Combating the epidemic of opioid abuse—including prescription painkillers and, increasingly, heroin—requires a multi-pronged approach that involves reducing drug diversion, expanding delivery of existing treatments (including medication-assisted treatments), and development of new medications for pain that can augment our existing treatment arsenal. But another crucial component we must not forget is that people who abuse or are addicted to opioids need to be kept alive long enough that they can be treated successfully. In this, the drug naloxone has a large potential role to play.

© M intropin

Naloxone is an opioid antagonist—meaning that it binds to opioid receptors and can reverse or block the effects of other opioids. It can very quickly restore normal respiration to a person whose breathing has slowed or stopped as a result of abusing heroin or prescription opioids, or accidentally ingesting too much pain medication.  Naloxone is widely used by emergency medical personnel and other first responders for this purpose. Unfortunately, by the time a person having an overdose is reached and treated, it is often too late. To solve this problem,  several experimental overdose education and naloxone distribution (OEND) programs have issued naloxone directly to opioid users and their friends or loved ones, or other potential bystanders, along with brief training in how to use these emergency kits. Such programs have been shown to be an effective, as well as cost-effective, way of saving lives.

For example, a Massachusetts OEND program that began in 2006, during a growing overdose epidemic in that state, significantly reduced overdose deaths in the 19 communities that implemented it. As of 2010, the CDC reported that lay-distributed naloxone had prevented more than 10,000 overdose deaths nationwide since 1996. So far, 17 states have passed laws allowing for wider prescription of naloxone to those in a position to help prevent overdose fatalities. These laws help put the life-saving drug not only in the hands of family members and friends of opioid-addicted persons but also a wider array of emergency personnel, such as police and firefighters.

Naloxone is currently only FDA approved in an injectable formulation. To facilitate ease of use, many OEND programs use syringes fitted with an atomizer to enable the drug to be sprayed into the nose. NIDA and other agencies are working with the FDA and drug manufacturers to support the development of an intranasal formulation that would match the pharmacokinetics (i.e., how much and how rapidly the drug gets into the body) of the injectable version.

Over 15,500 Americans died from an overdose involving prescription painkillers in 2009—more than from all other drugs combined--and we are now seeing indicators of a rise in heroin overdose deaths as well. If we are to reverse these terrible trends, we need to do all we can to ensure that emergency personnel as well as at-risk opioid users and their loved ones have access to tools like naloxone that may save people’s lives in the event of overdose.

The epidemic of prescription opioid abuse in this country is linked partly to the dramatic rise in prescriptions for these medicines over the last two decades, as well as the fact that many clinicians are inadequately trained to safely treat pain in their patients. Most medical schools only offer a few hours of instruction in safe prescribing of opioids for pain management. A recent review showed that only 3% of U.S. medical schools offer integrated pain management courses.

To help with this situation and to be sure clinicians are given guidance on communicating with patients about drug abuse, NIDA and the White House Office of the National Drug Control Policy (ONDCP) teamed last year with Medscape to create two interactive online continuing medical education (CME) modules—one on safe prescribing for pain, and another on managing pain patients who abuse prescription drugs. The modules launched a year ago on the Medscape Web site, and I am proud to say that they have been an overwhelming success.

Nearly 60,000 clinicians have so far completed one of these CMEs. Of those, more than15,000 are physicians and more than 30,000 are nurses. Over 100,000 additional “Learners” have visited and reviewed parts of the CMEs, but not for credit. Because of their popularity, NIDA is extending the availability of these CMEs for another year, through September 2014.

The training materials, which include video vignettes showing doctor–patient conversations on safe and effective use of opioid pain medications, are part of NIDA’s NIDAMED initiative to help clinicians understand and address the complex problem of prescription drug abuse. ONDCP funded the creation of the CMEs as part of the Administration’s efforts to achieve a 15-percent reduction in the abuse of prescription drugs by 2015. Enlisting physicians and other clinicians as the first line of defense against the prescription drug abuse problem will make a big difference.

Abuse of prescription opioids, stimulants, and other psychotherapeutic medications presents unique challenges. On the one hand, these drugs can produce serious harm (even death) when not taken as prescribed; on the other, they are powerful clinical allies that can be life saving.  Thus, the approach we take and the messages we convey to minimize harm need to be nuanced and multipronged.

This week I have the opportunity to meet with a group of impassioned stakeholders who have gathered in Atlanta, GA for the third annual National Rx Drug Abuse Summit. The Summit brings together people on all sides of the problem, including representatives from government agencies, law enforcement, and the treatment world. This year it is an impressive roster: NIH director Francis Collins is also here, along with Michael Botticelli, acting director of the White House Office of the National Drug Control Policy, and Dr. Thomas R. Frieden, director of the CDC, as well as representatives from the FDA and SAMHSA. The Summit is organized by Operation UNITE, which was founded by Representative Hal Rogers, Chair of the House Appropriations Committee, who is also speaking.

This high level of interest reflects the urgency of the prescription drug abuse problem in the United States. Every day about 105 Americans die from drug overdose, and the majority of those deaths now involve prescription drugs—usually opioid painkillers. In 2012, 2.1 million Americans were addicted to prescription opioids. We are currently also seeing a rise in heroin use and its consequences as people who are addicted to painkillers graduate to those drugs’ cheaper street relative.

Many areas of NIDA research are contributing to reducing this problem, including our advancement of research into pain and efforts to advance pain education in medicine, our research to develop new treatments for opioid addiction, and research to develop new pain treatments including pain medications with less potential for abuse. For example, NIDA is partnering with a pharmaceutical company called Signature Therapeutics to develop an abuse deterrent formulation of the widely abused painkiller OxyContin. This formulation will use prodrug technology—attaching an extension to the opioid molecule that renders it neutral (unable to interact with opioid receptors) if injected, snorted, or smoked; instead it must pass through the digestive system to begin the process of releasing the opioid.

I recently wrote about naloxone and how increased access to this opioid antagonist could help save many people from dying of opioid overdoses. Currently, it is only approved in injectable formulations, but NIDA is supporting several projects to develop intranasal delivery systems. Earlier this month, the FDA approved a hand-held naloxone auto-injector device called Evzio, which can be used by family members or other caregivers and thus also increases its potential to save lives.  Naloxone has a  high safety profile and no abuse potential; thus, advances in delivery devices that can increase its availability and usability are likely to have a large impact on the opioid (and heroin) overdose epidemic.   

While complex, the problem of prescription drug abuse is by no means insurmountable. We are continuously learning more about these drugs’ effects in the brain, and we are converging on new prevention and treatment approaches that, I hope, will soon begin to reverse the alarming statistics. But solving the problem also requires working across agencies and across public and private structures, so it is gratifying to be here in Atlanta among so many policymakers, scientists, and community stakeholders who all share the same goal of reversing this public health epidemic.

The National Institute on Drug Abuse (NIDA), part of the NIH, is pleased to introduce two new, science-based resources through its NIDAMED initiative to help healthcare professionals manage patients at risk for substance use disorders, including prescription drug abuse.

The American College of Physicians (ACP) now houses an Addressing Substance Use online module that can be used to help with implementing screening, counseling, and referral to treatment.  

