Abuse of prescription drugs has been a national problem for decades, but recently the number of young Americans using prescription drugs for nonmedical purposes has been increasing at an alarming rate. Between 1999 and 2006, the US Department of Health and Human Services reports, the number of surveyed 12- to 17-year-olds who reported nonmedical use of a psychotherapeutic medication within the previous year increased by more than 60%.1
High-profile cases have thrust the problem into public view. In July 2007, the son of former Vice President Al Gore was arrested on suspicion of illegal possession of Vicodin®, Xanax®, Valium®, and Adderall®.2 And in January 2008, the 28-year-old actor Heath Ledger was found dead of acute intoxication resulting from the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine.3
Recent public awareness campaigns have taken up the fight against prescription drug abuse, as demonstrated in television ads from the Partnership for a Drug-Free America (www.drugfree.org). Their clear message is that abuse of prescription drugs can be as dangerous as that of illicit drugs like cocaine or heroin.
In 2005, an estimated 1.4 million US emergency department (ED) visits were related to substance abuse—in 37% of cases, abuse of prescription drugs. Prescription drug overdose is common among 12- to 17-year-olds, with more than 13,000 ED visits per year attributed to overmedication.4 The prescription drugs that are most commonly abused have potentially serious adverse effects and can cause accidental disability or death. They are also frequently implicated in suicide attempts: 45% involve prescription pain medication and 56%, sedatives or stimulants.4
It is imperative for clinicians, especially emergency medicine providers (EMPs), to appreciate the magnitude of prescription drug abuse among adolescents so that overdoses or chronic abuse can be identified appropriately, and treatment and prevention strategies can be implemented. An understanding of the basic pharmacology and toxicology of commonly abused prescription medications is especially helpful.
Awareness of the current trends and demographics of prescription drug abuse will enable EMPs to reevaluate their prescribing practices. The challenge is to maximize safe and effective treatment while minimizing the diversion of prescription drugs and the development of substance abuse disorders.
Defining the Problem
Using the three behavioral variables of intent, practice, and consequences, this definition can be established: Prescription drug abuse is the use of a controlled substance for reasons other than that for which it was prescribed, often in dosages different from those prescribed, resulting in disability or dysfunction and often involving illegal activity and risk of harm to the abuser.5
The National Institute on Drug Abuse6 designates prescription drugs with potential for abuse as psychotherapeutics. Classes of psychotherapeutics, in descending order of prevalence of abuse, are pain relievers, tranquilizers, stimulants, and sedatives.1
Increasing Prevalence
The most recent National Survey on Drug Use and Health (NSDUH) showed use of illicit drugs and overall teen drug use at a five-year low. Since 2002, current illicit drug use among 12- to 17-year-olds has declined by 16%, including an 18% decrease in current marijuana use and a marked 25% decrease in marijuana use among teenage boys.1,7,8
Yet these promising findings are overshadowed by the alarming number of young people who report misusing prescription drugs. More youth now initiate drug use with prescription pain relievers than with marijuana.1 In two recent studies, 5.2 million respondents 12 or older had used prescription pain relievers nonmedically in the previous month—a 10% increase since 2005. Concurrently, overall nonmedical use of prescription drugs among 12- to 17-year-olds increased by 12%.1,7 (See figure.1)
Among adolescents, pain relievers are the most commonly abused prescription drugs. On an average day in 2006, 2,517 adolescents used pain relievers nonmedically for the first time.1 The wide availability of these drugs contributes significantly to the problem. A recent analysis of Drug Enforcement Administration (DEA) data shows that in 1996, Americans purchased more than 200,000 pounds of codeine, hydrocodone, meperidine, morphine, and oxycodone. Between 1997 and 2007, the volume of five major painkillers distributed in the US rose by 90%. Sales of oxycodone alone rose nearly 600% between 1997 and 20059,10 (see Table 19-11).
The simultaneous decline in use of illicit drugs and increase in prescription drug abuse may be explained in part by teenagers' perception that abusing prescriptions is less harmful and less risky than using illicit street drugs. Widespread direct-to-consumer advertising for pain relievers, psychotropics, and sedatives may also lead teens to rationalize their use of prescriptions.
What Demographics Tell Us
Prevalence of prescription drug abuse by adolescents varies by region, ethnicity, and gender. It is highest in small cities and the Western states and lowest in urban areas of the Northeast. Prevalence rates are highest among American Indians or Alaska Natives (17%) and lowest among adolescents of Asian descent (7%). In general, Caucasian youths are more likely to misuse prescription psychotherapeutics than are African-Americans or Asian-Americans.1