individual takes a drug for a long period of time and in high enough doses, the body adapts to it and develops a tolerance to it. Bigger doses are needed to produce the same effect (Carlson, Eisenstat, & Ziporyn, 2004). According to Alice Young, Ph. D. At Wayne State University in Detroit, "If the patient stops taking the drug, then withdrawal will occur" (cited in Meadows, 2001, p. 19). To avoid withdrawal symptoms, the patient has to taper down the doses gradually, taking progressively smaller and smaller amounts. Physical dependence does not necessarily lead to addiction, however, and naturally, that raises the question why some people become addicted but others do not. Byrd (2001) states, "Dopamine, a neurotransmitter in the brain, appears to be the major determinant in whether or not a person progresses from casual substance use to substance abuse" (p. 65).

Addiction is a brain disease and requires professional treatment to detoxify the body (get the drug out of the system) and to stop future use (Meadows, 2001). Usually, both physical and psychological components need to be addressed. Byrd (2001) explains, the function of brain cells (neurons) is affected when a drug is used repeatedly over a long period of time. Each neuron produces and releases chemicals called neurotransmitters. These neurotransmitters can impact the function of the nerve cell, making it produce and release hormones. "The neurotransmitters that have been associated with addiction include serotonin, dopamine, norepinephrine, gamma-amino-butyric acid, and glutamate" (p. 71). Drugs and the secretion of neurotransmitters can interfere with nerve cell functions and in some cases can damage them. Addiction becomes a fact when the body increases its level of resistance to immediate drug effects and develops a tolerance for the substance. As this happens, the brain tries to maintain a normal state, but the nerve cell membrane is changing. "Release of dopamine affects the part of the brain that regulates motor behavior. The destruction of the neurons that produce dopamine by substance abuse produces symptoms of Parkinson's disease, such as rigidity and tremor" (Byrd, 2001, p. 65).

Byrd (2001) explains that dopamine's role is to trigger the creation of a "memory of pleasure." The next time the person thinks about taking the drug there is an anticipation of pleasure already present. The Merck Manual of Diagnosis and Therapy (2006) explains, "A neural substrate for reinforcement (the tendency to seek more drugs and other stimuli) has been identified in animal models. In these studies, self-administration of such drugs as opioids, cocaine, amphetamine, nicotine, and benzodiazepines is associated with enhanced dopaminergic transmission in specific midbrain and cortical circuits. This finding suggests the existence of a brain reward pathway involving dopamine in the mammalian brain" (p. 1684).

As to the psychological aspects of addiction, the Merck Manual of Diagnosis and Therapy claims there is little scientific evidence that an "addictive personality" exists, although behavioral scientists have described it. Addicts are described as escapists, "people who cannot face reality and who run away" Others describe them as having schizoid traits -- "...fearfulness, withdrawal from others, feelings of depression and a history of frequent suicide attempts and numerous self-inflicted injuries" (p. 1685). Sometimes addicts are pictured as dependent and needy, grasping in relationships, and full of overt "unconscious rage and immature sexuality" (p. 1685). However, Merck points out that before these people got involved with drugs, they generally did not exhibit manipulative, "irresponsible behaviors" (p. 1685), so it's possible, if not probable, that these characteristics are related to the drug abuse and not part of the addict's basic "before-drugs" personality.

Drugs with Addictive Potential

The most commonly used drugs that lead to addiction on the market today are narcotic analgesics, also called opioids. Some of these are morphine, codeine, OxyContin, Vicodin, Demerol, Percadan, Percacet, Lortab and Dilaudid (Sverdlik, 2005; and Meadows, 2001). Currently, the most popular of these are OxyContin and Vicodin, which contain oxycodone HCI, an opioid similar to morphine in its addictive potential. Mortality and criminality are also associated with abuse of these drugs. Opioids work by blocking transmission of pain messages to the brain. A large single dose can produce euphoria, but can also depress respiration and cause death. Long-term use usually leads to physical dependence (Meadows, 2001).

Another class of drugs, to which people become addicted, is central nervous system depressants (tranquilizers, sedatives, and sleep aids). Usually, they are prescribed for anxiety, panic attacks, and sleep disorders. Nebutal, Valium, and Xanax are examples of central nervous system depressants that slow down normal brain function. The effect is usually a sleepy and uncoordinated feeling. Long-term use of these can also lead to physical dependence and addiction (Meadows, 2001).