Also, the American Academy of Physician Assistants (AAPA) and the American Association of Nurse Practitioners (AANP) are now offering opioid and pain management courses.

For more information, contact the NIDA press office at media@nida.nih.gov or 301-443-6245.

Some over-the-counter (OTC) and prescription cough and cold medicines contain active ingredients that are psychoactive (mind-altering) at higher-than-recommended dosages and are frequently abused for this purpose. These products may also contain other drugs, such as expectorants and antihistamines, which are dangerous at high doses and compound the dangers of abuse.

Two commonly abused cough and cold medicines are:

• Dextromethorphan (DXM), a cough suppressant and expectorant found in many OTC cold medicines. It may produce euphoria and dissociative effects or even hallucinations when taken in quantities greater than the recommended therapeutic dose.
• Promethazine-codeine cough syrup, a medication that contains codeine, an opioid that acts as a cough suppressant and can also produce relaxation and euphoria when consumed at a higher-than-prescribed dose. It also contains promethazine HCl, an antihistamine that additionally acts as a sedative. Although only available by prescription, promethazine-codeine cough syrup is sometimes diverted for abuse.

How Are Cough and Cold Medicines Abused?

Cough and cold medicines are usually consumed orally in tablet, capsule, or syrup form. They may be mixed with soda for flavor and are often abused in combination with other drugs, such as alcohol or marijuana.

Because they are easily purchased in drugstores without a prescription, cough syrups, pills, and gel capsules containing DXM—particularly “extra strength” forms—are frequently abused by young people (who refer to the practice as “robo-tripping” or “skittling”). To avoid nausea produced by high doses of the expectorant guaifenesin commonly found in DXM-containing syrups, young people may instead abuse Coricidin^® HBP Cough & Cold capsules (street name C-C-C or triple-C), which contain DXM but lack guaifenesin.

Drinking promethazine-codeine cough syrup mixed with soda (a combination called syrup, sizzurp, purple drank, barre, or lean) was referenced frequently in some popular music beginning in the late 1990s and has become increasingly popular among youth in several areas of the country. A variation of “purple drank” is promethazine-codeine cough syrup mixed with alcohol. Users may also flavor the mixture with the addition of hard candies.

How Does Abusing Cough and Cold Medicines Affect the Brain?

When taken as intended, cough and cold medicines safely treat symptoms of lower and upper respiratory congestion and discomfort caused by colds and flu. But when taken in higher quantities or when such symptoms aren’t present, they may affect the brain in ways very similar to illegal drugs.

When taken in high doses, DXM acts on the same cell receptors as dissociative hallucinogenic drugs like PCP or ketamine. Users describe effects ranging from mild stimulation to alcohol- or marijuana-like intoxication, and at high doses, sensations of physical distortion and hallucinations.

Codeine attaches to the same cell receptors targeted by illegal opioids like heroin. Consuming more than the daily recommended therapeutic dose of promethazine-codeine cough syrup can produce euphoria similar to that produced by other opioid drugs; people addicted to codeine may consume several times the recommended, safe amount. Also, both codeine and promethazine HCl act as depressants of the central nervous system, producing sedating or calming effects.

When abused, both codeine and DXM directly or indirectly cause a pleasurable increase in the amount of dopamine in the brain’s reward pathway. Repeatedly seeking to experience that feeling can lead to addiction—a chronic relapsing brain disease characterized by inability to stop using a drug despite damaging consequences to a person’s life and health.

What Are the Other Health Effects of Abusing Cough and Cold Medicines?

Abusing DXM can cause impaired motor function, numbness, nausea or vomiting, increased heart rate and blood pressure, and at high doses, extreme agitation, increased body temperature, and a buildup of excess acid in body fluids. High doses of acetaminophen, a pain reliever commonly found with DXM, can cause liver damage. On rare occasions, hypoxic brain damage—caused by severe respiratory depression and a lack of oxygen to the brain—has occurred as a result of the combination of DXM with decongestants often found in the medication.

When abused, promethazine-codeine cough syrup presents a high risk of fatal overdose due to its effect of depressing the central nervous system, which can slow or stop the heart and lungs. Mixing with alcohol greatly increases this risk. Promethazine-codeine cough syrup has been linked to the overdose deaths of a few prominent musicians.

Learn More

For more information on abuse of DXM, see
http://www.deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf (PDF, 37KB)

For more information on abuse of promethazine-codeine cough syrup, see
http://www.drugabuse.gov/drugs-abuse/emerging-trends

The principles listed below are the result of long-term research studies on the origins of drug abuse behaviors and the common elements of effective prevention programs. These principles were developed to help prevention practitioners use the results of prevention research to address drug use among children, adolescents, and young adults in communities across the country. Parents, educators, and community leaders can use these principles to help guide their thinking, planning, selection, and delivery of drug abuse prevention programs at the community level.

Prevention programs are generally designed for use in a particular setting, such as at home, at school, or within the community, but can be adapted for use in several settings. In addition, programs are also designed with the intended audience in mind: for everyone in the population, for those at greater risk, and for those already involved with drugs or other problem behaviors. Some programs can be geared for more than one audience.

NIDA's prevention research program focuses on risks for drug abuse and other problem behaviors that occur throughout a child's development, from pregnancy through young adulthood. Research funded by NIDA and other Federal research organizations - such as the National Institute of Mental Health and the Centers for Disease Control and Prevention - shows that early intervention can prevent many adolescent risk behaviors.

Principle 1 - Prevention programs should enhance protective factors and reverse or reduce risk factors (Hawkins et al. 2002).

• The risk of becoming a drug abuser involves the relationship among the number and type of risk factors (e.g., deviant attitudes and behaviors) and protective factors (e.g., parental support) (Wills et al. 1996).
• The potential impact of specific risk and protective factors changes with age. For example, risk factors within the family have greater impact on a younger child, while association with drug-abusing peers may be a more significant risk factor for an adolescent (Gerstein and Green 1993; Dishion et al. 1999).
• Early intervention with risk factors (e.g., aggressive behavior and poor self-control) often has a greater impact than later intervention by changing a child's life path (trajectory) away from problems and toward positive behaviors (Ialongo et al. 2001; Hawkins et al. 2008).
• While risk and protective factors can affect people of all groups, these factors can have a different effect depending on a person's age, gender, ethnicity, culture, and environment (Beauvais et al. 1996; Moon et al. 1999).

Principle 2 - Prevention programs should address all forms of drug abuse, alone or in combination, including the underage use of legal drugs (e.g., tobacco or alcohol); the use of illegal drugs (e.g., marijuana or heroin); and the inappropriate use of legally obtained substances (e.g., inhalants), prescription medications, or over-the-counter drugs (Johnston et al. 2002).

Principle 3 - Prevention programs should address the type of drug abuse problem in the local community, target modifiable risk factors, and strengthen identified protective factors (Hawkins et al. 2002).

Principle 4 - Prevention programs should be tailored to address risks specific to population or audience characteristics, such as age, gender, and ethnicity, to improve program effectiveness (Oetting et al. 1997; Olds et al. 1998; Fisher et al. 2007; Brody et al. 2008).

Principle 5 - Family-based prevention programs should enhance family bonding and relationships and include parenting skills; practice in developing, discussing, and enforcing family policies on substance abuse; and training in drug education and information (Ashery et al. 1998).

