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CORK Bibliography: Prescription Drugs

129 citations. July, 2007 to present

Prepared: June 2008

Aalto M; Halme J; Visapaa JP; Salaspuro M. Buprenorphine misuse in Finland. (letter). Substance Use & Misuse 42(6): 1027-1028, 2007. (3 refs.)

Alvarenga JM; de Loyola AI; Firmo JOA; Lima-Costa MF; Uchoa E. Prevalence and sociodemographic characteristics associated with benzodiazepines use among community dwelling older adults: Bambui Health and Aging Study (BHAS). Revista Brasileira de Psiquiatria 30(1): 7-11, 2008. (30 refs.)

Objectives: To assess the prevalence and sociodemographic characteristics associated with benzodiazepine use among community-dwelling older adults. Method. 1606 subjects, aged >= 60 years, corresponding to 92% of the residents of Bambui city, participated in this study. The information about medication use was obtained by means of a standard interview and the review of medication packaging. Substances were classified using the Anatomical Therapeutic Chemical Index. Results: The prevalence of benzodiazepine current use was 21.7% (26.7% among females and 14.0% among males). From these, 68.7% had been taking the medication for over one year 31.3% for over five years and 53.2% were using long half-life benzodiazepines. The medication most frequently used was bromazepam (35.6%), followed by diazepam (22.5%), clonazepam (12.6%) and lorazepam (7.8%). After adjustment for confounders, female gender (RP = 1.93; C195% = 1.51-2.46) was the only sociodemographic characteristic found to be independently associated with substance consumption. Conclusions: The prevalence of benzodiazepine use in the study population was high, but within the variation observed in developed countries. Chronic use of benzodiazepines and long half-life medications predominated.

Aschenbrenner DS. Early alerts: FDA begins safety reviews of an antibiotic and a smoking cessation drug. American Journal of Nursing 108(3): 35-35, 2008. (2 refs.)

This column "Drug Watch" reports that the FDA has also begun a safety review of varenicline (Chantix), a prescription drug used to assist smoking cessation in adults. Varenicline, approved for sale in May 2006, works by binding to a particular subset of nicotinic receptors. The FDA review was prompted by reports submitted by the manufacturer (Pfizer) describing suicidal ideation associated with use of the drug and a postmarketing case report of erratic behavior. Another reported adverse effect of varenicline is drowsiness.

Bannan N; Rooney S; O'Connor J. Zopiclone misuse: An update from Dublin. Drug and Alcohol Review 26(1): 83-85, 2007. (26 refs.)

The prevalence of zopiclone misuse in clients attending a methadone maintenance programme in Dublin through detection of its degradation product, 2-amino-5-chloropyridine (ACP) on urinalysis is outlined. Urine samples from all 158 clients were tested for the presence of ACP, opiates, benzodiazepines, cocaine, alcohol and cannabis. Of the 37 (23%) clients who tested positive for ACP, 23 (62%) were interviewed. A profile of zopiclone misusers is outlined, including details of demographics, drug history, viral status, recent urinalysis results and opinions on zopiclone. Of the 14 (38%) clients who were not interviewed, information was obtained from their clinical casenotes and documented urinalysis results. The prevalence of zopiclone misuse was reported as 23%. Benzodiazepines were the most popular drug of misuse with zopiclone followed by heroin/opiates. Zopiclone is being misused by drug users in Dublin in the context of many other drugs. Prescribing of zopiclone should be restricted, especially among drug misusers.

Becker WC; Fiellin DA; Desai RA. Non-medical use, abuse and dependence on sedatives and tranquilizers among US adults: Psychiatric and socio-demographic correlates. Drug and Alcohol Dependence 90(2/3): 280-287, 2007. (28 refs.)

Background: Non-medical use of sedatives and tranquilizers carries risks including development of abuse/dependence. Such use may correlate with psychiatric symptoms. Methods: Cross-sectional survey, the 2002-2004 National Survey on Drug Use and Health. Respondents 18 years and older (n = 92,020). Bivariate and multivariable associations were investigated. Results: The prevalence of past-year non-medical use of sedatives or tranquilizers was 2.3%. Of those with non-medical use, 9.8% met criteria for abuse/dependence. On multivariable analysis, panic symptoms and elevated serious mental illness scores were associated with past-year nonmedical use. Also, the following past-year socio-demographic and substance use covariates were associated with past-year non-medical sedative or tranquilizer use: female sex, white/hispanic/other ethnicity, criminal arrest, uninsurance, unemployment, alcohol abuse or dependence, cigarette use, illicit drug use, younger age of initiating illicit substance use, and any history of IV drug use. Among those with sedative or tranquilizer use, those with abuse/dependence were more likely to have agoraphobic symptoms. In addition, they were more likely to be older, unmarried, have a low education level and have been arrested. Conclusions: Non-medical use of sedatives and tranquilizers is common. Furthermore, nearly 10% of those with non-medical use meet criteria for abuse/dependence. Anxiety symptoms associated with non-medical use (panic symptoms) and abuse/dependence (agoraphobia) should alert clinicians to screen for these problems and consider alternate treatment or referral.

Becker WC; Sullivan LE; Tetrault JM; Desai RA; Fiellin DA. Non-medical use, abuse and dependence on prescription opioids among US adults: Psychiatric, medical and substance use correlates. Drug and Alcohol Dependence 94(1/3): 38-47, 2008. (34 refs.)

Background: Non-medical use of prescription opioids carries risks including development of abuse/dependence. Such use may correlate with psychiatric, medical. and substance use characteristics. Methods: Cross-sectional survey, the 2002-2004 National Survey on Drug Use and Health. Respondents 18 years and older (n = 91,823). Bivariate and multivariable associations were investigated. Results: The prevalence of past-year non-medical use of prescription opioids was 4.5%. Of those with non-medical use, 12.9% met criteria for abuse/dependence. On multivariable analysis, past-year non-medical used was associated with panic (AOR 1.2; 95% CI 1.04-1.5), depressive (AOR 1.2; 95% CI 1.01-1.5) and social phobic/agoraphobic symptoms (AOR 1.2; 95% CI 1.1-1.4). Among those with past-year non-medical prescription opioid use, those with abuse/dependence were more likely to have panic (AOR 1.7; 95% CI 1.2-2.4) and social phobic/agoraphobic symptoms (AOR 1.7: 95% Cl 1.2-2.4). In addition, they were more likely to report fair/poor health (AOR 2.1; 95% Cl 1.4-3.0), have misused another class of prescription medication (AOR 1.7; 95% Cl 1.2-2.3), have used heroin (AOR 2.9; 95% CI 1.2-6.9) and initiated substance use before the age of 13 (AOR 4.7 : 95% CI 1.1-19.9). Conclusions: Non-medical use of prescription opioids is common. Furthermore, nearly 13% of those with non-medical use meet criteria for abuse/dependence. Panic, social phobia and agoraphobia, low self-rated health status, and other substance misuse among those with non-medical use of prescription opioids should alert clinicians to screen for abuse and dependence.

Bell CM; Fischer HD; Gill SS; Zagorski B; Sykora K; Wodchis WP et al. Initiation of benzodiazepines in the elderly after hospitalization. Journal of General Internal Medicine 22(7): 1024-1029, 2007. (42 refs.)

Objective: To estimate the rate of new chronic benzodiazepine use after hospitalization in older adults not previously prescribed with benzodiazepines. Design: Retrospective cohort study using linked, population-based administrative data. Setting: Ontario, Canada between April 1, 1992 and March 31, 2005. Participants: Community-dwelling seniors who had not been prescribed benzodiazepine drugs in the year before hospitalization were selected from all 1.4 million Ontario residents aged 66 years and older. Main outcome measures: New chronic benzodiazepine users, defined as initiation of benzodiazepines within 7 days after hospital discharge and an additional claim within 8 days to 6 months. We used multivariate logistic regression to examine for the effect of hospitalization on the primary outcome after adjusting for confounders. Results: There were 405,128 patient hospitalizations included in the cohort. Benzodiazepines were prescribed to 12,484 (3.1%) patients within 7 days of being discharged from hospital. A total of 6,136 (1.5%) patients were identified as new chronic benzodiazepine users. The rate of new chronic benzodiazepine users decreased over the study period from 1.8% in the first year to 1.2% in the final year (P < .001). Multivariate logistic regression found that women, patients admitted to the intensive care unit or nonsurgical wards, those with longer hospital stays, higher overall comorbidity, a prior diagnosis of alcoholism, and those prescribed more medications had significantly elevated adjusted odds ratios for new chronic benzodiazepine users. Older individuals had a lower risk for the primary outcome. Conclusions: New benzodiazepine prescription after hospitalization occurs frequently in older adults and may result in chronic use. A systemic effort to address this risky practice should be considered.

