Reduce Prescription Drug Misuse
Prescription drug misuse has been recognized as a national problem since 1914, when the Harrison Narcotics Act separated medical and nonmedical drug use – criminalizing the nonmedical use and sale of drugs but permitting legitimate medical use of drugs with high potential for misuse. This distinction encouraged the development and widespread use of countless legal pharmaceutical products that improved the lives of millions of Americans while at the same time discouraged the illegal production, sale and use of these and related substances. Nonetheless, due to their addictive properties, some prescription drugs are widely misused.
The most commonly misused classes of controlled substances are:
Opioids: used to treat pain,
Central nervous system (CNS) depressants: used to treat anxiety, depression and sleep disorders, and
Stimulants: used to treat sleep disorders, ADHD and obesity.
In the early 1960s, the explosive growth of prescription benzodiazepines (e.g., the CNS drugs Valium, and Xanax) fueled widespread misuse of these products. However, it was not until the dramatic increase in the use of opioid painkillers that began in the 1990s that nonmedical use of prescription drugs became a deadly epidemic, as measured by a sharply rising annual death toll from overdoses.
New initiatives to prevent rampant access to these prescribed medicines have been developed in response, including the creation of prescription drug monitoring programs (PDMPs) which electronically track prescriptions in individual states, efforts to shut down “pill mills,” and through effective education of physicians and patients about the risks of prescription drug abuse. In 2016 the Centers for Disease Control and Prevention (CDC) issued guidelines for prescribing opioids to treat chronic pain — updated in 2022. Additionally, the Food and Drug Administration (FDA) promoted the use of abuse-resistant formulations of medicines, a policy pioneered by IBH over a decade ago. These initiatives directly impacted prescribing practices, and made it more difficult to obtain prescription opioids for nonmedical uses and more expensive to buy on illegal drug markets.
According to the initial drug policy narrative, the overdose epidemic was the result of two decades of over-prescribing of opioid pain medications. However, among prescription opiate users, the people most vulnerable to switching to heroin were those who were also using (and misusing) other drugs, including alcohol and marijuana. Of 80% of heroin users who used a prescription opioid before they first used heroin, the vast majority (over 96%) did not transition to using heroin. Five years after the initial nonmedical use of a prescription opioid, only 3.6% ever used any heroin.
Among 4,493 individuals treated for opioid addiction whose first exposure to opioids was through a prescription from their physician, notably 94.6% reported prior or coincident use of other psychoactive drugs. Alcohol was used by 92.9%, nicotine by 89.5% and marijuana by 87.4%, and excluding these top substances, fully 70.1% reported other prior or coincident drug use.
changes in Overdose deaths
Data from the National Center for Health Statistics (NCHS), part of the US Centers for Disease Control and Prevention (CDC), show that as of November 2021, past 12-month overdose deaths totaled more than 100,000. The most common drugs present in overdose death are opioids, with deaths involving synthetic opioids other than methadone (e.g., fentanyl, fentanyl analogues and tramadol). But overdose deaths are not only opioid-related; a growing number of deaths involve cocaine and psychostimulants. Polydrug use deaths are becoming much more common.
More young people are dying from overdose death, often involving polydrug use. The sheer numbers of those of all ages dying from overdose are impacting life expectancy in the US, which dropped two years in a row. The COVID-19 global pandemic has added to the overdose crisis, with provisional 2020 data indicating a 1.5 year decline in life expectancy in the US.
IBH Activities
A signature IBH contribution to this high-profile health challenge has been the recognition of the disparity between the way the nation – and the world – thinks about drug problems as substance-specific (e.g., the opioid epidemic) and the reality that the epidemic involves polysubstance use. Using data from the comprehensive Florida Drug-Related Outcomes Surveillance & Tracking System (FROST), IBH estimates about 95% of drug overdose deaths are from multiple drugs, with as many as 11 different drugs identified among decedents.
In September 2019, IBH President Robert L. DuPont, MD co-authored a report documenting the story of fentanyl as being a sign of this new polydrug epidemic in the US and identified key policy recommendations to address this new challenge to confronting national drug epidemic:
Fentanyl is a sentinel calling our attention to the potential for a slew of laboratory-based drugs produced by an ever-expanding illegal global drug market to meet a growing demand. Included in this threat are the fentanyl-laced counterfeit drugs manufactured to look like well-known and trusted pharmaceutical products but containing deadly amounts of fentanyl instead of the expected active pharmaceutical ingredient. Unrestrained by regulatory controls and labeling requirements, today’s drug trafficker-entrepreneur poses a serious threat to patients and non-patients alike. If we hope to meet these challenges successfully, we will need radically new thinking, better data systems, and improved technology to keep counterfeit drugs and deadly fentanyl analogs out of our communities and medicinal drug supplies.
IBH President Robert L. DuPont, MD authored an article that outlined A New Narrative to Understand the Opioid Epidemic to inform future drug policy. This article discussed the link to prior significant polydrug use. Another useful overview of the complexities of the opioid epidemic was provided in an edition of Emerging Drug Trends Report from the Hazelden Betty Ford Institute for Recovery Advocacy entitled, Widening the Lens on the Opioid Crisis.
IBH President Robert L. DuPont, MD describes the devastating effects of the opioid epidemic.