Family bonding is the bedrock of the relationship between parents and children. Bonding can be strengthened through skills training on parent supportiveness of children, parent-child communication, and parental involvement (Kosterman et al. 1997; Spoth et al. 2004).

Parental monitoring and supervision are critical for drug abuse prevention. These skills can be enhanced with training on rule-setting; techniques for monitoring activities; praise for appropriate behavior; and moderate, consistent discipline that enforces defined family rules (Kosterman et al. 2001).

Drug education and information for parents or caregivers reinforces what children are learning about the harmful effects of drugs and opens opportunities for family discussions about the abuse of legal and illegal substances (Bauman et al. 2001).

Brief, family-focused interventions for the general population can positively change specific parenting behavior that can reduce later risks of drug abuse (Spoth et al. 2002b).

Principle 6 - Prevention programs can be designed to intervene as early as infancy to address risk factors for drug abuse, such as aggressive behavior, poor social skills, and academic difficulties (Webster-Stratton 1998; Olds et al. 1998; Webster-Stratton et al. 2001; Fisher et al. 2007).

Principle 7 - Prevention programs for elementary school children should target improving academic and social-emotional learning to address risk factors for drug abuse, such as early aggression, academic failure, and school dropout. Education should focus on the following skills (Conduct Problems Prevention Research Group 2002; Ialongo et al. 2001; Riggs et al. 2006; Kellam et al. 2008; Beets et al. 2009):

• self-control;
• emotional awareness;
• communication;
• social problem-solving; and
• academic support, especially in reading.

Principle 8 - Prevention programs for middle or junior high and high school students should increase academic and social competence with the following skills (Botvin et al. 1995; Scheier et al. 1999; Eisen et al. 2003; Ellickson et al. 2003; Haggerty et al. 2007):

• study habits and academic support;
• communication;
• peer relationships;
• self-efficacy and assertiveness;
• drug resistance skills;
• reinforcement of anti-drug attitudes; and
• strengthening of personal commitments against drug abuse.

Principle 9 - Prevention programs aimed at general populations at key transition points, such as the transition to middle school, can produce beneficial effects even among high-risk families and children. Such interventions do not single out risk populations and, therefore, reduce labeling and promote bonding to school and community (Botvin et al. 1995; Dishion et al. 2002; Institute of Medicine 2009).

Principle 10 - Community prevention programs that combine two or more effective programs, such as family-based and school-based programs, can be more effective than a single program alone (Battistich et al. 1997; Spoth et al. 2002c; Stormshak et al. 2005).

Principle 11 - Community prevention programs reaching populations in multiple settings - for example, schools, clubs, faith-based organizations, and the media - are most effective when they present consistent, community-wide messages in each setting (Chou et al. 1998; Hawkins et al. 2009).

Principle 12 - When communities adapt programs to match their needs, community norms, or differing cultural requirements, they should retain core elements of the original research-based intervention (Spoth et al. 2002b; Hawkins et al. 2009), which include:

• Structure (how the program is organized and constructed);
• Content (the information, skills, and strategies of the program); and
• Delivery (how the program is adapted, implemented, and evaluated).

Principle 13 - Prevention programs should be long-term with repeated interventions (i.e., booster programs) to reinforce the original prevention goals. Research shows that the benefits from middle school prevention programs diminish without followup programs in high school (Botvin et al. 1995; Scheier et al. 1999).

Principle 14 - Prevention programs should include teacher training on good classroom management practices, such as rewarding appropriate student behavior. Such techniques help to foster students' positive behavior, achievement, academic motivation, and school bonding (Ialongo et al. 2001; Kellam et al. 2008).

Principle 15 - Prevention programs are most effective when they employ interactive techniques, such as peer discussion groups and parent role-playing, that allow for active involvement in learning about drug abuse and reinforcing skills (Botvin et al. 1995).

Principle 16 - Research-based prevention programs can be cost-effective. Similar to earlier research, recent research shows that for each dollar invested in prevention, a savings of up to $10 in treatment for alcohol or other substance abuse can be seen (Aos et al. 2001; Hawkins et al. 1999; Pentz 1998; Spoth et al. 2002a; Jones et al. 2008; Foster et al. 2007; Miller and Hendrie 2009).

