Clinicians, Patients, and Pharmacists
Physicians, their patients, and pharmacists all can play a role in identifying and preventing nonmedical use of prescription drugs.
- Clinicians. More than 84 percent of Americans had contact with a health care professional in 201654, placing doctors in a unique position to identify nonmedical use of prescription drugs and take measures to prevent the escalation of a patient’s misuse to a substance use disorder. By asking about all drugs, physicians can help their patients recognize whether a problem exists, provide or refer them to appropriate treatment, and set recovery goals. Evidence-based screening tools for nonmedical use of prescription drugs can be incorporated into routine medical visits (see the NIDAMED webpage for resources for medical and health professionals). Doctors should also take note of rapid increases in the amount of medication needed or frequent, unscheduled refill requests. Doctors should be alert to the fact that those misusing prescription drugs may engage in "doctor shopping"—moving from provider to provider—in an effort to obtain multiple prescriptions for their drug(s) of choice.
Prescription drug monitoring programs (PDMPs), state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients, are also important tools for preventing and identifying prescription drug misuse. While research regarding the impact of these programs is currently mixed, the use of PDMPs in some states has been associated with lower rates of opioid prescribing and overdose55–58, though issues of best practices, ease of use, and interoperability remain to be resolved.
In 2015, the federal government launched an initiative directed toward reducing opioid misuse and overdose, in part by promoting more cautious and responsible prescribing of opioid medications. In line with these efforts, in 2016 the Centers for Disease Control and Prevention (CDC) published its CDC Guideline for Prescribing Opioids for Chronic Pain to establish clinical standards for balancing the benefits and risks of chronic opioid treatment.29 Then, in 2017, President Trump established the President's Commission on Combating Drug Addiction and the Opioid Crisis. The commission outlined several priority areas aimed at improving the prevention and treatment of opioid addiction.
Coordinated federal efforts to reduce opioid addiction and overdose are ongoing.
Preventing or stopping nonmedical use of prescription drugs is an important part of patient care. However, certain patients can benefit from prescription stimulants, sedatives, or opioid pain relievers. Therefore, physicians should balance the legitimate medical needs of patients with the potential risk for misuse and related harms.
- Patients. Patients can take steps to ensure that they use prescription medications appropriately by:
- following the directions as explained on the label or by the pharmacist
- being aware of potential interactions with other drugs as well as alcohol
- never stopping or changing a dosing regimen without first discussing it with the doctor
- never using another person’s prescription and never giving their prescription medications to others
- storing prescription stimulants, sedatives, and opioids safely
Additionally, patients should properly discard unused or expired medications by following U.S. Food and Drug Administration (FDA) guidelines or visiting U.S. Drug Enforcement Administration collection sites.55 In addition to describing their medical problem, patients should always inform their health care professionals about all the prescriptions, over-the-counter medicines, and dietary and herbal supplements they are taking before they obtain any other medications.
- Pharmacists. Pharmacists can help patients understand instructions for taking their medications along with how the medication works for their condition. In addition, by being watchful for prescription falsifications or alterations, pharmacists can serve as the first line of defense in recognizing problematic patterns in prescription drug use. Some pharmacies have developed hotlines to alert other pharmacies in the region when they detect a fraudulent prescription. Along with physicians, pharmacists can use PDMPs to help track opioid-prescribing and dispensing patterns in patients.
Medication Formulation and Regulation
Manufacturers of prescription drugs continue to work on new formulations of opioid medications, known as abuse-deterrent formulations (ADF), which include technologies designed to prevent people from misusing them by snorting or injection. Approaches currently being used or studied for use include:
- physical or chemical barriers that prevent the crushing, grinding, or dissolving of drug products
- agonist/antagonist combinations that cause an antagonist (which will counteract the drug effect) to be released if the product is manipulated
- aversive substances that are added to create unpleasant sensations if the drug is taken in a way other than directed
- delivery systems such as long-acting injections or implants that slowly release the drug over time
- new molecular entities or prodrugs that attach a chemical extension to a drug that renders it inactive unless it is taken orally
Several ADF opioids are on the market, and the FDA has also called for the development of ADF stimulants.56 Abuse-deterrent formulations have been shown to decrease the illicit value of drugs.56 Medication regulation has been shown to be effective in decreasing the prescribing of opioid medications. In 2014, the Drug Enforcement Administration moved hydrocodone products from schedule III to the more restrictive schedule II, which resulted in a decrease in hydrocodone prescribing that did not result in any attendant increases in the prescribing of other opioids.32
Development of Safer Medications
The development of effective, non-addicting pain medications is a public health priority. A growing number of older adults and an increasing number of injured military service members add to the urgency of finding new treatments. Researchers are exploring alternative treatment approaches that target other signaling systems in the body such as the endocannabinoid system, which is also involved in pain.57 More research is also needed to better understand effective chronic pain management, including identifying factors that predispose some patients to substance use disorders and developing measures to prevent the nonmedical use of prescription medications.