II. Epidemiology

  1. Prescription Drug Diversion is common
    1. Prescription Drug Abusers get their medications from family or friends in over 70% of cases
  2. For every 1 death from prescription abuse
    1. Treatment admissions for Opioid Abuse: 10
    2. Emergency department visits for misuse or abuse: 32
    3. Abuse or dependence on prescriptions: 130
    4. Non-medical users of prescription Opioids: 825
  3. Opioid prescriptions are the leading entry point to Heroin abuse in U.S.
    1. Current Heroin abusers started with Opioid prescriptions in 75% of cases
    2. While prescription Opioids are expensive, Heroin remains relatively inexpensive
    3. Cicero (2014) JAMA Psychiatry 71(7): 821-6 [PubMed]

III. Signs: Drug Seeking, Misuse or Narcotic Addiction

  1. See Substance Abuse Evaluation
  2. Selling prescription drugs
  3. Prescription forgery
  4. Stealing or borrowing drugs from others
    1. Veterinary prescriptions (e.g. Opioids for pain or Cough Suppression) are being taken by pet owners
  5. Injecting oral Opioids
  6. Obtaining Opioids from multiple physicians
  7. Making appointments at the end of the day, weekends and evenings
  8. Concurrent use of psychoactive substances
    1. Illicit Drugs
    2. Alcohol
  9. Multiple dose increases
    1. Increase despite warnings
    2. Increase despite adverse effects
  10. Resistance to change therapy despite low efficacy
  11. Diminished work and home functioning
  12. Multiple episodes of prescription loss
  13. Excessive flattery of providers
  14. Refusing to grant permission to obtain old records from prior facilities
  15. New patients presenting for refill of long-standing use of controlled substances
  16. Out of town patient with unavailable primary provider and bypassed closer facilities
  17. No picture identification
  18. Patient is not interested in a diagnosis, tests or non-Opioid treatments
  19. Magnified symptoms with inconsistencies, but otherwise rehearsed textbook history of a painful condition

IV. Signs: Pseudo-addiction (seeking adequate pain relief)

  1. See Chronic Pain
  2. Aggressive pursuit of more Opioid
  3. Opioid hoarding when symptoms are reduced
  4. Requesting specific Opioids, especially via parenteral route (and refusing non-Opioid alternatives)
  5. Dose escalation without physician consent once or twice
  6. Unapproved Narcotic use to treat other symptoms

V. Management

  1. See Opioid Abuse
  2. Address suspected Opioid misuse or abuse directly and offer medical help and CD treatment referral
    1. I am concerned
    2. Patients treated for pain with prescription Opioids may become dependent on those medications
    3. Dependence may lead to addiction, and I suspect that may be the case for you
    4. I have Chemical Dependency counseling available
  3. References
    1. Mason and Papp in Herbert (2015) EM:Rap 15(3): 13

VI. Prevention: General

  1. Check Prescription Drug Monitoring Program (see link below under resources)
  2. Patient should sign a Controlled Substance Contract
  3. Random Urine Drug Screens every 3 to 6 months
    1. Drug screens should be positive for the medication prescribed
    2. Drug screens should be negative for other non-prescribed substances
  4. Discuss with patient the risks of sharing their controlled substances
    1. Risks include Overdose in a patient not tolerant to adverse effects (e.g. respiratory depression)
    2. Children are at particular risk of Overdose
  5. Patient's should properly dispose of unused controlled substances

VII. Prevention: Prescription Drug Monitoring Program (PDMP)

  1. As of 2015, monitoring programs are available in all U.S. states except Missouri
    1. Many states share data regionally
  2. Monitoring programs list nearly all controlled substances prescribed
    1. Typically displays last year of controlled substance pharmacy fills
    2. Displays prescribing provider, preparation and quantity given
    3. Methadone clinics and military pharmacies may not report controlled substance prescriptions
  3. Red flags for Opioid misuse on PDMP
    1. Early refills (except for limited quantities as part of taper)
    2. Similar prescriptions from multiple medical providers at different groups and facilities
    3. Combined controlled substance use (e.g. Opioids with Benzodiazepines)
    4. Total Morphine Equivalents >120 mg/day
  4. Prescription Drug Monitoring Programs (alliance of states sites)
    1. http://www.pmpalliance.org/content/pmp-access
  5. References
    1. (2015) Prescriber's Letter 22(11):64