References

1. Aos, S.; Phipps, P.; Barnoski, R.; and Lieb, R. The Comparative Costs and Benefits of Programs to Reduce Crime. Vol. 4 (1-05-1201).Olympia, WA: Washington State Institute for Public Policy, May 2001.
2. Ashery, R.S.; Robertson, E.B.; and Kumpfer, K.L., eds. Drug Abuse Prevention Through Family Interventions. NIDA Research Monograph No. 177. Washington, DC: U.S. Government Printing Office, 1998.
3. Battistich, V.; Solomon, D.; Watson, M.; and Schaps, E. Caring school communities. Educ Psychol 32(3):137-151, 1997.
4. Bauman, K.E.; Foshee, V.A.; Ennett, S.T.; Pemberton, M.; Hicks, K.A.; King, T.S.; and Koch, G.G. The influence of a family program on adolescent tobacco and alcohol. Am J Public Health 91(4):604-610, 2001.
5. Beauvais, F.; Chavez, E.; Oetting, E.; Deffenbacher, J.; and Cornell, G. Drug use, violence, and victimization among White American, Mexican American, and American Indian dropouts, students with academic problems, and students in good academic standing. J Couns Psychol 43:292-299, 1996.
6. Beets, M.W.; Flay, B.R.; Vuchinich, S.; Snyder, F.J.; Acock, A.; Li, K-K.; Burns, K.; Washburn, I.J.; and Durlak, J. Use of a social and character development program to prevent substance use, violent behaviors, and sexual activity among elementary-school students in Hawaii. Am J Public Health 99(8):1438-1445, 2009.
7. Botvin, G.; Baker, E.; Dusenbury, L.; Botvin, E.; and Diaz, T. Long-term follow-up results of a randomized drug-abuse prevention trial in a white middle class population. JAMA 273:1106-1112, 1995.
8. Brody, G.H.; Kogan, S.M.; Chen, Y.-F.; and Murry, V.M. Long-Term Effects of the Strong African American Families Program on youths' conduct problems. J Adolesc Health 43:474-481, 2008.
9. Chou, C.; Montgomery, S.; Pentz, M.; Rohrbach, L.; Johnson, C.; Flay, B.; and Mackinnon, D. Effects of a community-based prevention program in decreasing drug use in high-risk adolescents. Am J Public Health 88:944-948, 1998.
10. Conduct Problems Prevention Research Group. Predictor variables associated with positive Fast Track outcomes at the end of third grade. J Abnorm Child Psychol 30(1):37-52, 2002.
11. Dishion, T.; McCord, J.; and Poulin, F. When interventions harm: Peer groups and problem behavior. Am Psychol 54:755-764, 1999.
12. Dishion, T.; Kavanagh, K.; Schneiger, A.K.J.; Nelson, S.; and Kaufman, N. Preventing early adolescent substance use: A family centered strategy for the public middle school. Prev Sci 3(3):191-202, 2002.
13. Eisen, M.; Zellman, G.L.; and Murray, D.M. Evaluating the Lions-Quest "Skills for Adolescence" drug education program: Second-year behavior outcomes. Addict Behav 28(5):883-897, 2003.
14. Ellickson, P.L.; McCaffrey, D.F.; Ghosh-Dastidar, B.; and Longshore, D. New inroads in preventing adolescent drug use: Results from a large-scale trial of project ALERT in middle schools. Am J Public Health 93(11):1830-1836, 2003.
15. Fisher, P.A.; Stoolmiller, M.; Gunnar, M.R.; and Burraston, B.O. Effects of a therapeutic intervention for foster preschoolers on diurnal cortisol activity. Psychoneuroendocrinology 32(8-10):892-905, 2007.
16. Foster, E.M.; Olchowski, A.E.; and Webster-Stratton, C.H. Is stacking intervention components cost-effective? An analysis of the Incredible Years Program. J Am Acad Child Adolesc Psychiatry 46(11):1414-1424, 2007.
17. Gerstein, D.R., and Green, L.W., eds. Preventing drug abuse: What do we know? Washington, DC: National Academy Press, 1993.
18. Haggerty, K.P.; Skinner, M.L.; MacKenzie, E.P.; and Catalano, R.F.A. Randomized trial of parents who care: Effects on key outcomes at 24-month follow-up. Prev Sci 8:249-260, 2007.
19. Hawkins, J.D.; Catalano, R.F.; Kosterman, R.; Abbott, R.; and Hill, K.G. Preventing adolescent health-risk behaviors by strengthening protection during childhood. Arch Pediatr Adolesc Med 153:226-234, 1999.
20. Hawkins, J.D.; Catalano, R.F.; and Arthur, M. Promoting science-based prevention in communities. Addict Behav 27(6):951-976, 2002.
21. Hawkins, J.D.; Kosterman, R.; Catalano, R.; Hill, K.G.; and Abbott, R.D. Effects of social development intervention in childhood 15 years later. Arch Pediatr Adolesc Med 162(12):1133-1141, 2008.
22. Hawkins, J.D.; Oesterle, S.; Brown, E.C.; Arthur, M.W.; Abbott, R.D.; Fagan, A.A.; and Catalano, R. Results of a type 2 translational research trial to prevent adolescent drug use and delinquency: A test of communities that care. Arch Pediatr Adolesc Med 163(9):789-798, 2009.
23. Ialongo, N.; Poduska, J.; Werthamer, L.; and Kellam, S. The distal impact of two first-grade preventive interventions on conduct problems and disorder in early adolescence. J Emot Behav Disord 9:146-160, 2001.
24. Institute of Medicine. Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. National Academies Press, Washington DC, 2009.
25. Johnston, L.D.; O'Malley, P.M.; and Bachman, J.G. Monitoring the Future National Survey Results on Drug Use, 1975-2002. Volume 1: Secondary School Students. Bethesda, MD: National Institute on Drug Abuse, 2002.
26. Jones, D.E.; Foster, E.M.; and Group, C.P. Service use patterns for adolescents with ADHD and comorbid conduct disorder. J Behav Health Serv Res 36(4):436-449, 2008.
27. Kellam, S.G.; Brown, C.H.; Poduska, J.; Ialongo, N.; Wang, W.; Toyinbo, P.; Petras, H.; Ford, C.; Windham, A.; and Wilcox, H.C. Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes. Drug Alcohol Depend 95 (Suppl 1):S5-S28, 2008.
28. Kosterman, R.; Hawkins, J.D.; Spoth, R.; Haggerty, K.P.; and Zhu, K. Effects of a preventive parent-training intervention on observed family interactions: Proximal outcomes from preparing for the drug free years. J Community Psychol 25(4):337-352, 1997.
29. Kosterman, R.; Hawkins, J.D.; Haggerty, K.P.; Spoth, R.; and Redmond, C. Preparing for the drug free years: Session-specific effects of a universal parent-training intervention with rural families. J Drug Educ 31(1):47-68, 2001.
30. Miller, T.R., and Hendrie, D. Substance abuse prevention dollars and cents: A cost-benefit analysis. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention. Rockville, MD: DHHS Pub. No. (SMA) 07-4298, 2009.
31. Moon, D.; Hecht, M.; Jackson, K.; and Spellers, R. Ethnic and gender differences and similarities in adolescent drug use and refusals of drug offers. Subst Use Misuse 34(8):1059-1083, 1999.
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33. Olds, D.; Henderson, C.R.; Cole, R.; Eckenrode, J.; Kitzman, H.; Luckey, D.; Pettit, L.; Sidora, K.; Morris, P. and Powers, J. Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA 280(14):1238-1244, 1998.
34. Pentz, M.A.; Costs, benefits, and cost-effectiveness of comprehensive drug abuse prevention. In: Bukoski, W.J., and Evans, R.I., eds. Cost-benefit/cost-effectiveness research of drug abuse prevention: Implications for programming and policy. NIDA Research Monograph No. 176. Washington, DC: U.S. Government Printing Office, pp. 111-129, 1998.
35. Riggs, N.R.; Greenberg, M.T.; Kusche, C.A.; and Pentz, M.A. The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum. Prev Sci 7(1):91-102, 2006.
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Stimulant medications including amphetamines (e.g., Adderall) and methylphenidate (e.g., Ritalin and Concerta) are often prescribed to treat children, adolescents, or adults diagnosed with attention-deficit hyperactivity disorder (ADHD).

People with ADHD persistently have more difficulty paying attention or are more hyperactive or impulsive than other people the same age. This pattern of behavior usually becomes evident when a child is in preschool or the first grades of elementary school; the average age of onset of ADHD symptoms is 7 years. Many people’s ADHD symptoms improve during adolescence or as they grow older, but the disorder can persist into adulthood.

ADHD diagnoses are increasing. According to the U.S. Centers for Disease Control and Prevention, as of 2011, 11 percent of people ages 4–17 have been diagnosed with ADHD.

How Are Prescription Stimulants Used?

Prescription stimulants have a paradoxically calming and “focusing” effect on individuals with ADHD. They are prescribed to patients for daily use, and come in the form of tablets or capsules of varying dosages. Treatment of ADHD with stimulants, often in conjunction with psychotherapy, helps to improve ADHD symptoms along with the patient’s self-esteem, thinking ability, and social and family interactions.

Prescription stimulants are sometimes abused however—that is, taken in higher quantities or in a different manner than prescribed, or taken by those without a prescription. Because they suppress appetite, increase wakefulness, and increase focus and attention, they are frequently abused for purposes of weight loss or performance enhancement (e.g., to help study or boost grades in school; see box). Because they may produce euphoria, these drugs are also frequently abused for recreational purposes (i.e., to get high). Euphoria from stimulants is generally produced when pills are crushed and then snorted or mixed with water and injected.

How Do Prescription Stimulants Affect the Brain?

All stimulants work by increasing dopamine levels in the brain—dopamine is a neurotransmitter associated with pleasure, movement, and attention. The therapeutic effect of stimulants is achieved by slow and steady increases of dopamine, which are similar to the way dopamine is naturally produced in the brain. The doses prescribed by physicians start low and increase gradually until a therapeutic effect is reached.