Bell SC; Hanes RD. A microfluidic device for presumptive testing of controlled substances. Journal of Forensic Sciences 52(4): 884-888, 2007. (11 refs.)

A simple microfluidic device (MFD) has been developed to perform multiple color and crystal tests for controlled substance analysis. The MFD method uses less sample and reagents and generates less waste than traditional spot plate methods while performing several tests simultaneously. This methodology provides significantly more analytical information for a single sample analysis. The current generation device is the size of a microscope slide with four analytical channels: one for microcrystal tests and three for color tests. The optimized devices were subjected to a rigorous validation study using comparative replicate analyses and several operators. Target analytes were methamphetamine, amphetamine, cocaine, and oxycodone and color test reagents used were the Marquis, Simon, and cobalt thiocyanate. For the crystal tests, platinic chloride was used. The validation study showed the MFD's limits of detection to be in the picogram range. Positive tests results were observed in complex mixtures in which the controlled substance was present at concentrations of 5-10% (w/w). The microcrystal reagents showed greater sensitivity than color test reagents when used in the device. Reagent use and waste generation using the devices was 95% less that that used and generated using the traditional methods. The device performance was also shown to be operator independent.

Blanco C; Alderson D; Ogburn E; Grant BE; Nunes EV; Hatzenbuehler ML; Hasin DS. Changes in the prevalence of non-medical prescription drug use and drug use disorders in the United States: 1991-1992 and 2001-2002. Drug and Alcohol Dependence 90(2/3): 252-260, 2007. (39 refs.)

Objective: To examine changes in the prevalence of non-medical prescription drug use and DSM-IV non-medical prescription abuse and dependence in the United States between 1991-1992 and 2001-2002. Method: Comparison of the prevalence of past-year non-medical prescription drug use and drug use disorders in the total sample and among lifetime non-medical users in two large national surveys conducted 10 years apart. Results: From 1991-1992 to 2001-2002, the prevalence of DSM-IV non-medical prescription drug use increased by 53%, from 1.5% to 2.3% (p < 0.001), and the prevalence of drug use disorders increased by 67% from 0.3% to 0.5% (p < 0.001). The conditional prevalence of a disorder among users increased numerically from 19.9% to 23.6%, but this increase was not statistically significant (p = 0.15). Conclusions: There have been substantial increases in the prevalence of prescription drug non-medical use and prescription drug use disorders in the United States. Given the clinical utility of prescription drugs, urgent action is needed to find approaches that balance the need for access to these medications among those who need them, against their potential for abuse and dependence in subgroups of vulnerable individuals.

Boyd CJ. Prescription drug abuse among US adolescents: What nurses should know. (editorial). Journal of Addictions Nursing 18(3): 113-116, 2007. (26 refs.)

Bramness JG; Furu K; Engeland A; Skurtveit S. Carisoprodol use and abuse in Norway. A pharmacoepidemiological study. British Journal of Clinical Pharmacology 64(2): 210-218, 2007. (34 refs.)

What is already known about this subject: Carisoprodol was developed to create a drug with less abuse potential than meprobamate. Case reports have established carisoprodol as a drug of abuse, but no systematic studies have been published about the extent of abuse. What this study adds: A large number of patients used more carisoprodol than recommended. High use of carisoprodol was associated with high use of benzodiazepines and opiates. Compared with other medicinal drugs, carisoprodol showed many prescription database signals of being a potential drug of abuse. Carisoprodol was developed to create a drug with less potential for abuse than meprobamate. However, case reports have established carisoprodol as a drug of abuse. This paper explores the extent of potential abuse of this drug in Norway. The Norwegian Prescription Database contains information on prescription drugs dispensed to individuals in Norway. Patients can be followed over time. High levels of carisoprodol use could indicate use for pleasurable effects or development of tolerance. Concomitant use of other potential drugs of abuse was also studied. We studied drug-seeking behaviour by looking at patients who received carisoprodol from many different pharmacies and doctors or from high-prescribing doctors. Carisoprodol was compared with a series of other medicinal drugs with or without known potential for abuse. Some 53 889 Norwegian women (2.4%) and 29 824 men (1.3%) >= 18 years old received carisoprodol at least once in 2004. Prescribing of carisoprodol was skewed. As many as 32% of the patients received more than 15 defined daily doses (DDDs) of carisoprodol and > 11 000 patients (15%) received >= 75 DDDs in 2004. High users of carisoprodol also received more benzodiazepines and opioids. Few patients used three or more doctors for prescriptions, but carisoprodol-abusing patients more often received their prescription from high-prescribing doctors. Carisoprodol was widely used and the skewedness in use indicated that it is a potential drug of abuse. A large number of patients used more carisoprodol than recommended in the guidelines. The high level of use and abuse of carisoprodol should be of concern in Norway.

Bramness JG; Kornor H. Benzodiazepine prescription for patients in opioid maintenance treatment in Norway. Drug and Alcohol Dependence 90(2/3): 203-209, 2007. (44 refs.)

Background: Opioid maintained patients report high levels of anxiety, but the use of benzodiazepines among these patients has been associated with negative outcomes such as increased risk of overdose and death and poorer retention in programmes. Previous research has used interview or urine analysis to assess benzodiazepine use. In this study a prescription database was applied. Methods: The Norwegian Prescription Database covers all prescriptions for the entire population from 1 January 2004. Benzodiazepine prescriptions to patients receiving methadone (N= 1364) or buprenorphine (N= 805) in 2004 and 2005 were studied. Type and amount of drugs received were investigated. Results: Overall 40% of the patients received at least one prescription for a benzodiazepine drug. Oxazepam was the most frequently prescribed drug. Female patients, methadone-maintained patients and patients in the liberal programmes received a prescription more often. Prescribed doses were high and highest in the liberal programmes. Older patients received more hypnotics. Dose of maintenance drug was positively related to amount of anxiolytics prescribed. Conclusions: This study showed that more benzodiazepines were prescribed to opioid maintenance treatment patients than previously shown by investigations using interview or urine analysis. The doses prescribed were generally high. In light of the negative outcomes following benzodiazepine use in these patients, Norwegian doctors need to review their prescription practices.

Bramness JG; Skurtveit S; Morland J; Engeland A. The risk of traffic accidents after prescriptions of carisoprodol. Accident Analysis and Prevention 39(5): 1050-1055, 2007. (45 refs.)

Objective: Carisoprodol, a drug used for acute lower back pain, may cause psychomotor impairment. We wanted to investigate if patients using carisoprodol had increased risk of being involved in a traffic accident. Methods: Data were retrieved from three population-based registries for the period April 2004-September 2005. The Norwegian Prescription Database contained individual information on all dispensed drugs at all pharmacies outside hospitals. The Norwegian Road Accident Registry contained information on all drivers involved in motor vehicle accidents with person injury. The Norwegian Central Population Registry was used to control for emigration or death. The accident incidence among carisoprodol exposed and unexposed subjects was compared by standardized incidence ratio. Results: Having a prescription for carisoprodol dispensed increased the standardized incidence ratio for being involved in an accident with person injury to 3.7 (95% CI 2.9-4.8) the first week after the date of dispensing. This was similar to diazepam (2.8; 2.2-3.6), but higher than for salbutamol (1.1; 0.6-1.8). Conclusions: Patients receiving carisoprodol seem to have an increased risk of being involved in traffic accidents involving person injury. The study gives support to earlier work published on the impairing effects of carisoprodol.

Brooks JO; Hoblyn JC. Neurocognitive costs and benefits of psychotropic medications in older adults. (review). Journal of Geriatric Psychiatry and Neurology 20(4): 199-214, 2007. (222 refs.)

Psychotropic medications are widely used in older adults and may cause neurocognitive deficits. Older adults are at increased risk of developing adverse effects because of age-related pharmacodynamic and pharmacokinetic changes. This article provides a comprehensive review of the undesirable, and at times beneficial, effects of psychotropic medications. The review covers a wide range of medications that impair executive function, memory, and attention, as well as a much smaller group of medications that lead to improved neurocognitive function. Some of the most commonly used psychotropic medications in older adults, namely, antidepressants, sedatives, and hypnotics, are among the drugs that most consistently lead to cognitive impairments. Medications with anticholinergic properties almost invariably lead to neurocognitive dysfunction, despite symptom improvement. The neurocognitive costs and benefits of psychiatric medications should be considered in the context of disease treatment in older adults.

Bruce RD; Schleifer RA. Ethical and human rights imperatives to ensure medication-assisted treatment for opioid dependence in prisons and pre-trial detention. (editorial). International Journal of Drug Policy 19(1): 17-23, 2008. (66 refs.)

