Most people who take prescription medications take them responsibly; however, the nonmedical use or abuse of prescription drugs remains a serious public health concern. Certain prescription drugs - opioids, central nervous system (CNS) depressants, and stimulants - when abused, can alter the brain's activity and lead to dependence and possibly addiction.

An estimated 9 million people aged 12 and older used prescription drugs for nonmedical reasons in 1999; more than a quarter of that number reported using prescription drugs nonmedically for the first time in the previous year. We would like to reverse this trend by increasing awareness and promoting additional research on this topic.

The National Institute on Drug Abuse (NIDA) provides information to answer questions about the consequences of abusing commonly prescribed medications. In addition to offering information on what research has taught us about how certain medications affect the brain and body, they also cover treatment options.

This publication was developed to help health care providers discuss the consequences of prescription drug abuse with their patients. According to a recent national survey of primary care physicians and patients regarding substance abuse, 46.6 percent of physicians find it difficult to discuss prescription drug abuse with their patients.

Prescription drug abuse is not a new problem, but one that deserves renewed attention. We hope this scientific report is useful to the public, particularly to individuals working with the elderly, who because of the number of medications they may take for various medical conditions, may be more vulnerable to misuse or abuse of prescribed medications.

In addition to opiates and stimulants, which are described in more detail on their own pages, here are details on some of the most often abused prescription medications:

CNS depressants

CNS depressants 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 commonly prescribed for these purposes are the following:

Barbiturates, such as mephobarbital (Mebaral) and pentobarbital sodium (Nembutal), which are used to treat anxiety, tension, and sleep disorders.
Benzodiazepines, such as diazepam (Valium), chlordiazepoxide HCl (Librium), and alprazolam (Xanax), which can be prescribed to treat anxiety, acute stress reactions, and panic attacks; the more sedating benzodiazepines, such as triazolam (Halcion) and estazolam (ProSom) can be prescribed for short-term treatment of sleep disorders.

In higher doses, some CNS depressants can be used as general anesthetics.

How do CNS depressants affect the brain and body?

There are numerous CNS depressants; most act on the brain by affecting the neurotransmitter gamma-aminobutyric acid (GABA). Neurotransmitters are brain chemicals that facilitate communication between brain cells. GABA works by decreasing brain activity. Although the different classes of CNS depressants work in unique ways, ultimately it is through their ability to increase GABA activity that they produce a drowsy or calming effect that is beneficial to those suffering from anxiety or sleep disorders.

What are the possible consequences of CNS depressant use and abuse?

Despite their many beneficial effects, barbiturates and benzodiazepines have the potential for abuse 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 effects of the drug, these feelings begin to disappear. If one uses these drugs long term, the body will develop tolerance for the drugs, and larger doses will be needed to achieve the same initial effects. In addition, continued use can lead to physical dependence and - when use is reduced or stopped - withdrawal. Because all CNS depressants work by slowing the brain's activity, when an individual stops taking them, the brain's activity can rebound and race out of control, possibly leading to seizures and other harmful consequences. Although withdrawal from benzodiazepines can be problematic, it is rarely life threatening, whereas withdrawal from prolonged use of other CNS depressants can have life-threatening complications. Therefore, someone who is thinking about discontinuing CNS depressant therapy or who is suffering withdrawal from a CNS depressant should speak with a physician or seek medical treatment.

Is it safe to use CNS depressants with other medications?

CNS depressants should be used with other medications only under a physician's 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 cold and allergy medications, or alcohol. Using CNS depressants with these other substances - particularly alcohol - can slow breathing, or slow both the heart and respiration, and possibly lead to death.

Trends in prescription drug abuse

Several indicators suggest that prescription drug abuse is on the rise in the United States. According to the 1999 National Household Survey on Drug Abuse, in 1998, an estimated 1.6 million Americans used prescription pain relievers nonmedically for the first time. This represents a significant increase since the 1980s, when there were generally fewer than 500,000 first-time users per year. From 1990 to 1998, the number of new users of pain relievers increased by 181 percent; the number of individuals who initiated tranquilizer use increased by 132 percent; the number of new sedative users increased by 90 percent; and the number of people initiating stimulant use increased by 165 percent. In 1999, an estimated 4 million people - almost 2 percent of the population aged 12 and older - were currently (use in past month) using certain prescription drugs nonmedically: pain relievers (2.6 million users), sedatives and tranquilizers (1.3 million users), and stimulants (0.9 million users).

