November 1st, 2010

Escalating prescription drug abuse of concern

For the past decade or so, substance abuse counselors, law enforcement and families have been faced with a particularly pernicious problem: the skyrocketing abuse of prescription drugs. Instead of the elaborate schemes involved in getting, illegal drugs such as heroin or cocaine, painkillers like OxyContin and Vicodin are often easily procured from a medicine cabinet. In spite of educational campaigns, bottle collection programs and improved prescription-drug monitoring in some states, the problem continues, seemingly unabated – requiring a coordinated effort from physicians, pharmacists and families.

In all of the New England states except Vermont, drugs, both prescription and illicit, now cause more deaths than car accidents. Between 1998 and 2008, the number of people seeking treatment for painkiller addiction climbed 400 percent, according to the Substance Abuse and Mental Health Services Administration. In Massachusetts, the OxyContin addiction rate has increased by 950 percent over the last 10 years, according to a report by the Legislature’s OxyContin and Heroin Commission.

Although powerful painkillers have been widely used for at least the past few decades – before that, they were not so often prescribed unless the pain was linked to cancer – more recent years have seen the development of more powerful and more addictive, drugs. OxyContin, which the FDA approved in 1995, “blew this up,” says Michael Levy, Ph.D., director of Clinical Treatment Services at CAB Health and Recovery Services, Inc. in Peabody, Mass. “People started getting alarmed.”

A misperception lingers that prescription drugs – even when misused – are somehow safer than illegal drugs, Levy and others say. It’s not only painkillers like OxyContin and Vicodin that are being misused, but also mood stabilizers and antipsychotic drugs like Seroquel, Levy says. People who abuse painkillers tend to be a relatively heterogeneous group, adds Joel Guarna, Ph.D., founder of White Pine Behavioral Health in Portland, Maine and an addiction specialist.

“There are real cultural obstacles to using illicit drugs that aren’t there for prescription drugs,” he says. It’s far easier to “wander across the line” between prescribed use and misuse.

OxyContin has also found a foothold among teens that might crush it up and snort it or dissolve it in a drink in order to get a quick high. (A new formulation is supposed to prevent the pill from being crushed or otherwise broken).

“Kids nowadays don’t smoke cigarettes as much, they don’t like to inject… but they somehow think prescription drugs are safe,” says Robert Newlin Jamison, Ph.D., a psychologist with the Brigham and Women’s Hospital Pain Management Center in Chestnut Hill, Mass. “I think they’re more prone to using pills than any other street drugs.”

Levy says he’s seen more young people come through CAB’s detoxification program, many of them coerced by family members or probation officers.

“They’re not really 100 percent motivated to change or they have a tremendous ambivalence about changing,” Levy says. “People struggle with that.”

Treating a painkiller addiction

Addiction to a prescription drug is much like any other addiction, Guarna says, in that the drug begins competing with relationships and work.

People need to first figure out what a substance does for them and how they might otherwise structure their lives around other meaningful things, he says.

“Once they’ve been leaning on a chemical for a while and then they stop, they have a hole in their life,” he says. “Unless they find something meaningful, they’re going to fall back into the addiction.”

Sometimes, figuring out what those meaningful things might be takes time. But there has to be a clear sense that overcoming the addiction will be worth the effort in order for progress to be made.

“Getting over an addiction, in the early steps, is like wandering through a swamp,” Guarna says. “People are willing to do that – to get through the swamp – but they need to know there’s something on the other side that’s worth the work that dignifies the work. If it’s simply a matter of wanting to feel better to not be addicted … that’s usually not enough.”

In some cases, getting clean takes a short time and may be a matter of developing a few key skills, particularly if a person’s life is reasonably intact – with a job, family or other support network. For others, addiction can be a life-long struggle. In the most difficult cases – people with histories of trying unsuccessfully to stop using – a replacement drug such as Methadone or Suboxone might be recommended, Levy says.

Some psychologists who work with chronic pain patients have begun using assessments or a combination of assessments to gauge vulnerability to drug addiction. One such tool, the Screener and Opioid Assessment for Patients with Pain (SOAPP-R), is a self-report questionnaire designed to predict aberrant use of medications that asks about addiction history, psychological states and cravings for pain medication, among other items.

Results suggesting a likelihood of abuse do not necessarily mean patients shouldn’t be prescribed opioids, says Jamison, who helped develop the assessment. Rather, it shows they need to be monitored.

“There should be a multi-disciplinary approach when it comes to using opioids for pain and mental health providers should be involved,” he says. While some debate whether opioids should be used, they are undoubtedly efficacious, he says. In a careful approach, “psychological involvement is seen as the gold standard.”

By Ami Albernaz

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