Opioid dependence is a complex medical condition affecting neurocognitive and physical functioning. Forced or abrupt opioid withdrawal may cause profound physical and psychological suffering, including nausea, vomiting, diarrhoea, extreme agitation and/or anxiety. Opioid-dependent individuals are especially vulnerable at the time of arrest or initial detention, when they may, as a result of their chemical dependency, be coerced into providing incriminating testimony, or be driven to engage in risky behaviour (such as sharing needles in detention) in order to avoid painful withdrawal symptoms. Upon incarceration, many opioid-dependent prisoners are forced to undergo abrupt opioid withdrawal (both from legally prescribed agonist therapy such as methadone as well as illicit opioids). Physical and psychological symptoms attendant to withdrawal may impair capacity to make informed legal decisions, and cause prisoners to risk HIV and other blood-borne diseases by sharing injection equipment. Although prisons must provide at least the standard of care to prisoners that is available in the general population, medication-assisted treatment, endorsed by international health and drug agencies as an integral part of HIV prevention and care strategies for opioid-dependent drug users, is unavailable to most prisoners. Medication-assisted treatment is a well-studied and validated pharmacological therapy for the medical condition known as opioid dependence. The failure to ensure prisoner access to this medical therapy threatens fundamental human rights protections against cruel, inhuman or degrading treatment and rights to health and to life. It also poses serious ethical problems for health care providers, violating basic principles of beneficence and non-maleficence (i.e., do good/do no harm). Governments must take immediate action to ensure access to opioid substitution to prisoners to ensure fulfilment of ethical and human rights obligations.

Bulat T; Castle SC; Rutledge M; Quigley P. Clinical practice algorithms: Medication management to reduce fall risk in the elderly. Part 3, benzodiazepines, cardiovascular agents, and antidepressants. Journal of the American Academy of Nurse Practitioners 20(2): 55-62, 2008. (55 refs.)

There are associations between falls and the use of sedatives, psychotropics, cardiovascular agents, antidepressants, and polypharmacy. Our third article in the series will review the development of specific subalgorithms for benzodiazepines (BZDs), cardiovascular agents, and antidepressants (algorithms 3-5). We presented the process of development in our first article and the summary algorithm (algorithms 1 and 2) in our second article in this series. There are a number of ways in which drugs might increase the risk of an elderly person falling, most common being sedation, impaired balance and reaction time, orthostatic hypotension, and drug-induced parkinsonism. Medications are a potentially modifiable factor which can reduce fall risk The Guideline for the prevention of falls in older persons (American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel of Falls Prevention, 2001) states that patients who have fallen should have their medications reviewed and altered or stopped as appropriate in light of their risk of future falls.

Calver J; Sanfilippo F; Preen D; Bulsara M. Prescribed stimulant use by Western Australians with Attention Deficit Hyperactivity Disorder (ADHD): Does amount dispensed exceed the expected authorised use? Australian and New Zealand Journal of Public Health 31(6): 533-539, 2007. (20 refs.)

Objective: To investigate to what extent Western Australian (WA) patients with Attention Deficit Hyperactivity Disorder (ADHD) received prescribed stimulants in excess of their notified dose from WA pharmacies in 2004 (termed 'discrepancy'). Design and data sources: Analysis of administrative data about all people aged two years and older who were prescribed stimulants for the treatment of ADHD in WA, and had at least one stimulant prescription dispensed from a WA pharmacy during the period 1 January to 31 December 2004. Outcome measures: Discrepancies were identified using minimum and maximum estimation methods (MinDE, MaxDE). We calculated for both methods the discrepancy prevalence by age and sex and annual surplus of stimulant accrued by age. Results: Of the 15,190 ADHD patients who comprised the study population, 5.4% to 19.0% received stimulants surplus to requirement in 2004, with peak prevalences in 6-8 year-olds (MaxDE 20.1%) and 25-34 year-olds (MaxDE 27.6%; MinDE 10.5%). The amount of stimulant dispensed surplus to requirement was highly skewed, with median annual values that ranged from one to 4.1 standard bottles (100 tablets) of dexamphetamine 5 mg for the MinDE and MaxDE methods, respectively. Conclusion: It is difficult to definitively estimate to what extent WA ADHD patients accrued excess stimulant medication using routine administrative data. Improvements to the WA Stimulant Regulatory Guidelines are recommended in the interests of patient safety, public transparency, methodological rigour and encouraging good prescribing practices.

Caplan JP; Epstein LA; Quinn DK; Stevens JR; Stern TA. Neuropsychiatric effects of prescription drug abuse. (review). Neuropsychology Review 17(3): 363-380, 2007. (157 refs.)

Prescription drugs have become a major category of abused substances, and there is evidence that the prevalence of prescription drug abuse may soon overtake that of illicit drugs. Study of prescription drugs has been hampered by vague terminology, since prescription drugs are only separated from other drugs of abuse by social and legal constructs. Reviewed herein is published literature on the abuse of four major categories of abused prescription drugs: sedative-hypnotics, stimulants, anabolic steroids, and anticholinergics. The review emphasizes evidence regarding the effects of these drugs on neural systems. Other abused prescription drugs that fall outside of the major categories are also briefly addressed.

Carise D; Dugosh KL; McLellan AT; Camilleri A; Woody GE; Lynch KG. Prescription OxyContin abuse among patients entering addiction treatment. American Journal of Psychiatry 164(11): 1750-1756, 2007. (44 refs.)

Objective: OxyContin and other pharmaceutical opioids have been given special attention in the media, who frequently describe problematic users of the drug as previously drug-naive individuals who become addicted following legitimate prescriptions for medical reasons. The purpose of this study was to characterize the nature and origins of pharmaceutical opioid addiction among patients presenting at substance abuse treatment programs. Method: The authors evaluated the prevalence and correlates of OxyContin use and abuse among a population of 27,816 subjects admitted to 157 addiction treatment programs in the United States from 2001-2004. The data collected included the lifetime and past 30-day use of oxyContin and other drugs prior to admission to addiction treatment, source of drug supply, and prior treatment history. Results: Approximately 5% of all subjects who were admitted to the 157 addiction treatment programs reported prior use of OxyContin. Of those subjects, 4.5% reported using the drug on a regular basis for at least 1 year, and 2% reported use of the drug during the 30 days prior to admission. Seventy-eight percent of subjects who reported OxyContin use also reported that the drug had not been prescribed to them for any medical reason, 86% reported use of the drug to "get high or get a buzz," and 78% reported receiving prior treatment for a substance use disorder. Conclusions: The patients in this sample did not include individuals from private therapists or pain clinics. However, among treatment-seeking individuals who use OxyContin, the drug is most frequently obtained from nonmedical sources as part of a broader and longerterm pattern of multiple substance abuse.

Castells X; Casas M; Vidal X; Bosch R; Roncero C; Ramos-Quiroga JA; Capella D. Efficacy of central nervous system stimulant treatment for cocaine dependence: a systematic review and meta-analysis of randomized controlled clinical trials. (review). Addiction 102(12): 1871-1887, 2007. (105 refs.)

Aims: To evaluate the efficacy of central nervous system (CNS) stimulants compared with placebo for the treatment of cocaine dependence. Methods A systematic review and meta-analysis was carried out. Bibliographic databases were searched, reference lists of retrieved studies were hand-searched and the first authors of each study were contacted. All randomized controlled clinical trials (RCCT) comparing the efficacy of any CNS stimulant with placebo in cocaine-dependent patients were included. Quantitative data synthesis was performed for each single CNS stimulant and for all CNS stimulants. Results: Nine RCCT met the inclusion criteria. These RCCT included 640 patients and compared five CNS stimulants: mazindol, dextroamphetamine, methylphenidate, modafinil and bupropion with placebo. No CNS stimulant improved study retention [RR = 0.94 (0.81-1.09)] or cocaine use [RR = 0.90 (0.79-1.02)]. An exploratory analysis using indirect estimations of cocaine use showed that the proportion of cocaine-positive urine screens was lower with dexamphetamine than with placebo [RR = 0.73 (0.60-0.90)] and that all CNS stimulants pooled together also suggested a significant decrease of cocaine use [RR = 0.87 (0.77-0.99)]. Data on craving could not be meta-analysed due to heterogeneity, but no RCCT found differences in cocaine craving between active drug and placebo except one, whose outcome favoured dexamphetamine. No serious adverse event (AE) was reported. Average of AE-induced dropouts was low and was greater for CNS stimulants than placebo: 4.4% versus 1.3% (P = 0.03). Conslusions: The main outcomes of this study do not support the use of CNS stimulants for cocaine dependence. Nevertheless, secondary analyses provide some hopeful results that encourage further research with these drugs, mainly with dexamphetamine and modafinil.

Cicero TJ; Inciardi JA; Surratt H. Trends in the use and abuse of branded and generic extended release oxycodone and fentanyl products in the United States. Drug and Alcohol Dependence 91(2/3): 115-120, 2007. (27 refs.)