When taken in doses and via routes other than those prescribed, prescription stimulants can increase brain dopamine in a rapid and highly amplified manner (similar to other drugs of abuse such as methamphetamine), thereby disrupting normal communication between brain cells and producing euphoria and, as a result, increasing the risk of addiction.

What Are the Other Health Effects of Prescription Stimulants?

Stimulants can increase blood pressure, heart rate, and body temperature and decrease sleep and appetite. When they are abused, they can lead to malnutrition and its consequences. Repeated abuse of stimulants can lead to feelings of hostility and paranoia. At high doses, they can lead to serious cardiovascular complications, including stroke.

Addiction to stimulants is also a very real consideration for anyone taking them without medical supervision. Addiction most likely occurs because stimulants, when taken in doses and routes other than those prescribed by a doctor, can induce a rapid rise in dopamine in the brain. Furthermore, if stimulants are abused chronically, withdrawal symptoms—including fatigue, depression, and disturbed sleep patterns—can result when a person stops taking them. Additional complications from abusing stimulants can arise when pills are crushed and injected: Insoluble fillers in the tablets can block small blood vessels.

Learn More

For additional information on prescription stimulants, see http://www.drugabuse.gov/publications/research-reports/prescription-drugs

Use of any psychoactive (mind-altering) drug makes it highly unsafe to drive a car and is illegal—just like driving after drinking alcohol. Drugged driving puts at risk not only the driver but also passengers and others who share the road.

Why Is Drugged Driving Hazardous?

The effects of specific drugs of abuse differ depending on how they act in the brain, but all impair faculties necessary for the safe operation of a vehicle. These faculties include motor skills, balance and coordination, perception, attention, reaction time, and judgment. Even small amounts of some drugs can have a measurable effect on driving ability.

How Many People Take Drugs and Drive?

According to the 2012 National Survey on Drug Use and Health (NSDUH), an estimated 10.3 million people aged 12 or older (or 3.9 percent of adolescents and adults) reported driving under the influence of illicit drugs during the year prior to being surveyed. This was higher than the rate in 2011 (3.7percent) and lower than the rate in 2002 (4.7 percent). By comparison, in 2012, an estimated 29.1 million persons (11.2 percent) reported driving under the influence of alcohol at least once in the past year. (This percentage has dropped since 2002, when it was 14.2 percent.)

According to the National Highway Traffic Safety Administration’s (NHTSA) 2007 National Roadside Survey, more than 16 percent of weekend, nighttime drivers tested positive for illegal, prescription, or over-the-counter drugs. More than 11 percent tested positive for illicit drugs.

According to NSDUH data, men are more likely than women to drive under the influence of an illicit drug or alcohol. And young adults aged 18 to 25 are more likely to drive after taking drugs than other age groups.

How Often Does Drugged Driving Cause Accidents?

It is hard to measure the exact contribution of drug intoxication to driving accidents, because blood tests for drugs other than alcohol are inconsistently performed, and many drivers who cause accidents are found to have both drugs and alcohol in their system, making it hard to determine which substance had the greater effect.

One NHTSA study found that in 2009, 18 percent of fatally injured drivers tested positive for at least one illicit, prescription, or over-the-counter drug (an increase from 13 percent in 2005).

What Drugs Contribute to Accidents?

After alcohol, THC (delta-9-tetrahydrocannabinol), the active ingredient in marijuana, is the substance most commonly found in the blood of impaired drivers, fatally injured drivers, and motor vehicle crash victims. Studies in several localities have found that approximately 4 to 14 percent of drivers who sustained injury or died in traffic accidents tested positive for THC.

A study of over 3,000 fatally injured drivers in Australia showed that when THC was present in the blood of the driver, he or she was much more likely to be at fault for the accident. Additionally, the higher the THC concentration, the more likely the driver was to be culpable.

Considerable evidence from both real and simulated driving studies indicates that marijuana can negatively affect a driver’s attentiveness, perception of time and speed, and ability to draw on information obtained from past experiences. Research shows that impairment increases significantly when marijuana use is combined with alcohol.

Other drugs commonly implicated in accidents include opiates, amphetamines, benzodiazepines, and cocaine. For instance, in a 2003 study of seriously injured drivers admitted to a Maryland shock trauma center, drugs other than alcohol were present in more than half of the cases. These included marijuana (26.9 percent), cocaine (11.6 percent), benzodiazepines (11.2 percent), and opiates and other prescription drugs (10.2 percent). A quarter of the cases involved both alcohol and other drugs.

Many prescription drugs including opioid pain relievers and benzodiazepenes prescribed for anxiety or sleep disorders come with warnings against the operation of machinery—including motor vehicles—for a specified period of time after use. When prescription drugs are abused (taken without medical supervision), impaired driving and other harmful reactions become much more likely.

Learn More

For additional information on drugged driving, please see http://www.whitehouse.gov/ondcp/drugged-driving

• Infographic: Drugged Driving (August 2014)

National estimates on drug-related visits to hospital emergency departments (ED) are obtained from the Drug Abuse Warning Network (DAWN),^1,2 a public health surveillance system managed by the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). DAWN data* are based on a national sample of general, non-Federal hospitals operating 24-hour Emergency Departments (EDs). Information is collected for all types of drugs—including illegal drugs, inhalants, alcohol—and abuse** of prescription and over-the-counter (OTC) medications and dietary supplements.

Highlights from the 2009 Drug Abuse Warning Network

In 2009, there were nearly 4.6 million drug-related ED visits nationwide. These visits included reports of drug abuse, adverse reactions to drugs, or other drug-related consequences. Almost 50 percent were attributed to adverse reactions to pharmaceuticals taken as prescribed, and 45 percent involved drug abuse. DAWN estimates that of the 2.1 million drug abuse visits—

• 27.1 percent involved nonmedical use of pharmaceuticals (i.e., prescription or OTC medications, dietary supplements)
• 21.2 percent involved illicit drugs
• 14.3 percent involved alcohol, in combination with other drugs.

ED visits involving nonmedical use of pharmaceuticals (either alone or in combination with another drug) increased 98.4 percent between 2004 and 2009, from 627,291 visits to 1,244,679, respectively. ED visits involving adverse reactions to pharmaceuticals increased 82.9 percent between 2005 and 2009, from 1,250,377 to 2,287,273 visits, respectively.

The majority of drug-related ED visits were made by patients 21 or older (80.9 percent, or 3,717,030 visits). Of these, slightly less than half involved drug abuse. Patients aged 20 or younger accounted for 19.1 percent (877,802 visits) of all drug-related visits in 2009; about half of these visits involved drug abuse.

Illicit Drugs

In 2009, almost one million visits involved an illicit drug, either alone or in combination with other types of drugs. DAWN estimates that—

• cocaine was involved in 422,896 ED visits
• marijuana was involved in 376,467 ED visits
• heroin was involved in 213,118 ED visits
• stimulants, including amphetamines and methamphetamine, were involved in 93,562 ED visits
• other illicit drugs—such as PCP, ecstasy, and GHB—were involved much less frequently than any of the drug types mentioned above.

The rates of ED visits involving cocaine, marijuana, and heroin were higher for males than for females. Rates for cocaine were highest among individuals aged 35–44, rates for heroin were highest among individuals aged 21–24, stimulant use was highest among those 25–29, and marijuana use was highest for those aged 18–20.

