Imagine the teenager who walks into his parent’s bathroom looking for ibuprofen (e.g., Advil) for a headache. As he’s scanning the shelves, he sees a pill bottle labeled “hydrocodone” (or Vicodin). Something seems familiar about this—oh yeah, some kids at a party last weekend were raving about how great these pills made them feel. The teen takes two, hoping his mother won’t notice—which she may not since they were prescribed six months ago following dental surgery.
That’s how easy it can be for some teens to obtain potentially addictive and dangerous drugs. In 2007, the National Survey on Drug Use and Health (NSDUH) found that over half (57 percent) of individuals reporting nonmedical use of psychotherapeutics got them “from a friend or relative for free” (SAMHSA, 2008). Greater access to and availability of prescription medications make them easy to obtain. In fact, the total number of stimulant prescriptions in the United States has soared from around 5 million in 1991 to nearly 35 million in 2007. Prescriptions for opiates (hydrocodone and oxycodone products) have escalated from around 40 million in 1991 to nearly 180 million in 2007.
The National Institute on Drug Abuse (NIDA) has been increasingly concerned with the high rate of prescription drug abuse, especially among adolescents. NIDA’s most recent Monitoring the Future study found in 2008 that nearly one in 10 high school seniors reported abusing Vicodin within the past year, and nearly one in 20 reported abusing OxyContin. Moreover, of the top 11 drugs most commonly abused by high school seniors, seven are either prescribed or purchased over the counter (see Figure 2).
Many are shocked to learn that approximately 7 million Americans report past-month nonmedical use of prescription drugs—more than the number of persons abusing cocaine, heroin, hallucinogens and inhalants combined (SAMHSA, 2008). Nonmedical use is defined in NSDUH as use of medications without a prescription, or simply for the experience or feeling the drug caused.
What is going on here? Before we ad-dress that question, it is helpful to know how different prescription drugs work in the brain and body. The effects and properties of commonly abused prescription drugs are summarized below.
Commonly abused prescription drugs
Although many prescription drugs can be abused, the three most common classes include the following:
Opioids, most often prescribed to treat pain;
Central nervous system (CNS) depressants, used to treat anxiety and sleep disorders; and
Stimulants, prescribed to treat attention-deficit hyperactivity disorder (ADHD), and sometimes, the sleep disorder, narcolepsy.
Opioids. Medications that fall within this class—referred to as prescription painkillers—include morphine, codeine, oxycodone (e.g., OxyContin) and related drugs. Opioids are commonly prescribed because of their effective analgesic or pain-relieving properties. Morphine, for example, is often used before and after surgical procedures to alleviate severe pain.
Opioids attach to specific proteins called opioid receptors, which are found in the brain, spinal cord and gastrointestinal tract, among others. When these drugs bind to their receptors, they can alter the perception of pain; produce drowsiness, nausea, constipation; and, depending upon the amount of drug taken, depress respiration. Opioid drugs also can induce euphoria by affecting the brain regions that influence reward. People who abuse opioids will often intensify this feeling by grinding up the pills and snorting or injecting them. Snorting drugs like OxyContin increases the risk for serious medical consequences, such as opioid overdose (Lynskey, et.al., 2003).
Taken as directed, opioids can be used to manage pain effectively. Many studies have shown that when properly managed, short-term medical use of opioid analgesic drugs is safe and rarely causes addiction, defined as the compulsive and uncontrollable use of drugs despite adverse consequences. Long-term use of opioids, even if taken as prescribed, can lead to physical dependence (i.e., when the body adapts to the presence of a drug), producing tolerance (i.e., a need for higher dosages of the drug to produce an effect) and withdrawal symptoms when the drug is reduced or stopped abruptly. Withdrawal symptoms include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”) and involuntary leg movements. Nonmedical use of opioids can lead to addiction and/or overdose. Even a large single dose of an opioid could cause severe respiratory depression that can lead to death.