Although prescription drug abuse affects many Americans, some trends of concern can be seen among older adults, adolescents, and women. In addition, health care professionals - including physicians, nurses, pharmacists, dentists, anesthesiologists, and veterinarians - may be at increased risk of prescription drug abuse because of ease of access, as well as their ability to self-prescribe drugs. In spite of this increased risk, recent surveys and research in the early 1990s indicate that health care providers probably suffer from substance abuse, including alcohol and drugs, at a rate similar to rates in society as a whole, in the range of 8 to 12 percent.

Older adults

The misuse of prescription drugs may be the most common form of drug abuse among the elderly. Elderly persons use prescription medications approximately three times as frequently as the general population and have been found to have the poorest rates of compliance with directions for taking a medication. In addition, data from the Veterans Affairs Hospital System suggest that elderly patients may be prescribed inappropriately high doses of medications such as benzodiazepines and may be prescribed these medications for longer periods than are younger adults. In general, older people should be prescribed lower doses of medications, because the body's ability to metabolize many medications decreases with age.

An association between age-related morbidity and abuse of prescription medications likely exists. For example, elderly persons who take benzodiazepines are at increased risk for falls that cause hip and thigh fractures, as well as for vehicle accidents. Cognitive impairment also is associated with benzodiazepine use, although memory impairment may be reversible when the drug is discontinued. Finally, use of benzodiazepines for longer than 4 months is not recommended for elderly patients because of the possibility of physical dependence.

Adolescents and young adults

Data from the National Household Survey on Drug Abuse indicate that the most dramatic increase in new users of prescription drugs for nonmedical purposes occurs in 12- to 17-year-olds and 18- to 25-year-olds. In addition, 12- to 14-year-olds reported psychotherapeutics (for example, painkillers or stimulants) as one of two primary drugs used. The 1999 Monitoring the Future survey showed that for barbiturates, tranquilizers, and narcotics other than heroin, the general, long-term declines in use among young adults in the 1980s leveled off in the early 1990s, with modest increases again in the mid- to late 1990s. For example, the use of methylphenidate (Ritalin) among high school seniors increased from an annual prevalence (use of the drug within the preceding year) of 0.1 percent in 1992 to an annual prevalence of 2.8 percent in 1997 before reaching a plateau.

It also appears that college students' nonmedical use of pain relievers such as oxycodone with aspirin (Percodan) and hydrocodone (Vicodin) is on the rise. The 1999 Drug Abuse Warning Network, which collects data on drug-related episodes in hospital emergency departments, reported that mentions of hydrocodone as a cause for visiting an emergency room increased by 37 percent among all age groups from 1997 to 1999. Mentions of the benzodiazepine clonazepam (Klonopin) increased by 102 percent since 1992.

Gender differences

Studies suggest that women are more likely than men to be prescribed an abusable prescription drug, particularly narcotics and anti-anxiety drugs - in some cases 48 percent more likely.

Overall, men and women have roughly similar rates of nonmedical use of prescription drugs. An exception is found among 12- to 17-year-olds: In this age group, young women are more likely than young men to use psychotherapeutic drugs nonmedically.

In addition, research has shown that women and men who use prescription opioids are equally likely to become addicted. However, among women and men who use either a sedative, anti-anxiety drug, or hypnotic, women are almost two times more likely to become addicted.

Preventing and detecting prescription drug abuse

Although most patients use medications as directed, abuse of and addiction to prescription drugs are public health problems for many Americans. However, addiction rarely occurs among those who use pain relievers, CNS depressants, or stimulants as prescribed; the risk for addiction exists when these medications are used in ways other than as prescribed. Health care providers such as primary care physicians, nurse practitioners, and pharmacists as well as patients can all play a role in preventing and detecting prescription drug abuse.

