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AAMC Reporter: December 2006Viewpoint:
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The misuse, abuse, and diversion of prescription medications represents a serious national concern that affects millions of Americans. Recent indicators reveal that the misuse and abuse of prescription drugs are rising.
According to the Substance Abuse and Mental Health Services Administration's (SAMHSA) 2005 National Survey on Drug Use and Health, 32.7 million persons, or 13.4 percent, of the U.S. population aged 12 or older had used prescription pain relievers non-medically at least once in their lifetime. This is up from 29.6 million in 2002, clearly indicating a steady increase in the number of Americans using prescription medication other than under a physician's supervision for an established medical disorder.
Non-medical use of prescription drugs is associated with a variety of adverse health and social consequences. SAMHSA's Drug Abuse Warning Network (DAWN) shows nearly 1.3 million emergency department visits in 2004 were associated with drug misuse or abuse. Non-medical pharmaceutical use was involved in nearly 500,000 of those visits. Medical emergencies arise from overdoses, toxic reactions, and the interaction of multiple drugs, which can produce life-threatening conditions including respiratory depression, hypertension or hypotension, seizures, cardiovascular collapse, and death.
Each year, millions of U.S. patients use prescription drugs for a variety of medical problems. But drugs' therapeutic benefits are often accompanied by psychoactive effects. The fact that a very small portion of prescription medications are inappropriately prescribed by physicians and misused or abused by patients and others raises an important policy dilemma: how to ensure such medications continue to be readily available for therapeutic use, while limiting access for non-therapeutic misuse or abuse. This dilemma poses challenges very different from those raised by illicit drugs, because control of prescription drugs must be achieved without impeding patients' access to needed medical care. Since the early 20th century, the Harrison Narcotics Act, the original social contract governing the use of prescription drugs with abuse potential, has permitted medical treatment while protecting the public from the misuse of potentially dangerous medications. However, problems with diversion and abuse have persisted.
In the 1990s, pharmacological advancements on several fronts meant new medications were treating various medical disorders, sometimes even replacing surgery. To address the attendant increase in prescription drug diversion (meaning the illegal use or distribution of legal drugs) and abuse, Controlled Substance Monitoring Programs (CSMP) were designed to collect prescribing and dispensing data from pharmacies, and were subsequently adopted by nearly half of all states.
CSMPs are neither uniform nor integrated, and may be administered by health and human services, professional, consumer protection, public safety, or law enforcement groups. Patients who go "doctor shopping" for multiple prescriptions are typically able to obtain them merely by crossing state lines. In many states, practitioners and pharmacists have no way of knowing whether patients are receiving the same or similar medications from other practitioners.
In May 2002, the Government Accountability Office (GAO) concluded that CSMPs can help reduce drug diversion, offer quick access to information on abused drugs, and deter abusers from "doctor shopping" within the state. The GAO also concluded, however, that drug diversion continues to proliferate and sometimes shifts to states without CSMPs — highlighting the interstate nature of the problem and the need for a national database system.
Recognizing this need, in 2005 the president signed the National All Schedules Prescription Electronic Reporting Act, which facilitates the establishment of electronic prescription drug surveillance programs in all 50 states and the District of Columbia. This will help provide accurate, timely prescription history information so that providers can identify at-risk patients and in turn initiate appropriate interventions to avert the tragic personal, family, and community consequences of untreated addiction.
Amid the institution of these programs and changing standards for treating pain and addiction, medical education can serve as the conduit for training America's physicians and students in the proper prescribing of controlled substances. As part of our initiatives, SAMHSA will continue to address the therapeutic and non-therapeutic use of psychotherapeutics by educating physicians and other providers in all phases of medical education about ways to combat and reduce the diversion and abuse of prescription drugs through programs such as CSMPs.
All health professionals must be well-grounded in their knowledge of pharmacotherapies for all types of medical disorders. Such training should be part of the core educational curricula for all health care professionals. In particular, physicians need to understand the pharmacology and appropriate use of drugs with abuse potential, as well as specific indications and cautions to consider when deciding whether to use such medications in particular patients.
With your help, we will ensure that an appropriate balance is preserved between the legitimate needs of law enforcement and the legitimate needs of the health care
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