Only under a physician’s supervision can opioids be used safely with other drugs. Typically, they should not be used with other substances that depress the CNS, such as alcohol, antihistamines, barbiturates, benzodiazepines or general anesthetics, because these combinations increase the risk of life-threatening respiratory depression.
Central Nervous System Depressants. CNS depressants, sometimes referred to as sedatives and tranquilizers, are substances that can slow normal brain function. Because of this property, some CNS depressants are useful in the treatment of anxiety and sleep disorders. Among the medications that are prescribed for these purposes are barbiturates, such as pentobarbital sodium (Nembutal), most often used as a preanesthetic to induce sleep before surgery, or to treat seizures or insomnia; and benzodiazepines, such as alprazolam (Xanax), prescribed to treat anxiety and acute stress reactions. The more sedating benzodiazepines, such as triazolam (Halcion) and estazolam (ProSom) are prescribed for short-term treatment of sleep disorders. Usually, benzodiazepines are not prescribed for long-term use.
Most CNS depressants affect the neurotransmitter gamma-aminobutyric acid (GABA), which generally functions to inhibit brain activity. By increasing GABA, CNS depressants produce a drowsy or calming effect that can be beneficial to those suffering from anxiety or sleep disorders.
Despite their many beneficial effects, barbiturates and benzodiazepines have the potential for abuse and addiction, and should be used only as prescribed. During the first few days of taking a prescribed CNS depressant, a person usually feels sleepy and uncoordinated, but as the body becomes accustomed to the drug’s effects, they begin to lessen. Over time, the body can develop tolerance to many of the drugs’ effects, requiring larger doses to achieve the same initial benefits. Continued use leads to physical dependence, and when use is reduced or stopped, withdrawal. Because all CNS depressants work by slowing the brain’s activity, when a person stops taking them, the brain’s activity can rebound, potentially leading to seizures and other harmful consequences. Although withdrawal from benzodiazepines can be problematic, it is rarely life threatening. However, withdrawal from prolonged use of other CNS depressants can lead to life-threatening complications. Therefore, someone who is planning to discontinue CNS depressant therapy or who is suffering withdrawal from a CNS depressant should speak with a physician or seek medical treatment.
CNS depressants should be used in combination with other medications only under a physician’s close supervision. Typically, they should not be combined with any other medication or substance that causes CNS depression, including prescription pain medicines; some over-the-counter (OTC) cold and allergy medications; and alcohol. Using CNS depressants with these other substances, particularly alcohol, can slow both the heart and respiration, and may lead to death.
Stimulants. As the name suggests, stimulants increase alertness, attention and energy, as well as elevate blood pressure and increase heart rate and respiration. Stimulants historically were used to treat asthma and other respiratory problems, obesity, neurological disorders and a variety of other ailments, but as their potential for abuse and addiction became apparent, the medical use of stimulants began to wane. Now, stimulants are prescribed only for the treatment of a few health conditions, including ADHD, narcolepsy and depression that has not responded to other treatments.
Stimulants, such as dextroamphetamine (e.g., Adderall) and methylphenidate (e.g., Ritalin and Concerta), have chemical structures similar to a family of key brain neurotransmitters called monoamines, which include norepinephrine and dopamine. Stimulants enhance the effects of these chemicals in the brain. Oral formulations produce only modest increases in these chemicals, but if stimulants are taken at high doses or by other routes (e.g., crushed and snorted), these medications can dramatically increase dopamine, producing a sense of euphoria similar to illicit stimulants like cocaine. Stimulants also increase blood pressure and heart rate, constrict blood vessels, increase blood glucose and open up respiratory pathways.
As with other drugs of abuse, it is possible for people to become dependent on or addicted to stimulants. Taking high doses may result in dangerously high body temperature, an irregular heartbeat, cardiovascular failure or seizures. Repeated use of some stimulants can lead to feelings of hostility or paranoia, anxiety, weight loss and sleep disturbances. Withdrawal symptoms also can occur following abrupt cessation of chronic use—these include fatigue, depression and sleep disruptions.