A third category of drugs favored by drug abusers is central nervous system stimulants. These drugs were developed originally as "diet pills" because they lessen hunger. They are commonly used to treat narcolepsy, a sleeping disorder, and attention deficit hyperactivity disorder. Dexedrine and Ritalin are examples of CNS stimulants. People take them to increase alertness and energy, or to control their weight, but they elevate blood pressure, heart rate, and respiration and can be addictive. High doses can cause irregular heartbeat and high body temperature.

Longo et al. (2000) points out that all three categories of drugs have certain common characteristics. Self-administration studies have shown they are preferred over placebo, especially by patients who are addicted or have been addicted in the past. Although they affect different areas of the brain, they all cause dopamine release -- the "reward" pathway in the brain that causes anticipation of pleasure. All are habit-forming, lead to dependence, and have psychoactive effects. All of them have street value and a potential for abuse. Moreover, brand name drugs are worth more on the street than generic equivalents are because people feel sure they are getting the real thing.

Generally, addicts prefer drugs that have "a rapid onset of action, high potency, brief duration of action, high purity, water solubility (for intravenous use) or high volatility (ability to vaporize if smoked)" (Longo et al., 2000, p. 2402). Among benzodiazepines, Valium, Ativan and Xanax cross the blood-brain barrier more rapidly and have a high potential for abuse. Longo argues that a significant number of addicts started out using street drugs and progressed to prescription drugs as they became chronically ill. Sometimes, prescription drugs are used in conjunction with street drugs to heighten euphoric effects, alleviate withdrawal symptoms, augment alcohol effects synergistically, or temper cocaine highs.

Prescription Drug Abuse by Adolescents, Women, and the Elderly survey in 2002 at a rural Michigan high school revealed that 98% of the pupils knew about OxyContin, and 9.5% had tried it. Among those who had tried it, 50% reported taking it more than 20 times. Among the students who responded to the survey, 72% said OxyContin was "not at all hard to get..." (Katz & Hays, 2004). Adolescents are certainly not the only ones abusing OxyContin, but they seem to be more vulnerable to addiction. "The time from first exposure to abuse of or dependence on OxyContin may be more rapid due to (1) the wide availability of the drug in pharmacies and doctor's offices and on the street; (2) its aggressive marketing and promotion in an atmosphere of optimal pain management; (3) its positive image in comparison to heroin; (4) the ability to begin use with oral ingestion and to progress to snorting or intravenous use; and (5) the ease with which the tablet is crushed, thus destroying the controlled-release coating and making the active ingredient immediately available for a powerful heroin-like high" (Katz & Hays, 2004, p. 232). Because we live in a "pain culture" where young people constantly see reliance on pain medications modeled by adults and encouraged in media advertising, prescription drugs may seem more acceptable to adolescents than illegal drugs.

Women also appear to be more vulnerable to opioids than men. Carlson, Eisenstat, and Ziporyn (2004) call mood-altering drugs -- especially sedatives and tranquilizers -- a "major substance abuse problem" (p. 581). This may be because mood-altering drugs are often prescribed earlier -- at a younger age -- for women than for men. They are also prescribed more frequently for women, perhaps because women are more likely to seek help for emotional problems than men are. The opioids have a higher risk for dependence, especially if the woman has chronic pain. Women are also more likely to abuse diet pills (CNS stimulants). They start taking them for appetite suppression and weight control, despite the fact that amphetamines are rarely effective in the long-term, and within weeks users develop a tolerance to them. "As larger doses are taken to produce the same effects, women may become irritable, anxious, or overconfident and various physical symptoms may occur including blurred vision, dizziness, and insomnia." Chronic use of amphetamines can result in damage to the heart and blood vessels, irrational outbursts of anger, psychiatric problems, and susceptibility to infections (Carlson, Eisenstat, & Ziporyn, 2004).

Aging appears to produce greater sensitivity to drugs. A dose, for example, that is appropriate for a younger person might be too much in an older person. Many older people take multiple medicines, and when those that depress the Central Nervous System are mixed with tranquilizers or opioids, the effect can be very dangerous and even result in death. Older women, particularly, are often reticent to question the doctor about drug interactions, drug dependency, or addictive potential for fear of seeming to challenge the doctor's authority (Carlson, Eisenstat, and Ziporyn, 2004), so it's a problem doctors need to keep in mind.

