Potentially addictive medication can present prescribing puzzle

Ensuring appropriate use of strong prescription medications is the goal of a new campaign by the National Institute on Drug Abuse.

By Susan J. Landers, amednews staff. May 14, 2001.

Washington -- Physicians may sometimes find themselves caught between a rock and a hard place when it comes to prescribing potentially addictive medications.

There is always the fear that a patient will become addicted to the pain relievers, central nervous system depressants or stimulants being prescribed. And there is the problem of patients who are intent upon fraudulently obtaining the drugs. But those medications hold great promise of relief for most patients and to withhold them would unnecessarily prolong suffering.

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"We are dealing with medications that treat very real problems like depression, anxiety and attention-deficit disorder," said Karla Birkholz, MD, a family physician in Phoenix. "And these medications are wonderful for treating them," she said. "But the more wonderful drugs we have, the more people can find ways to misuse them."

Terry Horton, MD, medical director and vice president of Phoenix House Foundation, a national drug treatment agency headquartered in New York City, sees many patients who are addicted to prescription drugs.

Several years ago he asked a patient how she was able to get the various prescription drugs she had obtained. She explained that she would look in the Physicians' Desk Reference for a drug she liked, determine what the indications were for that drug and then parrot the symptoms to a doctor. "It was a very sophisticated approach to duping physicians," he said.

The National Institute on Drug Abuse recently joined with physician and pharmaceutical groups in a national effort to help prevent the misuse and abuse of prescription drugs.

NIDA estimates that 4 million people age 12 and older used prescription drugs for nonmedical reasons in 1999. Almost half had reported using the prescription drugs nonmedically for the first time in the previous year.

In addition, a recent survey of primary care physicians and their patients found that 46.6% of physicians find it difficult to discuss prescription drug abuse with their patients, according to NIDA.

Recent research conducted by Richard Brown, MD, associate professor of family medicine at the University of Wisconsin Medical School in Madison, reveals that physicians tend to err on both sides -- either underprescribing or overprescribing.

"Physicians need to learn a lot more about addiction than they typically do," said Dr. Brown. Primary care physicians often think specialists in pain management or addiction should handle this care, he said. "But there are a lot of anxious patients out there and a lot of people in pain and not enough specialists to go around."

There are several steps physicians can take to learn to prescribe more appropriately.

"Physicians need to understand the difference between addiction and physical dependence," said Dr. Brown. "A lot of physicians think that just because their patients are physically dependent they are addicted, but that's not true."

Physicians must also understand the complications, such as addiction, that can accompany some medications, said Dr. Horton. They must know how to diagnose or screen for those complications, and then treat them or refer the patient to a specialist for treatment, he said.

"If we were talking about an antibiotic that causes renal problems, I think most of us would expect a physician to follow that line of reasoning," he said.

Before prescribing medication, take a thorough medical history, said Dr. Birkholz. Try to uncover any underlying history of abuse and addiction, whether it's the patient's own history or a family member's history, she suggests.

Dr. Birkholz also recommends having a written contract with a patient. To try to prevent doctor- or pharmacy-shopping, include such statements as: "You will get your medications from only one physician and you'll use only one pharmacy." And, to forestall the patient who may repeatedly lose prescriptions, include the statement, "You will get your prescriptions only during office visits, don't call between visits."

Inform patients on a regular basis about the medications being prescribed and their potential risk, said Dr. Horton. Patients who are taking medications responsibly must also be warned about the value of the drugs on the marketplace.

Tell patients to flush any unused pills down the toilet, said Dr. Horton. Don't put them in the medicine cabinet. "I can't tell you how many of my [addicted] patients have learned to go ransacking someone's medicine cabinet," he said. "Sometimes a child will learn that the Vicodin in that medicine cabinet can be sold or used."

And "never, never, never prescribe if you aren't comfortable either with the patient or with the diagnosis," advises Howard Heit, MD, a gastroenterologist who treats opioid addicted pain patients in Fairfax, Va., and was himself a chronic pain patient.

Physicians are also not well-trained in addiction medicine. Currently, 76% of medical school students receive little or no training in addiction medicine, said Dr. Heit. "This must be changed."

Finally, physicians have an obligation to intervene if a patient is headed down the slippery slope toward addiction, said Dr. Horton. "I think the research is pretty clear that a physician has a lot of power in motivating change in a client."

ADDITIONAL INFORMATION:

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In its new report, "Prescription Drugs: Abuse and Addiction," the National Institute on Drug Abuse identified three classes of prescription drugs that are most commonly abused:

Opioids, which are most often used to treat pain and include OxyContin, Darvon, Vicodin and Demerol.
Central nervous system depressants, which are useful in treating anxiety and sleep disorders. They include barbiturates such as Mebaral and Nembutal and benzodiazepines such as Valium and Xanax.
Stimulants, which enhance brain activity and are used to treat narcolepsy and attention-deficit/hyperactivity disorder. They include Dexedrine and Ritalin.

Source: National Institute on Drug Abuse, April