It
was supposed to be a short course of treatment with tranquilizers
after the death of her infant son 15 years ago. But Lynn Ray, 46, of
Germantown, Md., says her abuse of the anti-anxiety drug Xanax and
other prescription drugs led to a long struggle with addiction that
nearly ruined her life.
Tranquilizers, which
slow down the central nervous system and cause drowsiness, numbed
Rays agony, helped her sleep, and untied the relentless knot in her
stomach. Soon, even if her doctor
had prescribed one pill in an eight-hour period, she took two or
three in an attempt to intensify the calming effect of the drug.
When the doctor stopped
writing prescriptions for her and encouraged grief counseling, Ray
began doctor-shopping--going from doctor to doctor, fabricating
panic attacks, backaches, migraines, and other ailments that would
get her multiple prescriptions for tranquilizers and pain
killers. "I became a very good actress," Ray says.
"I thought I needed these drugs no matter what, even if I had
to bamboozle the doctors to get them."
Most patients take
medicine responsibly, but approximately 9 million Americans used
prescription drugs for non-medical purposes in 1999, according to
the National Institute on Drug Abuse (NIDA). Non-medical purposes
include misusing prescription drugs for recreation and for psychic
effects--to get high, to have fun, to get a lift, or to calm down.
Experts stress that
prescription drug abuse isnt about bad drugs or even bad people. It
involves a complex web of factors, including the power of addiction,
misperceptions about drug abuse, and the difficulty both patients
and doctors have discussing the topic.
There is also the
delicate balance of curbing criminal activity related to drug abuse
while making sure that people with legitimate health needs can still
access care, says Alan I. Leshner, Ph.D., director of NIDA. "We
recognize the very real issue that millions of lives are improved
because of prescription drugs--the same drugs that are sometimes
abused," he says.
Consequences
of Abuse
Ray had convinced
herself that abusing prescription drugs was safer than abusing
heroin, marijuana, and other "street drugs." "I would
never do those," she says. "I figured I had a prescription
for what I was doing, which made it OK."
Scott Walker, program
director for substance abuse at the Mountain Comprehensive Care
Center in Prestonsburg, Ky., says he hears that rationalization over
and over. "Some people tell themselves they arent using
something old Joe cooked up in a garage somewhere," Walker
says. They may figure a legitimate manufacturer made this, "so
what could be the harm?"
As Rays life unraveled,
she found out the harm can be great, whether youre using heroin or
sleeping pills. She lost her job as a computer programmer after
repeatedly showing up late for work and falling asleep at her desk.
Her son, a preteen at the time, couldnt understand her erratic
behavior and didnt want anything to do with her.
Then in 1995, she
crashed her car three times in one month while under the influence
of tranquilizers and painkillers, seriously injuring others each
time. Her drivers license was revoked, and she served a one-year
jail sentence in 1998. "I will always know in my heart that I
could have killed those people," she says. "It doesnt
matter that I didnt kill them; it matters that I could have."
Walker says that roughly
half of the people undergoing substance abuse treatment at Mountain
Comprehensive Care Center come after realizing that they found
themselves in a hole too deep to get out of on their own. The other
half, like Ray, come because of some criminal charge related to drug
possession or drug use.
OxyContin
(oxycodone), a controlled drug approved in 1995 to treat chronic,
moderate-to-severe pain, has received considerable attention because
of deaths and crimes associated with its abuse. OxyContin is a
morphine-like narcotic that contains a high dose of oxycodone.
Manufactured by Purdue Pharma, Stamford, Conn., the drug was
originally believed to pose a lower risk for abuse because it is a
controlled-release drug designed to be taken orally and swallowed
whole, says Deborah Leiderman, M.D., director of the Food and Drug
Administrations controlled substance staff. The drugs active
ingredient, oxycodone, is slowly released over a 12-hour period.
"But the safety of the drug is based on taking the drug exactly
as intended," she says.
Abusers sometimes
disrupt the time-release formula of the drug to speed up absorption,
often chewing the tablets, crushing them and snorting the powder, or
dissolving them in water and injecting the drug to get a fast high.