Background: A great deal of previous work on the pharmacoeconomics of alcohol, tobacco and illicit drug abuse indicates that as cost decreases, abuse increases and vice versa. The application of these cost principles to the abuse of prescribed medications is largely unknown. In this paper we assessed whether the introduction of generic products in the U.S. increased the therapeutic use and illicit abuse of extended release oxycodone products and the fentanyl patch. Methods: As an index of therapeutic use, we purchased prescription data for each of the ZIP codes in which we had corresponding abuse data. To gather information about prescription drug abuse, we elicited cases with quarterly questionnaires completed by a key informant network. Results: The introduction of generic extended release (ER) oxycodone and fentanyl patch did not significantly change the total prescriptions written for these products, but markedly altered the composition of sales: branded sales dropped precipitously over a very short time and this was compensated for by a corresponding increase in sales of generics. Surprisingly, the introduction of generic products did not increase the abuse of ER oxycodone or fentanyl products; the branded version was the drug of choice for at least 2 years. Conclusions: Our data suggest that drug costs alone do not increase the overall likelihood that a prescription opioid analgesic will be used therapeutically or abused. However, while generics are rapidly endorsed by insurance companies as a prescribed entity, abuse of the branded versions of ER oxycodone and fentanyl remains predominant for some time.

Cicero TJ; Surratt H; Inciardi JA; Munoz A. Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Pharmacoepidemiology and Drug Safety 16(8): 827-840, 2007. (38 refs.)

Purpose: The goal of these studies was to determine the relationship between prescribed use of opioid analgesics and their non-medically related use (abuse) at a regional level across the country. Methods To gather information about prescription drug abuse, we asked 233 drug abuse treatment specialists to provide us Quarterly reports on the number of cases of prescription opioid analgesic abusers who used opioid analgesics to get high in the past 30 days. Results and Conclusions We found that there was a very strong correlation between therapeutic exposure to opioid analgesics, as measured by prescriptions filled, and their abuse. There were, however, geographical loci that represented outliers in which abuse was disproportionately high relative to therapeutic use (> 95th percentile), most of which were in very small urban, suburban, and rural areas. The rank order of abuse shows that buprenorphine products, extended release (ER) oxycodone and methadone are the most intensely abused prescription opioid analgesics, with hydrocodone the least abused, when the data are corrected for degree of exposure, i.e., cases/1000 persons filling a prescription. If, on the other hand, one uses the number of cases/100000 population, hydrocodone ranked as high as ER oxycodone and all other drugs grouped together at very low levels of abuse. Since the latter conclusion ignores therapeutic exposure, we conclude that the rate of abuse of highly efficacious opioid analgesics is best expressed as cases of abuse/1000 persons filling a prescription, which yields the best possible estimate of the risk-benefit ratio of these drugs.

Cimolai N. Zopiclone - Is it a pharmacologic agent for abuse? (review). Canadian Family Physician 53: 2124-2129, 2007. (56 refs.)

OBJECTIVE: To determine whether the hypnosedative drug zopiclone could be an agent for abuse. SOURCES OF INFORMATION: Using MEDLINE and PubMed, English-language medical literature was systematically reviewed for reports of direct drug abuse and addiction. A review was also conducted for clinical trials or patient series that discussed issues of addiction or rebound effects. MAIn MESSAGE Evidence of drug abuse and dependency was found in case reports and small patient series. Dependency symptoms of severe rebound, severe anxiety, tremor, palpitations, tachycardia, and seizures were observed in some patients after withdrawal. Abuse occurred more commonly among patients with previous drug abuse or psychiatric illnesses. Many clinical trials have found evidence of rebound insomnia after recommended dosages were stopped, albeit for a minority of patients. Comparative studies of zopiclone and benzodiazepines or other "Z" drugs are conflicting. CONCLUSION Zopiclone has the potential for being an agent of abuse and addiction. While many have suggested that the addictive potential for this and other "Z" drugs is less than for most benzodiazepines, caution should be taken when prescribing this agent for insomnia. ideally, prescriptions should be given for a short period of time and within the recommended dosage guidelines.

Compton P; Ling W; Chiang NC; Moody DE; Huber A; Ling D et al. Pharmacokinetics of buprenorphine: A comparison of sublingual tablet versus liquid after chronic dosing. Journal of Addiction Medicine 1(2): 88-95, 2007

Although buprenorphine is approved for use in the outpatient treatment of opioid addiction in 2 tablet formulations, a monoproduct containing buprenorphine only (Subutex) and a buprenorphine/naloxone combination product (Suboxone), much of the clinical data that support the approval by the U.S. Food and Drug Administration were generated by using a sublingual liquid. To interpret the literature in prescribing parameters for tablet buprenorphine, this study was designed to determine steady state buprenorphine plasma levels for the 2 formulations and to assess the relative bioavailability of each. A randomized, double-blind, crossover study with dose increases was conducted during a 12-week period at an outpatient treatment clinic. Of the 184 subjects initially randomized to treatment, 133 (72.3%) were evaluated for the steady-state trough plasma concentration, 16 (8.7%) for relative bioavailability, and 31 (16.8%) for dose proportionality. At steady state, differences in the trough plasma concentrations of buprenorphine between the 2 formulations were found across all the dose levels. Average plasma concentration (Cavg) of the tablet at twice the milligram dose of the liquid was twice that of the liquid; intersubject variability was greater for the tablet. At double the dose of tablet, there is no difference in steady state plasma concentrations. The bioavailability seems equivalent for the 2 formulations across all the dose levels.

Darredeau C; Barrett SP; Jardin B; Pihl R. Patterns and predictors of medication compliance, diversion, and misuse in adult prescribed methylphenidate users. Human Psychopharmacology: Clinical and Experimental 22(8): 529-536, 2007. (29 refs.)

Objectives To examine patterns and predictors of medication compliance, diversion, and misuse in a sample of adults with prescriptions for the stimulant medication methylphenidate (MPH). Methods Sixty-six adults currently prescribed MPH (53% male) completed structured interviews and provided details regarding their medication and other substance use histories. Results On average, participants reported using their medication as prescribed on 14.5 (SD 11.7) of the past 30 days; 44% admitted to diverting it and 29% admitted to inappropriate use. While analyses revealed that medication misuse, diversion, and level of compliance were interrelated and all associated with concurrent illicit substance use, each also had other distinct associations. Specifically, MPH misuse was associated with the use of illicit stimulants such as amphetamine and cocaine, diversion with age and age of MPH prescription, and compliance with participation in an attention deficit hyperactivity disorder (ADHD) support group. Regression analyses revealed that misuse and poor compliance were both best predicted by concurrent illicit substance use, while the model that best predicted diversion included age of first MPH prescription (younger) and MPH misuse. Conclusions: Poor medication compliance, diversion, and misuse are relatively common and interrelated among adult MPH users. MPH prescriptions should be monitored closely in individuals with histories of illicit substance use.

Davis WR; Johnson BD. Prescription opioid use, misuse, and diversion among street drug users in New York City. Drug and Alcohol Dependence 92(1/3): 267-276, 2008. (24 refs.)

Objective: The use of heroin, cocaine, and other drugs is well researched in New York City, but prescription opioids (POs) have been overlooked. This study documents patterns of PO use, misuse, and diversion among street drug users, and begins to indicate how drug culture practices interact with the legitimate therapeutic goals of PO prescriptions (e.g. pain management). Methods: Staff completed interviews inquiring about the reasons for use of POs and illicit drugs with 586 street drug users. Ethnographers wrote extensive field notes about subjects' complex patterns of PO use. Results: Methadone was used (71.9%) and sold (64.7%) at a higher level than OxyContin, Vicodin, and Percocet, used by between 34% and 38% of the users and sold by between 28% and 41% of the sellers. Recent PO use is associated with the recency of using heroin and cocaine (P <.001). Half of the heroin/cocaine sellers sold POs, and one quarter of the PO sellers only sold POs. Subjects were classified into four groups by whether they diverted POs or used POs to relieve pain or withdrawal rather than for euphoria. This classification was associated with frequency of PO use, whether POs were obtained from doctors/pharmacies or from drug dealers and family members, and those mostly likely to use POs for pain and withdrawal. Conclusions: POs are an important component of street drug users' drug-taking regimes, especially those who are Physically III Chemical Abusers. Future research is needed to model PO use, misuse, and diversion among this population.

Day E; Best D; George S; Copello A. Drug users' experiences of prescribed injectable methadone: The impact on drug use and perceptions of stability. Journal of Drug Issues 37(2): 341-355, 2007. (16 refs.)