As with any prescription drug, stimulants should be used in combination with other medications only under a physician’s supervision. Patients also should be aware of the dangers associated with mixing stimulants and OTC cold medicines that contain decongestants; combining these substances may cause blood pressure to become dangerously high or lead to irregular heart rhythms.
Prescription drugs: a hidden threat
Many young people do not perceive their nonmedical use of physician-prescribed drugs as dangerous—after all, these are prescription drugs, so how bad can they be for you, goes the reasoning. But while the proper use of prescription drugs can be lifesaving, the consequences of their abuse can be as dangerous as those from illegal drugs, leading to emergency department (ED) visits.
In 2004, almost 8,000 visits to the ED involved methylphenidate (marketed as Ritalin or Concerta) or amphetamine (marketed as Adderall). Also, the rates of ED visits resulting from the non-medical use of either of these medications were higher among 12- to 17-year-olds than 18 and older. Data suggests that poly-drug use was common in these ED visits, and could increase health risks (SAMHSA, 2006). In 2006, 65,000 emergency room visits involved the nonmedical use of pharmaceuticals by those aged 12 to 17 (SAMHSA, 2006).
Indeed, adolescents may be at particular high risk for the deleterious consequences of prescription drug abuse. Research has shown that the earlier drug abuse is initiated, the more likely an individual will become addicted (Lynskey, et. al., 2003). Addiction is considered a “developmental” disease because it typically begins during the critical teen years when the brain is still developing. The brain does not fully mature until a person is in their 20s (Gogtay, N., Giedd, J.N., et. al., 2004). Scientists suspect that the brain’s inherent flexibility, or “plasticity,” during this time puts young people at greater risk of addiction when they abuse drugs (see Figure 1). It is particularly troubling that approximately one in five seventhto twelfthgraders who admitted to any lifetime drug abuse in a large research survey answered “No” when asked whether in the past 12 months they were always able to stop abusing drugs when they wanted to (Boyd et. al., 2006).
According to results from a recent analyses of aggregated NSDUH data from 2002 to 2004, approximately one-fourth of 12- to 17-year-olds said they used a prescription drug nonmedically for between 12 and 49 days over the past year; and more than one in 10 of past-year nonmedical users used between 100 and 299 days. Indeed, dependence or abuse involving any prescription psychotherapeutic drug (as defined by DSM-IV), is greater among past-year nonmedical users in the 12- to 17-year-old age group than for young adults ages 18 to 25—15.9 percent versus 12.7 percent (Colliver, J.D., Kroutil, L.A. & Gfroerer, J.C., 2006). Within this user group, the data suggest that girls may be more vulnerable than boys to developing abuse and dependence involving any prescription psychotherapeutic drug. Also disturbing is the percentage of pregnant females 15- to 17-years-old reporting nonmedical use of prescription medications—18.2 percent, a rate much higher than pregnant women aged 18 or older (Colliver, J.D., Kroutil, L.A. & Gfroerer, J.C., 2006).
Adolescents’ use of prescription medications seems to tie in with their engaging in other risky behaviors. For example, adolescents’ nonmedical use of pain medication is part of a cluster of risk behaviors that includes cigarette smoking, binge drinking, marijuana abuse and other illicit drug abuse. A recent study found that “compared to nonusers, those who reported nonmedical use of prescription drugs were seven times more likely to smoke cigarettes, five times more likely to drink alcohol and smoke marijuana, almost four times more likely to binge drink, and eight times more likely to have abused several other drugs” (Boyd et. al., 2006). Further, young people who abuse prescription drugs commonly mix them with other drugs, particularly alcohol, which amplifies the risk of overdose and even death.
Unlike abusers of illicit or “street” drugs, adolescents and young adults seem to fall into two groups of prescription drug abusers: those who seek to medically “self-treat” and those who want to get high or experiment. This idea challenges our notion of what an adolescent substance abuser is.