Alcohol and Other Drugs

Approximately 32 percent (658,263) of all drug abuse ED visits in 2009 involved the use of alcohol, either alone or in combination with another drug. DAWN reports alcohol-related data when it is used alone among individuals under the age of 21 or in combination with other drugs among all groups, regardless of age. Because DAWN does not account for ED visits involving alcohol use alone in adults, the actual number of ED visits involving alcohol among the general population is thought to be significantly higher than what is reported in DAWN.

In 2009, DAWN estimated 519,650 ED visits related to the use of alcohol in combination with other drugs. Alcohol was most frequently combined with—

• central nervous system agents (e.g., analgesics, stimulants, sedatives) (229,230 visits)
• cocaine (152,631 visits)
• marijuana (125,438 visits)
• psychotherapeutic agents (e.g., antidepressants and antipsychotics) (44,217 visits)
• heroin (43,110 visits).

While alcohol use is illegal for individuals under age 21, DAWN estimates that in 2009 there were 199,429 alcohol-related ED visits among individuals under age 21; 76,918 ED visits were reported among those aged 12 to 17, and 120,853 alcohol-related ED visits were reported among those aged 18 to 20.

Nonmedical Use of Pharmaceuticals

In 2009, 1.2 million ED visits involved the nonmedical use of pharmaceuticals or dietary supplements. The most frequently reported drugs in the nonmedical use category of ED visits were opiate/opioid analgesics, present in 50 percent of nonmedical-use ED visits; and psychotherapeutic agents, (commonly used to treat anxiety and sleep disorders), present in more than one-third of nonmedical ED visits. Included among the most frequently reported opioids were single-ingredient formulations (e.g., oxycodone) and combination forms (e.g., hydrocodone with acetaminophen). Methadone, together with single-ingredient and combination forms of oxycodone and hydrocodone, was also included under the most frequently reported opioids classification—

• hydrocodone (alone or in combination) in 104,490 ED visits
• oxycodone (alone or in combination) in 175,949 ED visits
• methadone in 70,637 ED visits.

Increases in drug-related ED visits over time

The total number of drug-related ED visits increased 81 percent from 2004 (2.5 million) to 2009 (4.6 million). ED visits involving nonmedical use of pharmaceuticals increased 98.4 percent over the same period, from 627,291 visits to 1,244,679.

The largest pharmaceutical increases were observed for oxycodone products (242.2 percent increase), alprazolam (148.3 percent increase), and hydrocodone products (124.5 percent). Among ED visits involving illicit drugs, only those involving ecstasy increased more than 100 percent from 2004 to 2009 (123.2 percent increase).

For patients aged 20 or younger, ED visits resulting from nonmedical use of pharmaceuticals increased 45.4 percent between 2004 and 2009 (116,644 and 169,589 visits, respectively). Among patients aged 21 or older, there was an increase of 111.0 percent.

ED visits involving adverse reactions to pharmaceuticals increased 82.9 percent between 2005 and 2009, from 1,250,377 visits to 2,287,273. The majority of adverse reaction visits were made by patients 21 or older, particularly among patients 65 or older; the rate increased 89.2 percent from 2005 to 2009 among this age group.

Other Data Sources

* DAWN relies on longitudinal data collected from selected hospitals across the United States. Beginning in 2004, DAWN adjusted its sampling and weighting methodologies in order to improve the quality, reliability, and generalizability of its estimates. Thus, trends reported earlier than 2004 cannot be compared to more current estimates due to changes in the DAWN data collection reporting system.

** The abuse of pharmaceuticals (prescription and over-the-counter medications) is also referred to as “nonmedical use.”

References

1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (formerly the Office of Applied Studies). The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD, December 28, 2010. Available at: http://www.oas.samhsa.gov/2k10/DAWN034/EDHighlights.htm.
2. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Drug Abuse Warning Network: Detailed Tables: National Estimates, Drug-Related Emergency Department Visits for 2004–2009. Rockville, MD, December 28, 2010. Available at: http://www.samhsa.gov/data/DAWN.aspx.

Every year, the Monitoring the Future (MTF) survey measures drug, alcohol, and tobacco use and related attitudes among 8th, 10th, and 12th graders. Following are facts and statistics about youth substance use from the 2013 MTF report

Illicit Drug Use

Illicit drug use among teenagers remains high, largely due to increasing popularity of marijuana. Marijuana use by adolescents declined from the late 1990s until the mid-to-late 2000s, but has been on the increase since then. In 2013, 7.0 percent of 8th graders, 18.0 percent of 10th graders, and 22.7 percent of 12th graders used marijuana in the past month, up from 5.8 percent, 13.8 percent, and 19.4 percent in 2008. Daily use has also increased; 6.5 percent of 12th graders now use marijuana every day, compared to 5 percent in the mid-2000s.

Rising marijuana use reflects changing perceptions and attitudes. Historically, as perception of risks goes down, use goes up (and vice versa). Young people are showing less disapproval of marijuana use and decreased perception that marijuana is dangerous. The growing perception of marijuana as a safe drug may reflect recent public discussions over “medical marijuana” and movements to legalize the drug for adult recreational use in some states.

New synthetic drugs are a cause for concern, but their use is not increasing. Synthetic marijuana (also known as Spice or K2)—referring to herbal mixtures laced with synthetic chemicals similar to THC, the main active ingredient in marijuana—was added to the MTF survey in 2011, when 11.4 percent of high school seniors reported using it in the past year; in 2013, it had dropped to 7.9 percent. These mixtures could be obtained legally until 2012 and are still wrongly perceived as a safe alternative to marijuana. The synthetic stimulants known as “bath salts” were added to the survey in 2012; in 2013, just 0.9 percent of seniors had used these drugs in the past year.

Nonmedical use of prescription and over-the-counter medicines remains a significant part of the teen drug problem. In 2013, 15.0 percent of high school seniors used a prescription drug non-medically in the past year. The survey shows continued abuse of Adderall, commonly used to treat attention deficit hyperactivity disorder, or ADHD, with 7.4 percent of seniors reporting taking it for non-medical reasons in the past year. However, only 2.3 percent of seniors report abuse of Ritalin, another ADHD medication. Abuse of the opioid pain reliever Vicodin has shown a marked decrease in the last 10 years, now measured at 5.3 percent for high school seniors, compared to 10.5 percent in 2003. In addition, 5 percent of seniors report abuse of cough products containing dextromethorphan, down from 6.9 percent in 2006, the first year it was measured by the survey.

Positive trends in the past several years include reduced use of inhalants and less use of cocaine, especially crack cocaine. Past-year inhalant use by younger teens continued a downward trend in 2013, with 5.2 percent of 8th graders and 3.5 percent of 10th graders reporting use. Five-year trends of past-year cocaine use across all grades showed a drop as well. Other drugs, such as heroin, methamphetamine, ecstasy (MDMA) and hallucinogens, are holding fairly steady.