Twenty of the 24 drug users receiving prescribed injectable methadone from a city-wide drug treatment service agreed to participate in a semi-structured interview about their drug use and treatment. Participants reported that they were originally prescribed injectable methadone to replace street purchases because they could not tolerate oral methadone or because of an inability to stop injecting. The experience of injectable methadone was reported as having led to significant improvements in drug use and life stability and reductions in risk behavior, but several participants compared injectable methadone unfavorably to injectable heroin, either in the form of street heroin or prescribed diamorphine. Although a number of the respondents reported sufficient stability to contemplate employment and relationships, few spoke about abstinence as a viable goal in the short-term and many participants reported considerable ambivalence about the experience of receiving injectable methadone prescriptions,

Degenhardt L; Chiu WT; Sampson N; Kessler RC; Anthony JC. Epidemiological patterns of extra-medical drug use in the United States: Evidence from the National Comorbidity Survey Replication, 2001-2003. Drug and Alcohol Dependence 90(2/3): 210-223, 2007. (35 refs.)

Background: In 1994, epidemiological patterns of extra-medical drug use in the United States were estimated from the National Comorbidity Survey. This paper describes such patterns based upon more recent data from the National Comorbidity Survey Replication (NCS-R). Methods: The NCS-R was a nationally representative face-to-face household survey of 9282 English-speaking respondents, aging 18 years and older, conducted in 2001-2003 using a fully structured diagnostic interview, the WHO Composite International Diagnostic Interview (CIDI) Version 3.0. Results: The estimated cumulative incidence of alcohol use in the NCS-R was 92%; tobacco, 74%; extra-medical use of other psychoactive drugs, 45%; cannabis, 43% and cocaine, 16%. Statistically robust associations existed between all types of drug use and age, sex, income, employment, education, marital status, geography, religious affiliation and religiosity. Very robust birth cohort differences were observed for cocaine, cannabis, and other extra-medical drug use, but not for alcohol or tobacco. Trends in the estimated cumulative incidence of drug use among young people across time suggested clear periods of fluctuating risk. Conclusions: These epidemiological patterns of alcohol, tobacco, and other extra-medical drug use in the United States in the early 21st century provide an update of NCS estimates from roughly 10 years ago, and are consistent with contemporaneous epidemiological studies. New findings on religion and religiosity, and exploratory data on time trends, represent progress in both concepts and methodology for such research. These estimates lead to no firm causal inferences, but contribute to a descriptive epidemiological foundation for future research on drug use and dependence across recent decades, birth cohorts, and population subgroups.

Degenhardt L; Roxburgh A; Van Beek I; Hall WD; Robinson MKF; Ross J et al. The effects of the market withdrawal of temazepam gel capsules on benzodiazepine injecting in Sydney, Australia. Drug and Alcohol Review 27(2): 145-151, 2008. (26 refs.)

Introduction and Aims. This study assessed the impact on benzodiazepine injection among IDU in Sydney of removing temazepam gel capsule preparations from the Australian market. Design and Methods. Several data sources were used: (1) data from the NSW Illicit Drug Reporting System (IDRS) (an annual, cross-sectional survey of regular IDU in Sydney) for the period 1996-2005; (2) data from inner Sydney outreach services and the Sydney Medically Supervised Injecting Centre (MSIC) on last drug injected; and (3) national benzodiazepine prescription data, by formulation, from the Drug Utilisation Sub-Committee for the period 2001-06. Results. Removal of temazepam gel capsule formulations from the Australian market in 2004 resulted in increased prescribing of tablet formulations but overall benzodiazepine prescription numbers remained stable. Injection of benzodiazepines ceased as a mode of administration of benzodiazepines among IDU in inner Sydney, but very frequent oral use of benzodiazepines remained highly prevalent. Discussion and conclusions. Removal of an easily injectable form of benzodiazepines appeared to halt injection of benzodiazepines among disadvantaged IDU. However, IDU continue to use the drug heavily and interventions to assist IDU with reducing dependent benzodiazepine use are warranted. There is a need for continued vigilance to emergent injecting drug use risks to implement timely harm reduction strategies.

Dong YH; Winslow M; Chan YH; Subramaniam M; Whelan G. Benzodiazepine dependence in Singapore. Substance Use & Misuse 42(8): 1345-1352, 2007. (12 refs.)

The study, conducted in 2003-2005, was aimed at investigating the pattern of benzodiazepine (BZD) use and the attitudes and perceptions of doctors' prescribing practices by a hundred BZD-dependent patients in Singapore. Data on patients' demographic characteristics, psychiatric profiles, patterns of BZD use, and perceptions about doctors' prescribing practices were collected. A benzodiazepine dependence self-report questionnaire (Bendep-SRQ) was also administered. The mean age of the study participants was 39.4 years (SD = 9.7); 88% were Chinese, 58% were males, 46% were married, 48% had received secondary school education, and 48% were unemployed. BZD abuse in Singapore is contributed to by both doctor-shopping behavior and doctors' prescribing practices. Doctors need training on the assessment and management of BZD dependence. The study's limitations were noted. This project was supported by an institutional block grant received from the National Medical Research Council, Singapore.

Dunbar JL; Turncliff RZ; Hayes SC; Farrell CB. Population pharmacokinetics of extended-release injecttable naltrexone (XR-NTX) in patients with alcohol dependence. Journal of Studies on Alcohol and Drugs 68(6): 862-870, 2007. (21 refs.)

Objective: Injectable extended-release naltrexone (XR-NTX; Vivitrol) has recently been approved for the treatment of alcohol dependence. A population pharmacokinetic (PPK) analysis examined the possibility of altered pharmacokinetics for naltrexone and its primary metabolite, 6 beta-naltrexol, in subpopulations with a potential for alcohol dependence treatment. Method: Data from four clinical studies of XR-NTX were pooled. Absorption was modeled as a sequential release in three phases. The pharmacokinetics of naltrexone and 6 beta-naltrexol were modeled as one-compartment disposition submudels, parameterized in terms of clearance (CL) and volume of distribution (V). The impact of age, weight, gender, race, hepatic function, renal function, smoking, and alcohol/opioid dependence on PPK parameter estimates was analyzed. Results: Plasma concentrations were available from 453 subjects. More than half of the subjects (59%) were alcohol dependent, and 27% were dependent on both alcohol and opioids. Naltrexone CL (140 L/h) and V (38,300 L) were dependent on weight (changes of 0.548 L/h/kg and 0.655 L/kg, respectively) and were 23% and 35% higher, respectively, in subjects with alcohol and/or opioid dependence than in healthy subjects. Naltrexone CL also was dependent on age (-0. 108 L/h/year); 6pnaltrexol CL (65.1 L/h) was dependent on creatinine CL (0.229 L/h/ml /minute) and alkaline phosphatase (-0. 130 L/h/IU/L), and was increased by 18% in smokers and in alcohol- and/or opioid-dependent subjects. Conclusions: Although statistically significant covariate-parameter relationships were identified, they were not considered clinically meaningful, suggesting that adjustments of XR-NTX based on weight, age, gender, health status, smoking status, creatinine CL, and hepatic function differences should not be necessary.

Edlund MJ; Sullivan M; Steffick D; Harris KM; Wells KB. Do users of regularly prescribed opioids have higher rates of substance use problems than nonusers? Pain Medicine 8(8): 647-656, 2007. (30 refs.)

Objective. To determine whether individuals who use prescribed opioids for chronic noncancer pain have higher rates of any opioid misuse, any problem opioid misuse, nonopioid illicit drug use, nonopioid problem drug use, or any problem alcohol use, compared with those who do not use prescribed opioids. Methods. Respondents were from a nationally representative survey (N = 9,279), which contained measures of regular use of prescribed opioids, substance use problems, mental health disorders, physical health, pain, and sociodemographics. Results. In unadjusted models, compared with nonusers of prescription opioids, users of prescription opioids had significantly higher rates of any opioid misuse (odds ratio [OR] = 5.48, P < 0.001), problem opioid misuse (OR = 14.76, P < 0.001), nonopioid illicit drug use (OR = 1.73, P < 0.01), nonopioid problem drug use (OR = 4.48, P < 0.001), and problem alcohol use (OR = 1.89, P = 0.04). In adjusted models, users of prescribed opioids had significantly higher rates of any opioid misuse (OR = 3.07, P < 0.001) and problem opioid misuse (OR = 6.11, P < 0.001) but did not have significantly higher rates of the other outcomes. Conclusions. Users of prescribed opioids had higher rates of opioid and nonopioid abuse problems compared with nonusers of prescribed opioids, but these higher rates appear to be partially mediated by depressive and anxiety disorders. It is not possible to assign causal priority based on our cross-sectional data, but our findings are more compatible with mental disorders leading to substance abuse among prescription opioid users than prescription opioids themselves prompting substance abuse iatrogenically. In patients receiving prescribed opioids, clinicians need to be alert to drug abuse problems and potentially mediating mental health disorders.