Drug Seekers

Certain characteristics are common in persons who are addicted to prescription drugs. One is escalating use. A drug-seeker may exhibit manipulative, demanding behavior in order to obtain a prescription. He or she may claim his only chance of improving is to get a prescription for an addictive substance. A drug-seeker may describe symptoms that are not supported by physical evidence or insist that non-addictive medicines "don't work." He or she may claim to be allergic to non-addictive medicines. The drug-seeker may claim his medicine was lost or stolen or that he ran out early (Longo, et al., 2000). Addicts also sometimes forge prescriptions or use somebody else's prescription. He or she may try to set one doctor against another or threaten to get the drug he wants (needs) from a "more caring" or "smarter" doctor. The patient may offer bribes of money or sex to get a prescription. The patient may threaten to do the doctor bodily harm.

Some patients go to two or more doctors getting prescriptions from each one in order to obtain a more abundant supply. Sometimes addicts appear after hours in emergency departments claiming to be from out of town.

Doctors can work in cooperation with pharmacists to prevent this type of exploitation. Working together they can identify drug abusers.

A classic indicator of a scam is the patient's propensity to push the doctor when resistance is encountered. They are often "quite adept at projecting their misery and helplessness onto 'prospective prescribers'" (p. 2406). Once a scam has worked successfully, it will continue in that doctor's practice periodically until it is no longer successful. According to Longo et al. (2000), "Dealing with scams consists of learning to recognize the common ones and refusing to give in to them" (p. 2406).

Pharmaceutical Involvement

Doctors actually spend very little time learning about addiction and addictive behaviors in medical school (Meadows, 2001), and Ukens (2005) reports only 48% of pharmacists received any training at all in preventing drug theft or in recognizing drug seekers. But both doctors and pharmacists say a large part of the responsibility lies with pharmaceutical companies. Take Purdue, for example, the manufacturer of OxyContin. Purdue representatives ("detail men") encouraged doctors to prescribe OxyContin for minor ailments like chronic back pain. Currently, Purdue is facing more than 300 lawsuits for improper promotion of the drug as well as overly aggressive marketing (Gillis, 2004).

Spence (2004) and Critser (2006) discuss the modus operandi of drug companies whose top priority is to make money and the more, the better. It cannot be denied that making money they are, indeed. In 2004, for example, the combined worth of the world's top five drug companies "was twice the GNP of the whole of sub-Saharan Africa...with gross profit margins...around 70 to 80 per cent" (p. 32). Every year drug companies budget a substantial amount of money for doctor "perks," that is gifts, trips and other goodies such as branded pens, stethoscopes, and "sponsored" nights out. Naturally, the doctors are flattered and grateful. They sometimes change the drugs they prescribe as a result, so it's worth it to the drug companies to invest the money.

Pharmaceutical companies also pay doctors and hospitals to conduct research for them with the agreement that the drug company only will publish the findings. Spence (2004) points out that in order to remain profitable, pharmaceutical companies have to invent new drugs regularly. "In the last six years," he states, "U.S. pharmaceutical firms have introduced 487 drugs to the market" (p. 33). When they think they have come up with a new drug that will make money, they ask doctors and hospitals to test it. Some hospitals depend on drug company research money to stay open. The doctors and hospitals do the research, but the drug company only is entitled to interpret the findings. They employ ghostwriters to put a positive spin on the findings and suppress negative views. The findings will be published in medical journals that rely on drug company advertising to stay afloat. Later, they will advertise the research on television as "impartial," which always increases sales. "After the research is published, and the drugs cleared, high-flying doctors in the NHS, along with a coterie of health editors from the national press, are often whisked away to five-star hotels to attend glitzy international drug launches. These all-expenses-paid promotional trips are passed off as 'educational.' As a result, top doctors and journalists are given a warm feeling about the companies and act as advocates for their new drugs" (Spence, 2004, p. 38).

Drug company sales representatives who visit doctors to hawk their products are influential. A survey done in 2003 revealed that general practitioners who allowed detail men to see them in the office at least once a week were more likely to prescribe drugs that really were not necessary to preserve the health of the patient. The National Center on Addiction and Drug Abuse also found that information provided to doctors by drug representatives is not really helpful, especially when doctors are deciding what medication will be best for a particular patient.