Alcohol

Alcohol use among teens remains at historically low levels. In 2013, 3.5 percent of 8th graders, 12.8 percent of 10th graders, and 26 percent of 12th graders reported getting drunk in the past month, continuing a downward trend from previous years. Significant declines include sharp drops from previous years in daily alcohol use by 10th and 12th graders (0.9 percent and 2.2 percent, respectively, in 2013). In 2013, 22.1 percent of high school seniors reported binge drinking (defined as 5 or more drinks in a row in the past 2 weeks)—a drop of almost one-third since the late 1990s.

Tobacco

Fewer teens smoke cigarettes than smoke marijuana. Cigarette smoking by high school students peaked in 1996–1997 and has declined continuously since then. In 2013, 16.3 percent of 12th-grade students surveyed by MTF were current (past-month) cigarette smokers—the lowest teen smoking has been in the history of the survey. By comparison, 22.7 percent were current marijuana smokers.

Other forms of smoked tobacco are becoming popular, however. The use of hookah water pipes and small cigars has raised public health concerns and has recently been added to the MTF survey. In 2013, 21.4 percent of 12th graders had smoked a hookah at some point in the past year, an increase from 18.3 percent in 2012, and 20.4 percent had smoked a small cigar.

Learn More

Complete MTF survey results are available at www.monitoringthefuture.org. For more information on the survey and its findings, also visit www.drugabuse.gov/related-topics/trends-statistics/monitoring-future.

• View the Monitoring the Future data table.

Other sources of information on drug use trends among youth are available:

The annual National Survey of Drug Use and Health, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), gathers detailed data on drug, alcohol, and tobacco use by all age groups. It is a comprehensive source of information on substance use and dependence among Americans aged 12 and older. Data and reports can be found at http://samhsa.gov/data/NSDUH.aspx.  More information is also available at the Substance Abuse & Mental Health Data Archive (SAMHDA) - http://www.datafiles.samhsa.gov/

The Youth Risk Behavior Survey is a school-based survey conducted every other year by the Centers for Disease Control and Prevention. It gathers data on a wide variety of health-related risk behaviors, including drug abuse, from students in grades 9–12. More information is available at www.cdc.gov/nccdphp/dash/yrbs/index.htm

A major source of information on substance use, abuse, and dependence among Americans aged 12 and older is the annual National Survey on Drug Use and Health (NSDUH) conducted by the Substance Abuse and Mental Health Services Administration. Following are facts and statistics on substance use in America from 2012, the most recent year for which NSDUH survey data have been analyzed.

Illicit Drug Use

Illicit drug use in America has been increasing. In 2012, an estimated 23.9 million Americans aged 12 or older—or 9.2 percent of the population—had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month. This is up from 8.3 percent in 2002. The increase mostly reflects a recent rise in the use of marijuana, the most commonly used illicit drug.

Marijuana use has increased since 2007. In 2012, there were 18.9 million current (past-month) users—about 7.3 percent of people aged 12 or older—up from 14.4 million (5.8 percent) in 2007.

Use of most drugs other than marijuana has not changed appreciably over the past decade or has declined. In 2012, 6.8 million Americans aged 12 or older (or 2.6 percent) had used psychotherapeutic prescription drugs nonmedically (without a prescription or in a manner or for a purpose not prescribed) in the past month. And 1.1 million Americans (0.4 percent) had used hallucinogens (a category that includes Ecstasy and LSD) in the past month.

Cocaine use has gone down in the last few years; from 2007 to 2012, the number of current users aged 12 or older dropped from 2.1 million to 1.7 million. Methamphetamine use has remained steady, from 530,000 current users in 2007 to 440,000 in 2012.

Most people use drugs for the first time when they are teenagers. There were just over 2.8 million new users (initiates) of illicit drugs in 2012, or about 7,898 new users per day. Half (52 per-cent) were under 18.

More than half of new illicit drug users begin with marijuana. Next most common are prescription pain relievers, followed by inhalants (which is most common among younger teens).

Drug use is highest among people in their late teens and twenties. In 2012, 23.9 percent of 18- to 20-year-olds reported using an illicit drug in the past month.

Drug use is increasing among people in their fifties. This is, at least in part, due to the aging of the baby boomers, whose rates of illicit drug use have historically been higher than those of previous cohorts.

Alcohol

Drinking by underage persons (ages 12–20) has declined. Current alcohol use by this age group declined from 28.8 to 24.3 percent between 2002 and 2012, while binge drinking declined from 19.3 to 15.3 percent and the rate of heavy drinking went from 6.2 to 4.3 percent.

Binge and heavy drinking are more prevalent among men than among women. In 2012, 30.4 percent of men 12 and older and 16.0 percent of women reported binge drinking (five or more drinks on the same occasion) in the past month; and 9.9 percent of men and 3.4 percent of women reported heavy alcohol use (binge drinking on at least five separate days in the past month).

Driving under the influence of alcohol has also declined slightly. In 2012, an estimated 29.1 million people, or 11.2 percent of persons aged 12 or older, had driven under the influence of alcohol at least once in the past year, down from 14.2 percent in 2002. Although this decline is encouraging, any driving under the influence remains a cause for concern.

Tobacco

Fewer Americans are smoking. In 2012, an estimated 57.5 million Americans aged 12 or older, or 22 percent of the population, were current (past month) cigarette smokers. This reflects a continual but slow downward trend from 2002, when the rate was 26 percent.

Teen smoking is declining more rapidly. The rate of past-month cigarette use among 12- to 17-year-olds went from 13 percent in 2002 to 6.6 percent in 2012.

Substance Dependence/Abuse and Treatment

Rates of alcohol dependence/abuse declined from 2002 to 2012 In 2012, 17.7 million Americans (6.8 percent of the population) were dependent on alcohol or had problems related to their use of alcohol (abuse). This is a decline from 18.1 million (or 7.7 percent) in 2002.

After alcohol, marijuana has the highest rate of dependence or abuse among all drugs. In 2012, 4.3 million Americans met clinical criteria for dependence or abuse of marijuana in the past year—more than twice the number for dependence/abuse of prescription pain relievers (2.1 million) and four times the number for dependence/abuse of cocaine (1.1).

There continues to be a large “treatment gap” in this country. In 2012, an estimated 23.1 million Americans (8.9 percent) needed treatment for a problem related to drugs or alcohol, but only about 2.5 million people (1 percent) received treatment at a specialty facility.

*Note that the terms dependence and abuse as used in the NSDUH are based on diagnostic categories used in the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); in the newly published Fifth Edition (DSM-V), those categories have been replaced by a single Substance Use Disorder spectrum.

Learn More

Complete NSDUH findings are available at http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm.

Some medications have psychoactive (mind-altering) properties and, because of that, are sometimes abused—that is, taken for reasons or in ways or amounts not intended by a doctor, or taken by someone other than the person for whom they are prescribed. In fact, prescription and over-the-counter (OTC) drugs are, after marijuana (and alcohol), the most commonly abused substances by Americans 14 and older.

The classes of prescription drugs most commonly abused are: opioid pain relievers, such as Vicodin or Oxycontin; stimulants for treating Attention Deficit Hyperactivity Disorder (ADHD), such as Adderall, Concerta, or Ritalin; and central nervous system (CNS) depressants for relieving anxiety, such as Valium or Xanax.¹ The most commonly abused OTC drugs are cough and cold remedies containing dextromethorphan.