Eloi-Stiven ML; Channaveeraiah N; Christos PJ; Finkel M; Reddy R. Does marijuana use play a role in the recreational use of sildenafil? (editorial). Journal of Family Practice 56(11): 932-932, 2007. (0 refs.)

Engeland A; Skurtveit S; Morland J. Risk of road traffic accidents associated with the prescription of drugs: A registry-based cohort study. Annals of Epidemiology 17(8): 597-602, 2007. (24 refs.)

PURPOSE: The aim of this study was to examine the risk of a car driver being involved in a road traffic accident while using prescribed drugs. We used data from population-based registries. METHODS: Information on prescriptions, road traffic accidents, and emigrations/deaths was obtained from population-based registries. The incidence of accidents in the exposed person-time was compared with the incidence in the unexposed person-time, by the standardized incidence ratio (SIR). All Norwegians ages 18-69 between April 2004 and September 2005 (3.1 million), were included in the study. RESULTS: A total of 13,000 road traffic accidents with personal injuries were registered. The risk of being involved in an accident was somewhat increased in users of prescribed drugs in the first seven days after the date of dispensing (SIR for both sexes combined = 1.4; 95% confidence interval: 1.3-1.5). The risk was markedly increased in users of natural opium alkaloids (2.0; 1.7-2.4), benzodiazepine tranquillizers (2.9; 2.5-3.5), and benzodiazepine hypnotics (3.3; 2.1-4.7). Somewhat increased or unchanged SIRs were found for nonsteroidal antiiflammatory drugs 0.5; 1.3-1.9), selective beta-2-adrenoreceptor agonists (i.e., antiasthmatics, 1.5; 1.0-2.1), calcium receptor antagonists (0.9; 0.5-1.5), and penicillin (1.1; 0.8-1.5). CONCLUSIONS: The increased risk of being involved in a road accident as driver while receiving prescribed opiates and benzodiazepines supported the results from other studies.

Farre M; Abanades S; Roset PN; Peiro AM; Torrens M; O'Mathuna B et al. Pharmacological interaction between 3,4-methylenedioxymethamphetamine (Ecstasy) and paroxetine: Pharmacological effects and pharmacokinetics. Journal of Pharmacology and Experimental Therapeutics 323(3): 954-962, 2007. (39 refs.)

3,4-Methylenedioxymethamphetamine (MDMA, "ecstasy") is increasingly used by young people for its euphoric and empathic effects. MDMA can be used in combination with other drugs such as selective serotonin reuptake inhibitors. A clinical trial was designed where subjects pretreated with paroxetine, one of the most potent inhibitors of both 5-hydroxytryptamine reuptake and CYP2D6 activity, were challenged with a single dose of MDMA. The aim of the study was to evaluate the pharmacodynamic and pharmacokinetic interaction between paroxetine and MDMA in humans. A randomized, double-blind, crossover, placebo-controlled trial was conducted in 12 healthy male subjects. Variables included physiological parameters, psychomotor performance, subjective effects, and pharmacokinetics. Subjects received 20 mg/day paroxetine (or placebo) orally for the 3 days before MDMA challenge (100 mg oral). MDMA alone produced the prototypical effects of the drug. Pretreatment with paroxetine was associated with marked decreases of both physiological and subjective effects of MDMA, despite a 30% increase in MDMA plasma concentrations. The decreases of 3-methoxy-4-hydroxymethamphetamine plasma concentrations suggest a metabolic interaction of paroxetine and MDMA. These data show that pretreatment with paroxetine significantly attenuates MDMA-related physiological and psychological effects. It seems that paroxetine could interact with MDMA at pharmacodynamic (serotonin transporter) and pharmacokinetic (CYP2D6 metabolism) levels. Marked decrease in the effects of MDMA could lead users to take higher doses of MDMA and to produce potential life-threatening toxic effects.

Farrell LJ; Kerrigan S; Logan BK. Recommendations for toxicological investigation of drug impaired driving. Journal of Forensic Sciences 52(5): 1214-1218, 2007. (6 refs.)

Investigation of a suspected alcohol or drug impaired driving (DUID) case ideally contains several key elements, including a trained officer documenting observations of driving and subject behavior, and collection of a biological specimen for comprehensive toxicology testing. There is currently no common standard of practice among forensic toxicology laboratories in the United States as to which drugs should be tested for, and at what analytical cutoff. Having some uniformity of practice among laboratories would ensure that drugs most frequently associated with driving impairment were consistently evaluated, that appropriate methods were used to screen and confirm the presence of drugs, and that more accurate data were collected on the extent of drug use among drivers. A survey of United States laboratories actively involved in providing analytical support to the Drug Evaluation and Classification Program identified marijuana, benzodiazepines, cocaine, prescription and illicit opiates, muscle relaxants, amphetamines, CNS depressants, and sleep aids used as hypnotics, as being the most frequently encountered drugs in these cases. This manuscript presents recommendations as to what specific members of these drug classes should at a minimum be tested for in the investigation of suspected DUID cases. Additionally we include recommendations for analytical cutoffs for screening and confirmation of drugs in blood and urine. Adopting these guidelines would ensure that the most common drugs would be detected, that laboratories could compare epidemiological findings between jurisdictions, and that aggregate national statistics on alcohol and drug use in drivers involved in fatal injury collisions were representative of the true rates of drug use in the driving population.

Field T; Yando R; Bendell D; Hernandez-Reif M; Diego M; Vera Y et al. Prenatal depression effects on pregnancy feelings and substance use. Journal of Child & Adolescent Substance Abuse 17(1): 111-125, 2007. (45 refs.)

Depressed (n = 110) and nondepressed (n = 104) mothers were given a set of self-report measures, including the CES-D (depression), the STAI (anxiety), the STAXI (anger), the Perinatal Anxieties and Attitudes Scale, a questionnaire on substance use and the Feelings About Pregnancy and Delivery Scale that was designed for this study and that includes scales on coping, support, intimacy, common knowledge of depression, and cultural effects on pregnancy. During the neonatal period, the depressed mothers scored higher on the depression, anger, and anxiety scales as well as the Perinatal Anxieties and Attitudes Scale. They also reported using more substances including cigarettes, caffeine, and medications (primarily antibiotics). Their scores on the Feelings About Pregnancy and Delivery Scale were lower including the coping, support, intimacy, and cultural effects scores. In addition, they reported having more stressful situations during pregnancy, being less happy when finding out them were pregnant and their significant other being less happy when finding out about the pregnancy. A regression analysis on maternal depression suggested that 28% of the variance was explained by low support scale scores, not co-sleeping with their infant and high caffeine intake.

Fiellin DA. The first three years of buprenorphine in the United States: Experience to date and future directions. Journal of Addiction Medicine 1(2): 62-67, 2007

Buprenorphine, primarily as the buprenorphine/naloxone combination, has been available in the United States for office and specialty treatment program-based care since 2003. The existing evidence, collected primarily from federal sources, indicates that access to this type of treatment has expanded, that more than 50% of the 12,000 physicians able to provide this care are not addiction specialists, that buprenorphine diversion is low, that physician scrutiny by federal agents is infrequent, and among those receiving treatment patient acceptance is high. Implementation has been slowed because of physician training and support needs, reimbursement, and limits on the number of patients each physician can treat. As a result there are geographic variations in access and unmet treatment needs. The United States Congress has moved twice to loosen numerical limitations, now allowing each physician to treat up to 100 patients. Future research and evaluation are needed to ensure that opioid-dependent patients receive optimal care with buprenorphine.

Fischer B; Rehm J. Illicit opioid use in the 21st century: Witnessing a paradigm shift? (review). Addiction 102(4): 499-501, 2007. (26 refs.)

The authors of this editorial note the historical emphasis upon heroin as "the" illicit drug of concern, and a virtual caricature of the nature of the drug problem, and review the treatment approaches, particularly the emergence of drug substitution therapy. It is noted that increasingly heroin use is declining, with prescription opioids now being more widely used which in turn also changes the face of the drug trade. Questions are raised as how to best tackle the misuse of these prescription medications without placing the legitimate use for pain management at risk.

Fischer B; Rehm J. Understanding the parameters of non-medical use of prescription drugs: Moving beyond mere numbers. (editorial). Addiction 102(12): 1931-1932, 2007. (19 refs.)

Forrester MB. Adderall abuse in Texas, 1998-2004. Journal of Toxicology and Environmental Health. Part A, Current Issues 70(7): 658-664, 2007. (11 refs.)

