Welcome to Priory Bitesize, your monthly e-bulletin in which a mental health expert will discuss dealing with certain conditions to support your patient discussions.
This month, Dr Michael Bristow, Consultant Psychiatrist at The Priory Hospital Woking, talks about the impact of prescription drug abuse, and offers advice on how to support patients.
The silent epidemic
2013 was the year that saw more deaths in prescription drugs overdoses than illegal drugs such as heroin and cocaine. This is not that surprising given the gradual and inexorable rise in the abuse of prescribed and over-the-counter (OTC) preparations in the preceding decade.
In Britain, the problem is on the whole a subtle one, with no particular demographic focus – which is why the phenomenon has been given the name ‘the silent epidemic’.
There are several drivers behind the problem:
- Promotion of pleasurable aspects of drugs on the internet
- The increasing spread of psychotropic drug use
- The migration towards pharmaceutical drugs for reasons of purity and easy access
- The rise of the online pharmacy which means that local prescription drug cultures can quickly become global
There are many types of prescription and OTC drugs misused. This article covers a number of them, identifies some of the symptoms and offers advice on how you can offer support to any at risk patients.
Not all prescription drug abusers are the same...
Broadly speaking, abusers of prescription drugs tend to fall into two categories:
1. Those that become dependent on drugs originally prescribed for a medical reason
- Musculoskeletal pain often involves combinations of opiates and benzodiazepines
- Generally this population is middle aged plus, often with otherwise stable circumstances
- As the original pain and disability die down they are unable to desist from the drugsthat have enabled them to regain full function in sometimes busy lives
- Habituation and tolerance is variable so dose range varies from the borders of BNF limits to large multiples that would be dangerous to a first time user
2. Those who misuse prescription drugs as one more facet of a tendency to misuse drugs in general
- These individuals may be taking ‘legal highs’ and illicit recreational drugs as well
- Prescription drugs may come from other users, from online stores or from pharmacies in developing countries where pharmaceuticals are more freely available
- Younger users, with possible psychiatric comorbidity who take the drugs for a specific ‘high’, in contrast to the first group who take them to function normally
- Prescription drug abuse is as common if not more common in women
Signs & symptoms are occasionally life threatening but usually subtle
Consequences of prescription drug addiction are variable. At one end there are life threatening overdoses, often caused by mixing drugs together or with alcohol, causing cardiovascular events linked to consumption of stimulants. Severe liver and kidney damage as a result of long term minor analgesic abuse or other organ damage are possible but rare. Sometimes problems may result from the supply being cut off such as an unexplained seizure.
The most common consequences are subtle however – anorexia, drowsiness, apathy or other mood changes, memory lapses, dizzy spells and other subjective changes from normal. Other people may be the first to notice problems or there may be a fall-off in work performance. The problem may pass unnoticed until the individual themselves seek help or are persuaded to do so by family members.
Recognition is the most important step
Recognition may be difficult. Sometimes a person may be obtaining prescriptions from more than one source (doctor/shopping/online pharmacies). Other possible warnings are:
- Frequently lost prescriptions or repeats needed early
- Presence of persistent symptoms
When faced with an individual who has been abusing prescription drugs it could be natural to feel somewhat betrayed. However it is important to remember this may be out of the control of the individual, and it has taken a lot of courage to ‘own up’. An unsympathetic approach is likely to delay resolution and the problem may become covert, possibly to resurface at a later stage.
It is worth enquiring about coping mechanisms from the outset in those presenting with minor mood or anxiety disorders or conditions involving chronic pain; vigilance is needed in those who rely greatly on OTC or as-required medication.
Agree a plan
- Outline the extent of the problem, duration of usage, dosage and frequency of use
- If usage is sporadic, look for alternative responses via Pain Management or Psychology, whichever is appropriate
- Continuous usage requires an agreed reduction strategy. Slow withdrawal over weeks or months in primary care is entirely feasible – there is no evidence that rapid withdrawal of benzodiazepines is better either in terms of tolerability or outcome
Specialist help may be needed
Referral to or advice from Specialist Substance Misuse services either statutory or private may be advisable if:
- The patient is taking very large doses of the drug in question
- The patient is taking large doses of more than one drug
- Reduction of the drug produces symptoms of significant psychological problems or frank mental illness
Don’t forget self-help groups
Prescription drug abusers may feel very isolated. Self-help groups such as Narcotics Anonymous or SMART Recovery may have something that can help. The internet can also play a part in remedy, with useful support groups online.
Below is a list of a number of prescription drugs that may be involved in addiction cases:
- Originally prescribed in general practice for anxiety and sleep disorders, dependence may occur during use for musculoskeletal problems/spasms
- Dependence through continuation of hypnotic use following an acute physical or psychological crisis
- Relatively strong abuse potential has led to them being removed, although drugs such as Alprazolam, originally marketed as an anti-depressant and Z drugs such as Zopiclone, are still causing problems
- Baclofen is currently being trialled for the treatment of alcohol abuse; though not yet approved by NICE it remains to be seen what problems this drug could cause in an already vulnerable population
- Current candidates for abuse include Codeine due to familiarity and availability in OTC preparations, Dihydrocodeine and Tramadol that also has some Serotonin re-uptake inhibitory potential which may convey extra emotional relief
- These can be provided for relatively common moderate pain syndromes
- Perhaps less common because of their association with more severe pain, are long-acting Morphine such as MST-1 and the rapidly acting Fentanyl
- In America, Oxycontin has caused the most problems – a relatively powerful long acting opiate but an added potential for abuse arose from the ability to crush the tablets and inject an aqueous solution
- Manufacturers responded by making it immiscible with water, but the risk of abuse still persists from the tablets themselves. Not yet widely used in the UK, it is becoming more common in some areas
Cough and cold medicines
- Abused in both OTC and prescribed varieties, they can provide mild stimulant effects of pseudephedrine, or sedative effects of an antihistamine
- Dextromethorphan, a more rarely used cough suppressant, is often abused because of its ketamine like dissociative effects at a higher dose
- Pholcodine is not euphoriant but abrupt cessation may lead to withdrawal related coughing thus encouraging persistent usage
Other psychotropic drugs
- Although abuse of most psychotropic drugs is not common because of their slow and cumulative mode of action, some SSRIs are abused for a stimulant effect
- Mirtazepine may be abused for its sedative hypnotic effect and Pregabalin is being abused for its sedative effect
- Methylphenidate and Amphetamine – diagnosis of ADHD in the UK is steadily increasing and with it the prescription of these stimulant drugs
- Abuse of these drugs tend to occur in certain sites such as colleges and universities or other long-stay institutions such as prisons, where psychotropics are often prescribed and alternatives are not available
- The abuse of OTC preparations of non-opiate painkillers such as Paracetamol must not be forgotten. They are often taken in combination with codeine or caffeine but their own analgesic effect may lead to abuse
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