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Related Studies

Ontology: Prescription Drug Misuse (C0581388)

Definition (MSH) Improper use of drugs or medications outside the intended purpose, scope, or guidelines for use. This is in contrast to MEDICATION ADHERENCE, and distinguished from DRUG ABUSE, which is a deliberate or willful action frequently associated with psychological disorders.
Concepts Finding (T033)
MSH D015537 , D063487
SnomedCT 191939002
English Misuse of prescription only drugs (finding), Misuse of prescription only drugs (disorder), Misuse of prescription drugs, Misuse, Prescription Drug, Prescription Drug Misuse, Drug Misuse, Prescription, Prescription Drug Misuses, misuses drugs prescription only, misuses drugs prescription only (history), Non-Medical Use of Prescription Drugs, Non Medical Use of Prescription Drugs, NMUPD, Misuse of prescription only drugs
Swedish Överdos
Spanish uso indebido de fármacos de venta con receta (trastorno), uso indebido de fármacos de venta con receta (hallazgo), Mal Uso de Medicamentos de Venta con Receta, uso indebido de fármacos de venta con receta
Finnish Yliannos
Czech předávkování, otrava léky, nadměrná dávka
French Surdose, Dose massive, Dose excessive, Overdose
German Überdosis
Italian Overdose
Polish Niewłaściwe używanie leków, Niewłaściwe stosowanie leków recepturowych, Niewłaściwe używanie leków recepturowych
Norwegian Overdose
Portuguese Uso Indevido de Medicamentos sob Prescrição

Ontology: prescription drug abuse (C0747950)

Definition (MEDLINEPLUS)

If you take a medicine in a way that is different from what the doctor prescribed, it is called prescription drug abuse. It could be

  • Taking a medicine that was prescribed for someone else
  • Taking a larger dose than you are supposed to
  • Taking the medicine in a different way than you are supposed to. This might be crushing tablets and then snorting or injecting them.
  • Using the medicine for another purpose, such as getting high

Abusing some prescription drugs can lead to addiction. These include narcotic painkillers, sedatives, tranquilizers, and stimulants.

Every medicine has some risk of side effects. Doctors take this into account when prescribing medicines. People who abuse these drugs may not understand the risks. The medicines may not be safe for them, especially at higher doses or when taken with other medicines.

NIH: National Institute on Drug Abuse

Concepts Mental or Behavioral Dysfunction (T048)
English abuse drugs prescription, abuse drug prescription, prescription drug abuse, Prescription Drug Abuse, Drug Abuse, Prescription

Ontology: Prescription Drug Diversion (C3658253)

Definition (MSH) The transfer of prescription drugs from legal to illegal distribution and marketing networks.
Concepts Human-caused Phenomenon or Process (T068)
MSH D064226
English Diversions, Prescription Drug, Drug Diversion, Prescription, Diversions, Controlled Substance, Drug Diversions, Prescription, Prescription Drug Diversions, Controlled Substance Diversions, Substance Diversion, Controlled, Prescription Drug Diversion, Diversion, Prescription Drug, Diversion, Controlled Substance, Controlled Substance Diversion, Substance Diversions, Controlled
Czech nelegální distribuce léčiv na předpis, zneužívání kontrolovaných látek, zneužívání léčiv na předpis, zneužívání kontrolovaných substancí
French Détournement de médicaments d'ordonnance, Détournement de médicaments de prescription, Détournement de substances contrôlées, Détournement de médicaments sur ordonnance, Détournement de substances réglementées, Détournement de substances inscrites aux Tableaux, Détournement de médicaments délivrés sur ordonnance
German Abzweigung verschreibungspflichtiger Drogen, Abzweigung verschreibungspflichtiger Arzneimittel, Abzweigung erfasster Stoffe
Italian Diversione di sostanze controllate, Diversione di farmaci prescrivibili