Role of health care providers

About 70 percent of Americans - approximately 191 million people - visit a health care provider, such as a primary care physician, at least once every 2 years. Thus, health care providers are in a unique position not only to prescribe needed medications appropriately, but also to identify prescription drug abuse when it exists and help the patient recognize the problem, set goals for recovery, and seek appropriate treatment when necessary. Screening for any type of substance abuse can be incorporated into routine history taking with questions about what prescriptions and over-the-counter medicines the patient is taking and why. Screening also can be performed if a patient presents with specific symptoms associated with problem use of a substance.

Over time, providers should note any rapid increases in the amount of a medication needed - which may indicate the development of tolerance - or frequent requests for refills before the quantity prescribed should have been used. They should also be alert to the fact that those addicted to prescription medications may engage in "doctor shopping," moving from provider to provider in an effort to get multiple prescriptions for the drug they abuse.

Preventing or stopping prescription drug abuse is an important part of patient care. However, health care providers should not avoid prescribing or administering strong CNS depressants and painkillers, if they are needed. (See box on pain and opiophobia.)

Role of pharmacists

Pharmacists can play a key role in preventing prescription drug misuse and abuse by providing clear information and advice about how to take a medication appropriately, about the effects the medication may have, and about any possible drug interactions. Pharmacists can help prevent prescription fraud or diversion by looking for false or altered prescription forms. Many pharmacies have developed "hotlines" to alert other pharmacies in the region when a fraud is detected.

Role of patients

There are several ways that patients can prevent prescription drug abuse. When visiting the doctor, provide a complete medical history and a description of the reason for the visit to ensure that the doctor understands the complaint and can prescribe appropriate medication. If a doctor prescribes a pain medication, stimulant, or CNS depressant, follow the directions for use carefully and learn about the effects that the drug could have, especially during the first few days during which the body is adapting to the medication. Also be aware of potential interactions with other drugs by reading all information provided by the pharmacist. Do not increase or decrease doses or abruptly stop taking a prescription without consulting a health care provider first. For example, if you are taking a pain reliever for chronic pain and the medication no longer seems to be effectively controlling the pain, speak with your physician; do not increase the dose on your own. Finally, never use another person's prescription.

Treating prescription drug addiction

Years of research have shown us that addiction to any drug, illicit or prescribed, is a brain disease that can, like other chronic diseases, be effectively treated. But no single type of treatment is appropriate for all individuals addicted to prescription drugs. Treatment must take into account the type of drug used and the needs of the individual. To be successful, treatment may need to incorporate several components, such as counseling in conjunction with a prescribed medication, and multiple courses of treatment may be needed for the patient to make a full recovery.

The two main categories of drug addiction treatment are behavioral and pharmacological. Behavioral treatments teach people how to function without drugs, how to handle cravings, how to avoid drugs and situations that could lead to drug use, how to prevent relapse, and how to handle relapse should it occur. When delivered effectively, behavioral treatments - such as individual counseling, group or family counseling, contingency management, and cognitive-behavioral therapies - also can help patients improve their personal relationships and ability to function at work and in the community.

Some addictions, such as opioid addiction, can also be treated with medications. These pharmacological treatments counter the effects of the drug on the brain and behavior. Medications also can be used to relieve the symptoms of withdrawal, to treat an overdose, or to help overcome drug cravings. Although a behavioral or pharmacological approach alone may be effective for treating drug addiction, research shows that a combination of both, when available, is most effective.

Treating addiction to CNS depressants

Patients addicted to barbiturates and benzodiazepines should not attempt to stop taking them on their own, as withdrawal from these drugs can be problematic, and in the case of certain CNS depressants, potentially life-threatening. Although no extensive body of research regarding the treatment of barbiturate and benzodiazepine addiction exists, patients addicted to these medications should undergo medically supervised detoxification because the dose must be gradually tapered off. Inpatient or outpatient counseling can help the individual during this process. Cognitive-behavioral therapy also has been used successfully to help individuals adapt to the removal from benzodiazepines.

Often the abuse of barbiturates and benzodiazepines occurs in conjunction with the abuse of another substance or drug, such as alcohol or cocaine. In these cases of polydrug abuse, the treatment approach must address the multiple addictions.

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