Adderall is used in the treatment of attention deficit hyperactivity disorder (ADHD) in children and is subject to abuse. This study describes the patterns of Adderall abuse calls received by several poison control centers in Texas during 1998 - 2004. Drug abuse calls were assessed by call year and geographic location. Drug abuse calls were then compared to all other human exposure (nonabuse) calls with respect to various factors. Of all Adderall exposure calls, 12% involved abuse. The number of drug abuse calls received per year increased during the first part of 7-yr period but then declined. Male patients accounted for almost 60% of both drug abuse and nonabuse calls. Adolescent patients comprised 69% of drug abuse calls and children less than 13 yr old comprised 66% of nonabuse calls. Although the majority of both types of human exposures occurred at the patient's own residence, drug abuse calls were more likely than nonabuse calls to involve exposures at another residence (6% vs. 3%), school (22% vs. 5%) and public areas (2% vs. 0.4%). Drug abuse calls were less likely than nonabuse calls to be managed outside of a health care facility ( 18% vs. 51%) and to be classified as no adverse effect (23% vs. 48%). Adderall abusers are more likely to be adolescents. Adderall abuse as compared to other exposures is more likely to occur outside of the person's home and involve more serious medical outcomes.

Forrester MB. Oxycodone abuse in Texas, 1998-2004. Journal of Toxicology and Environmental Health. Part A. Current Issues 70(5-6): 534-538, 2007. (15 refs.)

Oxycodone is frequently abused, and this abuse appears to be increasing. The purpose of this study was to describe the patterns of oxycodone abuse identified by Texas poison control centers. All oxycodone calls received by Texas poison control centers during 1998-2004 were identified. Annual trends and geographic distributions were determined for drug identification (ID) calls and abuse calls. The distribution of abuse calls was then compared to the distribution of all other types of human exposure calls for a variety of factors. Both drug ID and abuse calls involving oxycodone increased over the 7-yr period. The numbers of abuse calls were higher than expected in the central part of Texas, while drug ID calls were higher than expected in eastern and central Texas. A higher proportion of oxycodone abuse than other types of oxycodone exposures involved males, adolescents, exposures at other residences and public areas, referral by the poison control center to a health care facility, and some sort of clinical effect. Oxycodone abuse calls in Texas are increasing. The proportion of calls varies by geographic region. Oxycodone abuse calls differ from other types of exposures with respect to both demographic factors and clinical management and outcome.

Gallagher RM; Rosenthal LJ. Chronic pain and opiates: Balancing pain control and risks in long-term opioid treatment. (review). Archives of Physical Medicine and Rehabilitation 89(3(Supplement 1)): s77-s82, 2008. (59 refs.)

The risks and benefits of opioid analgesics for chronic pain conditions and diseases are discussed in the context of the concern about the public health problems of poorly managed pain and prescription drug abuse and addiction. New strategies for risk management in treating patients with chronic pain are described. Opioids for chronic pain may be used effectively in the context of clinical strategies for risk management and selectively tailored, biopsychosocial pain management. Overall Article Objective: To present the case for balanced use of opioid therapy in the treatment of chronic pain conditions.

Ghiculescu RA; Kubler PA; Gleeson P. Drug utilization evaluation of i.v. paracetamol at a large teaching hospital. Internal Medicine Journal 37(9): 620-623, 2007. (9 refs.)

Background: I. v. paracetamol has recently become available in Australia for the treatment of pain when the oral or rectal administration route is not accessible. Our primary aim was to assess compliance with prescribing guidelines and our secondary aim to evaluate the safety of i.v. paracetamol use (4 g/day) and the effect of patient comorbidities on drug safety. Methods: Eighty-five consecutive patients were identified through the pharmacy dispensing system at a 900-bed, metropolitan, primary care and tertiary referral hospital over a period of 7 months from December 2005 to June 2006. Cross-sectional evaluation by patient interview, review of medical records and pathology parameters were carried out. The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee. Results: I.v. paracetamol was given for pain following abdominal surgery (90%) and musculoskeletal pain (10%). The comorbid conditions included severe renal impairment (9.4%), alcohol dependence (3.5%), pre-existing liver failure (2.4%) and malnutrition (18.8%). Prescribing guidelines were not adhered to in 25% of patients. The main cause for discordance observed in 90% of this group was the administration of i.v. paracetamol despite the presence of an alternative route of administration. Eight patients received i.v. paracetamol despite not having had a surgical procedure. Twelve patients received i.v. paracetamol for longer than 48 h; no injection site reactions or toxicity were noted. Conclusion: A lack of concordance between i.v. paracetamol use and prescribing guidelines was identified. There were no new safety concerns.

Graham AW; Schultz TK; Mayo-Smith MF; Ries RK; Wilford BB, eds. Principles of Addiction Medicine. Chevy Chase MD: American Society of Addiction Medicine, 2003. (Chapter refs.)

This volume is a comprehensive text on addictions. It is organized into 14 major sections, each of which has multiple chapters. There are over 200 contributors. The sections deal with the following themes: basic science and core concepts; pharmcology; diagnosis, assessment and early intervention; overview of addiction treatment; management of intoxication and withdrawal; pharmacologic interventions; behavioral interventions; 12-step programs and other recovery-oriented interventions; alcohol and drug problems in the workplace; medical disorders and complications of addiction; co-occurring addictive and psychiatric disorders; pain and addiction; and children and adolescents. There are also six appendices.

Grau LE; Dasgupta N; Harvey AP; Irwin K; Givens A; Kinzly ML; Heimer R. Illicit use of opioids: Is OxyContin (R) a "Gateway drug''? American Journal on Addictions 16(3): 166-173, 2007. (42 refs.)

This study examines whether individuals who engage in illicit, non-medical use of OxyContin((R)) are distinguishable from other non-medical users of opioids and whether OxyContin serves as a "gateway'' to heroin and/or injection drug use. The study sample included active non-medical users of opioids, who are 16 years or older and residents of Cumberland County, Maine. Possible associations between type of opioid used and behavioral and descriptive variables were assessed. The study sample was predominantly urban-dwelling, male, Caucasian, and economically disadvantaged. OxyContin users could only be distinguished from heroin users (non-heroin opioid users). Polyopioid use within the first year of initiation was associated with quicker progression to heroin and injection drug use.

Hall W; Degenhardt L. Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: An overdue topic for research. (editorial). Addiction 102(11): 1685-1688, 2007. (16 refs.)

Haw C; Stubbs J. Benzodiazepines - a necessary evil? A survey of prescribing at a specialist UK psychiatric hospital. Journal of Psychopharmacology 21(6): 645-649, 2007. (23 refs.)

Guidelines on the prescription of benzodiazepines recommend their use be limited to the short-term relief of severe anxiety or insomnia. However, clinical experience suggests that in psychiatry these drugs may be being prescribed more widely. The aim of this survey was to investigate benzodiazepine prescribing in a specialist UK psychiatric hospital using a structured interview with consultant psychiatrists. Prescribers were also asked their views on the UK CSM guidance on benzodiazepines (1988). Of 412 inpatients, 77 (18.7%) were receiving 90 benzodiazepine prescriptions for psychiatric indications. Most prescriptions were for anxiety (45/90; 50.0%), aggression (23/90; 25.6%) and agitation (13/90; 14.4%). Use was commonest for acquired brain injury, schizophrenia and personality disorders. Much usage was chronic (only 4/90 (4.4%) prescriptions had been initiated within the previous 4 weeks) and off-label (85/90; 94.4%). Prescribers were concerned about the addictive nature of benzodiazepines for these patients and to a lesser extent about their abuse potential. Most consultants believed the UK CSM guidance was too restrictive in relation to their clinical practice and needed modification to encompass new indications, for example rapid tranquillization, and specialist prescribing. In psychiatry benzodiazepines are quite frequently used in the management of a number of groups of difficult to treat patients. Although largely not evidence based, some psychiatrists report a favourable risk-benefit ratio for benzodiazepines in the treatment of certain patients.

Hayes BD; Klein-Schwartz W; Doyon S. Toxicity of buprenorphine overdoses in children. Pediatrics 121(4): e782-e786, 2008. (21 refs.)

OBJECTIVE. There are few reports in children of overdoses of buprenorphine, a partial opioid agonist used in the treatment of opioid dependence and pain. The purpose of this study was to analyze buprenorphine overdoses in young children reported by US poison centers to the Researched Abuse, Diversion, and Addiction-Related Surveillance System. METHODS. A retrospective review of buprenorphine overdoses in children < 6 years of age reported to the Researched Abuse, Diversion, and Addiction-Related Surveillance System from November 2002 through December 2005 was performed. Patients lost to follow- up and those ingesting multiple substances were excluded. RESULTS. Eighty-six cases met inclusion criteria. In the 54 children who developed toxicity, the clinical effects included drowsiness or lethargy (55%), vomiting (21%), miosis (21%), respiratory depression (7%), agitation or irritability (5%), pallor (3%), and coma (2%). There were no fatalities. The mean time to onset of effects was 64.2 minutes, with a range of 20 minutes to 3 hours. Duration of clinical effects was under 2 hours in 11%, 2 to 8 hours in 59%, 8 to 24 hours in 26%, and > 24 hours in 4%. Children who ingested >= 2 mg of buprenorphine were more likely to experience clinical effects, and all of the children who ingested > 4 mg experienced some effect. No child ingesting > 4 mg experienced a severe effect. Of the 22 children administered naloxone, 67% had at least a partial response. CONCLUSIONS. Buprenorphine overdoses are generally well tolerated in children, with significant central nervous system and respiratory depression occurring in only 7%. Any child ingesting > 2 mg and children < 2 years of age ingesting more than a lick or taste should be referred to the emergency department for a minimum of 6 hours of observation. Naloxone can be used to reverse respiratory depression.