While girls and boys both abuse prescription drugs for several of the same reasons, one large survey found that girls are more likely to do so for their intended effects (e.g., stimulants to increase alertness), while boys are more likely to report that they abuse the drugs to get high (Boyd et. al., 2006). In the case of nonmedical use of prescription stimulants (e.g., Ritalin, prescribed for ADHD), girls name “alertness” and “concentration” as their top two reasons (~50 percent of females v. 25 percent of males), while boys name “high” and “experimentation” (~65 percent of males v. 40 percent of females) as theirs (Boyd et. al., 2006).
These motives point to the need for prevention messages targeted to unique user groups. Interventions that show promise are discussed later in this article.
Prescription drug sources
As stated previously, the leading source for nonmedically used pain medication appears to be family and friends (SAMHSA, 2006). Preliminary evidence suggests that parents sometimes provide their children with prescription medications to relieve their discomfort, not to get them “high,” of course (Boyd et. al., 2006). Some psychologists suggest that abuse of these medications may indeed stem from modeling by family members and social networks (Compton, W. & Volkow, N., 2005), one of a set of potential motivations that need more exploration. These are keys reasons why parents must be proactively involved in preventing prescription drug abuse by their kids. Counseling parents to lock away prescription drugs with abuse liability is a good start.
The data demand that we act now before the problem of prescription drug abuse escalates further. Increases in a number of key indicators and troubling research findings call for immediate action. NIDA is committed to raising awareness of this problem and we hope that, as counselors, you agree that this is a topic worth responding to. While the data seem grave, there is hope, as demonstrated by science-based research revealing effective intervention strategies for adolescents.
Prevention science has made great progress in recent years. Many interventions are being tested in “real-world” settings so they can be more easily adapted for community use. Scientists are studying a broader range of populations and topics. They have identified, for example, effective interventions with younger populations to help prevent risk behaviors before drug abuse occurs. Researchers are also studying older teens who already use drugs, to find ways to prevent further abuse or addiction.
A new study examined the long-term effects of universal preventive interventions on prescription drug misuse (Spoth, R. Trudeau, L., Shin, C. & Redmond, C., 2008). The interventions tested were the Iowa Strengthening Families Program (ISFP), Preparing for the Drug- Free Years and a control condition. Among other findings, the study revealed that students taking part in the Iowa Strengthening Families Program reported significantly less past year and lifetime nonmedical opioid use than control condition participants (0 percent of ISFP participants compared to 3.8 percent of controls; and 0.6 percent of ISFP participants compared to 8.7 percent of controls, respectively).
Another recent NIDA-funded study found that beginning prevention programs early can yield great rewards. The Positive Action program was a trial that took place in 20 public elementary schools (Kindergarten through fifth grade, or Kindergarten through sixth grade) on three Hawai`ian islands (Beetman, in press). The study followed two cohorts of students who began the program in the first or second grades and who received up to four years of the intervention. In the fifth grade, students were asked to complete a questionnaire. Results showed a 58 percent reduction in self-reported substance use and violent behaviors, as well as a 76 percent reduction in the odds of having voluntary sex. The study’s authors note there were four key factors that were most likely responsible for the large effect sizes: (1) interactive presentation formats; (2) a comprehensive approach that involved students, teachers and parents; (3) a comprehensive approach to social and emotional development; and (4) the intensive nature of the program. This study highlighted the fact that when initiated early, prevention programs can have dramatic and lasting effects.
Although not a new problem, prescription drug abuse is one that deserves renewed attention. NIDA hopes to decrease the prevalence of this problem by increasing awareness and promoting additional research. It is imperative that as a Nation we make ourselves aware of the consequences associated with the misuse and abuse of these medications. As counselors, you are in unique positions to help bring attention to this urgent public health problem. A key component to addressing prescription drug abuse among youth is opening the lines of communication between not only youth and their parents but also between healthcare professionals, parents and youth and as healthcare professionals you can be a key part of this process.
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