People often think that prescription and OTC drugs are safer than illicit drugs, but that’s only true when they are taken exactly as prescribed and for the purpose intended. When abused, prescription and OTC drugs can be addictive and put abusers at risk for other adverse health effects, including overdose—especially when taken along with other drugs or alcohol.

How Are Prescription Drugs Abused?

Prescription and OTC drugs may be abused in one or more of the following ways:

Taking a medication that has been prescribed for somebody else. Unaware of the dangers of sharing medications, people often unknowingly contribute to this form of abuse by sharing their unused pain relievers with their family members. 

Taking a drug in a higher quantity or in another manner than prescribed. Most prescription drugs are dispensed orally in tablets, but abusers sometimes crush the tablets and snort or inject the powder. This hastens the entry of the drug into the bloodstream and the brain and amplifies its effects.

Taking a drug for another purpose than prescribed. All of the drug types mentioned can produce pleasurable effects at sufficient quantities, so taking them for the purpose of getting high is one of the main reasons people abuse them.

ADHD drugs like Adderall are also often abused by students seeking to improve their academic performance. However, although they may boost alertness, there is little evidence they improve cognitive functioning for those without a medical condition.

How Do Prescription and OTC Drugs Affect the Brain?

Taken as intended, prescription and OTC drugs safely treat specific mental or physical symptoms. But when taken in different quantities or when such symptoms aren’t present, they may affect the brain in ways very similar to illicit drugs.

For example, stimulants such as Ritalin achieve their effects by acting on the same neurotransmitter systems as cocaine. Opioid pain relievers such as OxyContin attach to the same cell receptors targeted by illegal opioids like heroin. Prescription depressants produce sedating or calming effects in the same manner as the club drugs GHB and rohypnol. And when taken in very high doses, dextromethorphan acts on the same cell receptors as PCP or ketamine, producing similar out-of-body experiences.

When abused, all of these classes of drugs directly or indirectly cause a pleasurable increase in the amount of dopamine in the brain’s reward pathway. Repeatedly seeking to experience that feeling can lead to addiction.

What Are the Other Health Effects of Prescription and OTC Drugs?

Stimulants can have strong effects on the cardiovascular system. Taking high doses of a stimulant can dangerously raise body temperature and cause irregular heartbeat or even heart failure or seizures. Also, taking some stimulants in high doses or repeatedly can lead to hostility or feelings of paranoia.

Opioids can produce drowsiness, cause constipation, and—depending upon the amount taken—depress breathing. The latter effect makes opioids particularly dangerous, especially when they are snorted or injected or combined with other drugs or alcohol. More people die from overdoses of prescription opioids than from all other drugs combined, including heroin and cocaine (see "The Prescription Opioid Abuse Epidemic" below).

The Prescription Opioid Abuse Epidemic

Over 2 million people in the United States suffer from substance use disorders related to prescription opioid pain relievers. The terrible consequences of this epidemic include overdose deaths, which have more than quadrupled in the past decade and a half. The causes are complex, but they include overprescription of pain medications. In 2013, 207 million prescriptions were written for prescription opioid pain medications.

CNS depressants slow down brain activity and can cause sleepiness and loss of coordination. Continued use can lead to physical dependence and withdrawal symptoms if discontinuing use.

Dextromethorphan can cause impaired motor function, numbness, nausea or vomiting, and increased heart rate and blood pressure. On rare occasions, hypoxic brain damage—caused by severe respiratory depression and a lack of oxygen to the brain—has occurred due to the combination of dextromethorphan with decongestants often found in the medication.

All of these drugs have the potential for addiction, and this risk is amplified when they are abused. Also, as with other drugs, abuse of prescription and OTC drugs can alter a person’s judgment and decision making, leading to dangerous behaviors such as unsafe sex and drugged driving.

Learn More

For more information on prescription and OTC drugs, please refer to the following sources on NIDA’s Web site:

• Research Report: Prescription Drugs
• Prescription Stimulants (Abuse) Health Effects
• Prescription Sedatives, sleeping pills*, or anxiolytics (Abuse) Health Effects
• Prescription Opioids (Abuse) Health Effects

References

1. These are proprietary names of particular drug products. Generic versions may also exist.

All materials appearing in the ​Research Reports series are in the public domain and may be reproduced without permission from NIDA. Citation of the source is appreciated.

Opioid prescriptions have increased three-fold over the past two decades, and we have seen how this skyrocketing availability of medications has helped create a new drug abusing population, some of whom suffer severe health consequences. More deaths now occur as a result of overdosing on prescription opioids than from all other drug overdoses combined, including heroin and cocaine. The opioid epidemic is tied closely to another epidemic in our country, that of chronic pain—although the ties are very complex.

Chronic pain now affects more than a third of Americans (see Infographic below). Although chronic pain patients themselves account for only a small percentage of those who are abusing opioid painkillers and dying from them, these pain sufferers may not even be obtaining significant benefit from the opioids used to treat their condition. In fact, growing evidence suggests that long-term treatment with opioids may induce hyperalgesia, an increase in pain sensitivity as a result of the chronic administration of opioid medications, at least in some patients.

Chronic pain is a major public health problem. It affects more than one-third of the U.S. and 20%-30% of the world's population.  Prevalence of persistent pain is expected to rise with the increase in diabetes, cardiovascular disorders, obesity, arthritis and cancer in the aging U.S. population. Opioids can produce significant side effects such as respiratory depression, mental clouding, nausea, constipation and physical dependence. Opioid prescribing has increased 300% in the last 20 years. Today, the number of people who die from prescription opioids exceeds the number from heroin and cocaine combined. See a larger version from NIH Prevention site.

This year, the Agency for Healthcare Research and Quality reviewed studies on the effectiveness and risks of long-term opioid treatment of chronic pain. The results are eye-opening: No randomized trials or comparative observational studies meeting the reviewers’ criteria were found that addressed opioids’ effectiveness for chronic pain or comparing their effectiveness to other treatments, making it impossible to know whether long-term treatment with opioids adequately addresses patients’ symptoms or improves their functioning or quality of life. At best there was weak evidence regarding optimal dosing strategies with these medications.

I have argued before that opioids are overused and overprescribed because of a lack of clear understanding of how to treat pain by doctors. (Pain management is barely covered in medical schools—a situation that NIDA has worked to help rectify through various initiatives including leading the creation of 11 Centers of Excellence in Pain Education, in partnership with the NIH Pain Consortium and other NIH Institutes.) If it is indeed the case that opioid overtreatment is not only contributing to addiction but also contributing to the chronic pain problem, then that makes all the more urgent the need to investigate new treatment approaches and perhaps even create new medications that operate on other signaling systems in the body.

On September 29-30, NIDA along with the NIH Pain Consortium, the NIH Office of Disease Prevention, and the National Institute of Neurological Disorders and Stroke is cosponsoring a Pathways to Prevention workshop to discuss what we know and don’t know about opioids in the management of chronic pain. Participants will discuss the effectiveness and potential risks of long-term opioid treatment for different patient populations, different pain management strategies and their outcomes, ways of limiting opioids’ risks, and our future research needs.

Get more information on the workshop, The Role of Opioids in the Treatment of Chronic Pain. You can also see my video on pain research at NIDA and the NIH Pain Consortium (below).