Challenge of Prescription Drug Misuse…

The Challenge of Prescription Drug Misuse: A Review and Commentary (full text + link to PDF) William Hurwitz, M.D.; Pain Medicine; 6(2); 152-161; March 2005.

INTRODUCTION, REFERENCES, and FOOTNOOTES

This article presents an analysis of the patterns of illicit use of prescription pain relievers, of the likely structure of the illicit market, and of the complexity of pain management. It suggests that a federal enforcement policy focused on physicians is unlikely to reduce the overall use of illicit drugs, but that it is likely to have an adverse impact on the ethical structure of medical care and to compromise the effectiveness of pain treatment. Pain medications, such as OxyContin, Vicodin, and Methadone, have received increased government and media attention over the last 2 or 3 years, as the growth of their application in the treatment of patients with acute and chronic pain has been accompanied by an increase in reported drug abuse and dependence, adverse medical events, and pharmacy robberies. In response, the federal government announced a new initiative to control prescription drug abuse. ¹ Various proposed measures, including heightened scrutiny of physicians’ practices, increased prosecution of physicians, increased restrictions on a number of pain medications, drug monitoring programs to catch “doctor shoppers,” and encouragement of more rigorous patient screening, will, it is claimed, limit the diversion of prescription medications from medical channels. In its 2002 review of OxyContin diversion, the Drug Enforcement Administration (DEA) stated “Illegal acts by physicians and pharmacists are the primary sources of diverted pharmaceuticals available on the illicit market.” ² The DEA report goes on to identify other sources of diversion, including doctor shopping, robberies, burglaries, thefts, illicit internet distribution, drug gang distribution, and foreign diversion. In view of the multiplicity of sources and the lack of quantitative information regarding the contribution of each source to the illicit market, it is not clear on what basis the DEA claimed that physicians and pharmacists are the primary sources. However, the recently proposed measures to control diversion and abuse appear to be predicated on the assumption that medications diverted to illicit use come primarily from prescriptions issued by criminal or inadequately vigilant doctors to inappropriate patients, who abuse or divert prescribed medications. It would follow from this assumption that removal of the “bad apples” among doctors and that greater precision by well-intentioned doctors in directing prescriptions to appropriate patients would reduce the quantities available for misuse. It is further assumed that restricting the supply of medications available for diversion from medical practice will restrict the access of would-be illicit users to prescription medications, and that restricted access will lower the overall burden of substance abuse. Whether the new enforcement policy will limit diversion or reduce substance abuse remains to be seen.

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FOOTNOTES ¹Office of National Drug Control Policy Press Release, U.S. Drug Prevention, Treatment, Enforcement Agencies Take on “Doctor Shoppers,”"Pill Mills,” March 1, 2004. ²Drug Intelligence Brief, Oxycontin: Pharmaceutical Diversion March 2002. Available at http://www.usdoj.gov/dea/pubs/intel/02017/02017p.html (Note: All websites in the footnotes were accessed in June, 2004). ³The National Survey of Drug Use and Health (NSDUH) is available online at http://www.oas.samhsa.gov/nhsda/2k2nsduh/html/toc.htm . The drug use prevalence data in this article are extracted from Tables 1.1B, 1.2B, 1.3B, 1.4B, 1.19B, 1.26B, 5.25B, 5.27B, and 8.2N accessible through the referenced website or from Tables H.1 through H.6, H.16, H.22, and H.44 from SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 at http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/appH.htm . ⁴Diagnostic and Statistical Manual of Mental Disorders

Fourth Edition (DSM-IV), published by the American Psychiatric Association, Washington, DC, 1994. ⁵Available at http://allpsych.com/disorders/substance/index.html . ⁶Table H.16, Alcohol Use, Percentages, 2002, Table H.22, Cigarette Use, Percentages, 2002, and Table H.6, Any illicit Drug Use, Percentages, 2002 referenced earlier. ⁷These data are extracted from the DAWN data available at http://dawninfo.samhsa.gov . ⁸Table H.27 (Marijuana), H.28 (Cocaine), H.30 (Ecstasy), and H.31 (Pain Reliever) at http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/appH.htm . ⁹Table H.35 (Marijuana), H.36 (Cocaine), H.38 (Ecstasy), and H.39 (Pain Reliever) at http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/appH.htm . ¹⁰Information Brief: Prescription Drug Abuse and Youth, National Drug Intelligence Center, Document ID: 2002-L0424-004, August 2002. ¹¹“On average, 2 drugs were mentioned in each ED visit involving narcotic analgesics, and more than 1 drug was involved in 72% of the visits . . . Cocaine taken with unspecified narcotic analgesics was the most frequently reported combination in 2001.”The Dawn Report, January 2003. Available at http://dawninfo.samhsa.gov/pubs_94_02/shortreports/files/DAWN%20Report%20 NA_10.pdf.

¹²Table H.1, NSDUH, 2002.

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