Abusers have also used OxyContin with other painkillers, alcohol,
and marijuana. Several deaths have resulted, mostly in rural areas
of the Eastern United States, especially in Virginia and West
Virginia.
Other products
containing oxycodone such as Percodan and Percocet have also been
abused over the years. Abuse of opiates is not new; whats new is
the recent surge in local epidemics of opiate abuse.
The most highly abused
stimulants are illicit drugs, including cocaine and methamphetamines.
There also have been recent reports of Ritalin
(methylphenidate) abuse among middle and high school students. The
drug, which produces effects more potent than caffeine and less
potent than amphetamine, is prescribed to treat
attention-deficit/hyperactivity disorder and other conditions. But
some have used it to suppress their appetite or to stay awake while
studying. The DEA lists Ritalin as a "drug of concern" and
reports that some abusers have dissolved the tablets in water and
injected the mixture, which can block small blood vessels and damage
the lungs and retina of the eye.
Complexities
of Addiction
Its not that
potentially addictive medications shouldnt be used, says Richard
Brown, M.D., M.P.H., associate professor of family medicine at the
University of Wisconsin Medical School. "They have an important
place in the treatment of debilitating conditions." According
to NIDA, drug addiction--characterized by drug craving that is out
of control--is actually uncommon among people who use drugs as
prescribed.
NIDA, along with several
health organizations, has launched a national initiative to educate
the public about the dangers of the non-medical use of prescription
drugs, and the potential for abuse and addiction. With psychological
addiction, there is a preoccupation with obtaining and using drugs
that persists despite the consequences. Psychological addiction is
distinct from physical dependence and tolerance, but the presence of
these problems can complicate the treatment of addiction, says Alice
Young, Ph.D., a professor in the department of psychology at Wayne
State University in Detroit. "It is true that both
psychological addiction and physical dependence can happen
together," she says, "but they are not the same."
Young says that physical
dependence, which is sometimes unavoidable, develops when an
individual is exposed to a drug at a high enough dose for long
enough that the body adapts and develops a tolerance for the drug.
This means that higher doses are needed to achieve a drugs original
effects. "If the patient stops taking the drug, then withdrawal
will occur," Young says. But the development of physical
dependence doesnt necessarily lead to addiction in all cases, she
explains. "It means that the individual cant just stop taking
the drug; the dose has to be tapered," a method to gradually
decrease a drugs amount over time to prevent withdrawal reactions.
In addition to promoting
public education, NIDAs initiative will foster new research on why
certain people become addicted, says Leshner. "Some choose
prescription drugs as the drug of choice, and others become addicted
inadvertently," he says. "We want to learn more about what
makes some people more likely to stray from the prescribed plan than
others." NIDA also will support research into the mechanisms by
which certain substances produce addiction.
Appropriate
Use Is Key
Physician supervision
and appropriate use is critical for all prescription drugs. Doctors
consider a patients diagnosis and whether non-addictive treatments
should be considered first.
"Very strong opiate
drugs play a critical role in pain management," FDAs Leiderman
says. "But they arent appropriate for all pain. Treatment
needs to be tailored depending on a patients specific
condition."
Brown says doctors must
also consider the patients medical history and whether an
individual has had addictive disorders in the past. But a history of
substance abuse doesnt necessarily rule out using potentially
addictive medications. "Patients should be honest about their
substance abuse history because then it tells me to watch them even
more closely," Brown says.
A good rapport between a
patient and doctor can make it easier to discuss problems that come
up, and health-care professionals should carefully monitor patients
who take potentially addictive medication. For some, that might
require a periodic urine drug screen, Brown says. "This is not
an issue of distrust or intrusiveness," he says. "I
explain to patients that its a way to help protect them, especially
because people who are addicted may not recognize it. Addiction can
make people do things they wouldnt normally do."
A couple of Browns
patients experienced trouble with opioids and impulsivity--symptoms
that led them to take more medicine than prescribed instead of
waiting for the initial medicine to work. Brown picked up on the
problems because both patients requested early refills. He switched
them to non-drug treatments, such as physical therapy and relaxation
techniques, until they could more successfully take prescription
drugs.
Complicating matters is
the fact that physicians are vastly undertrained in identifying drug
abuse. "The average physician gets little training in drug
abuse, mainly because drug abuse has only been recently recognized
as a health problem," Leshner says. Brown says that some
doctors are so concerned about penalties for overprescribing
potentially addictive medications that they dont treat patients
appropriately. "Other physicians mean well and prescribe the
drugs, but dont know the warning signs of abuse," he says.
"Then there are those who just cant say No to patients who
violate the prescribed plan."
One recent survey from
the National Center on Addiction and Substance Abuse at Columbia
University in New York City indicated that nearly half of primary
care physicians report having difficulty talking about substance
abuse with patients. H. Westley Clark, M.D., J.D., director of the
Center for Substance Abuse Treatment at the Substance Abuse and
Mental Health Services Administration (SAMHSA), says his agency
began a training program last year to help address this major
problem.
The joint project with
the Health Resources and Services Administration will train faculty
members in the health professions. "Its not only for
doctors," Clark says. "Other health professionals,
including nurses
and pharmacists,
should also learn about recognizing the signs of substance abuse,
talking about it, and knowing when patients should be referred for
treatment."
There
Is Help
For Ray, jail was the
turning point. "Theres something about those metal bars
slamming shut behind you that makes it all very real," she
says. A drug program in prison helped her beat addiction and taught
her to cope with the triggers or life stressors that pushed her down
the path to drug abuse.
"If you find
yourself not following your doctors orders, buying drugs off the
street, or doctor-shopping, know that there is effective treatment
and you can get help," Clark says. "If there is a
treatment center within 100 miles of you, we can help you find
it." Addiction is a brain disease typically treated with
behavioral intervention, drug treatment, or often a combination.
Some treatments need to
alleviate both withdrawal symptoms and the psychological addiction
to drugs. Detoxification, the process by which the body recovers
from tolerance and dependence, is considered a first stage in the
sense that it purges drugs from the body. "It doesnt
constitute a treatment," Young says. "Treatment has to
address stopping future use."
Methadone, a synthetic
opioid, has been used for more than 30 years to treat some opioid
addictions. Levo-alpha-acety/methadol (LAAM) is another opioid
treatment.
With methadone
treatment, the patient receives both behavioral intervention and an
oral, daily dose that maintains the physical dependence. When people
abuse drugs, they commonly use fast routes of administration such as
injection or inhalation, which basically slam the drugs into the
brain. Methadone treatment delivers the narcotic orally so that it
is slowly released in the body. The intent is to lessen the chance
that the patient will use illegal opioids, Young explains. Among the
goals is to decrease cravings for the "rush" created when
opioids are taken by fast routes, and to prevent the occurrence of
withdrawal signs by maintaining a steady level of opiate in the
body. "Its a maintenance therapy over a long period of time,
just like maintenance for diabetes, asthma, or any other chronic
problem."
Striking
a Balance
Prescription drugs
commonly are diverted through fraudulent prescriptions,
doctor-shopping, over-prescribing, and pharmacy theft. Clark says
that dealing with diversion requires the involvement of patients,
physicians, and pharmacists, and that there are many variables
linking these three groups.
"Sometimes its a
matter of patients and physicians without adequate information about
drug abuse," Clark says. "Sometimes overworked pharmacies
dont notice when a patient is doubling up on a medication."
But as pharmacists look
out for false or altered prescription forms and doctors look out for
suspicious complaints, patients with legitimate medical problems
still need fair treatment, Clark says. "We dont want to wind
up punishing people in need."
Ellen Stovall, president
of the National Coalition of Cancer Survivorship, says some cancer
patients have been frustrated with the lack of appreciation for
assessment of their own pain. The last thing patients need is a
setback to pain management, Stovall says. "We have all the
important laws around the abuse of narcotics, but we need
legislation and support to protect people who are experiencing real,
honest suffering."