Hermos JA; Winter MR; Heeren TC; Hingson RW. Early age-of-onset drinking predicts prescription drug misuse among teenagers and young adults: Results from a national survey. Journal of Addiction Medicine 2(1): 22-30, 2008

Early age-of-onset drinking is associated with alcohol problems and related, high-risk behaviors. We analyzed data from 18- to 34-year-old respondents from the 2001 to 2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC) to determine to what extent early age-of-onset drinking increased risks for prescription drug misuse (PDM), defined as 1 or more positive responses to: "ever having misused sedatives, tranquilizers, painkillers or stimulants, obtained either as prescriptions or from indirect sources." Lifetime prevalence of PDM was 15.4% among 8306 "drinkers" and 3% among 4652 "nondrinkers." Unadjusted odds for PDM for both men and women increased with each successively younger drinking age-of-onset, reaching a 10-fold risk at <14 years (odds ratio [OR], 10.7; 95% confidence interval [CI], 7.43-15.3) for men and women combined). In adjusted analyses, early age-of-onset marijuana use among drinkers reduced these odds and independently increased the risks for PDM 2-fold (adjusted OR, 2.07; 95% CI, 1.17-3.64). Lifetime alcohol dependence independently predicted PDM (adjusted OR, 2.43; 95% CI, 2-2.96) and obscured the association of early drinking, but not of early marijuana use, with PDM. This finding suggests a specific mediating effect of alcohol dependence between early drinking and PDM. Findings support the need for effective programs to prevent and reduce harm from early-onset drinking and from the associated risk of alcohol dependence and prescription drug misuse.

Hoiseth G; Brarnness JG; Christophersen AS; Morland J. Carisoprodol intoxications: A retrospective study of forensic autopsy material from 1992-2003. International Journal of Legal Medicine 121(5): 403-409, 2007. (41 refs.)

Carisoprodol is commonly prescribed as a centrally acting muscle relaxant, but it is also subject to abuse. The literature describing fatal intoxications with the drug is limited to a relatively small number of cases, and there are inconsistencies with regard to which concentration levels that are toxic. We therefore investigated all forensic autopsies at the Norwegian Institute of Public Health during the period 1992-2003 where carisoprodol was detected. The median concentrations of carisoprodol in intoxication with carisoprodol only or with only minor other analytical findings was 36 mg/l (range 8-65 mg/l; n=5). In the rest of the intoxications, the relevance of carisoprodol relative to the other drugs detected was variable (n=93). When the number of intoxications with carisoprodol each year were divided by the number of defined daily doses (DDD) sold, a fatal toxicity index between 5.6 and 6.9 deaths/1 million DDD was obtained. The total number of cases where carisoprodol was detected increased during the period studied, which correlated to sales figures for the drug. We conclude that carisoprodol can be fatal in concentrations below those indicated in some of the previously published literature. There were, however, only a small number of cases where the cause of death can be attributed to use of carisoprodol alone.

Horgan CM; Reif S; Hodgkin D; Garnick DW; Merrick EL. Availability of addiction medications in private health plans. Journal of Substance Abuse Treatment 34(2): 147-156, 2008. (31 refs.)

Health plans have implemented cost sharing and administrative controls to constrain escalating prescription expenditures. These policies may impact physicians' prescribing and patients' use of these medications. Important clinical advances in the pharmacological treatment of addiction highlight the need to examine how pharmacy benefits consider medications for substance dependence. The extent of restrictions influencing the availability of these medications to consumers is unknown. We use nationally representative survey data to examine the extent and stringency of private health plans' management of naltrexone and disulfiram for alcohol dependence, and buprenorphine for opiate dependence. Thirty-one percent of insurance products excluded buprenorphine from formularies, whereas 55% placed it on the highest cost-sharing tier. Generic naltrexone is the only substance dependence medication that is both rarely excluded from formularies and usually placed on a lower cost-sharing tier. These findings demonstrate that pharmacy benefits have an impact on access to medications for substance abuse.

Horvath KJ; Calsyn DA; Terry C; Cotton A. Erectile dysfunction medication use among men seeking substance abuse treatment. Journal of Addictive Diseases 26(4): 7-13, 2007. (20 refs.)

Few studies of erectile dysfunction erectile dysfunction medications use among heterosexual drug using or abusing men have been conducted. The aims of this study were to provide information on erectile dysfunction medication use prevalence, method of acquisition, and sexual effects among men seeking substance abuse treatment. A single time point cross-sectional anonymous Survey was completed by 297 men over the age of 18 seeking substance abuse treatment at an Outpatient clinic at a Veterans Affairs Medical Center in the Pacific Northwest. Mean age of participants was 49.7 years and 59.4% self-identified as Caucasian. Alcohol (56.7%) and cocaine (26.16%) were the primary drugs of abuse. Lifetime use of ED medications was reported by 24% (95%CI = 8.6%, 39.4%) of men. Almost 69% of erectile dysfunction medication users reported obtaining ED medications from a physician. Fifty-nine percent of erectile dysfunction medication users reported taking the medications to enhance their sexual experience rather than to treat erectile dysfunction, which was marginally associated with stimulant use (OR = 3.86, 95%CI = 0.96, 15.54, p =.057). These results add to an emerging recognition of the need to address the health implications of ED medication use among heterosexual drug using populations.

Hovda KE; Bjornaas MA; Skog K; Opdahl A; Drottning P; Ekeberg O et al. Acute poisonings treated in hospitals in Oslo: A one-year prospective study (I): Pattern of poisoning. Clinical Toxicology 46(1): 35-41, 2008. (25 refs.)

Objectives. Prospective design is mandatory to study pattern of poisoning and suicidal intention of patients. Material and Methods. Prospective cross-sectional multi-center study of all patients contacting health care services because of acute poisoning during one year in Oslo, irrespective of intention. Data on the adult hospitalized patients ( :16 years) are presented here. Results. Of a total of 3,775 such adult contacts (3,025 episodes), there were 947 (31%) hospitalizations; annual incidence 1.9 (per 1,000) in males and 2.1 in females. Median age was 36 years (range 16 - 89); 54% females. Benzodiazepines (18%), ethanol (17%), paracetamol (12%), opioids (7%), and gamma hydroxybutyric acid (GHB) (7%) were most frequently taken. Patients stated suicidal intention in 29% of the admissions; physicians in 10%. Conclusion. Benzodiazepines and ethanol were the most common agents, but newer illicit drugs were frequent, especially GHB. Males often took ethanol and drugs of abuse; females often used prescription drugs with suicidal intention.

Hull MJ; Juhascik M; Mazur F; Flomenbaum MA; Behonick GS. Fatalities associated with fentanyl and co-administered cocaine or opiates. Journal of Forensic Sciences 52(6): 1383-1388, 2007. (19 refs.)

Fatalities associated with fentanyl hydrochloride are increasingly seen in Massachusetts. Between September 2005 and November 2006, 5009 medicolegal investigations associated 107 deaths with licit or illicit fentanyl use, along with a co-detection of an opiate/opioid or cocaine/benzoylecognine, or both. Deaths associated with illicit fentanyl use occur in younger people (39.4 vs. 61.5 years) with higher fentanyl (17.1 ng/mL vs. 4.4 ng/mL) and lower morphine (76.9 ng/mL vs. 284.2 ng/mL) postmortem blood concentrations, and more frequent cocaine co-intoxication (65% vs. 3%), than deaths associated with licit fentanyl use. A wide range of postmortem blood concentrations of fentanyl was detected (trace-280 ng/mL), with a minimum concentration of 7 ng/mL of fentanyl strongly associated with illicit use of fentanyl in poly-drug cases. The most commonly detected opiates/opioids in illicit fentanyl users were: morphine (29%), oxycodone (14.5%), and methadone (14.5%). Ethanol, cannabinoids, diazepam, citalopram, and diphenhydramine were each detected in greater than 10% of the illicit fentanyl cases. Most fentanyl abusers died at their own home and their deaths were most often classified as accidental. Mapping of primary residences of decedents revealed conspicuous clustering of the illicit fentanyl use cases, as opposed to the random pattern in licit use cases. Fentanyl misuse is a public health problem in Massachusetts.

John U; Baumeister SE; Volzke H; Meyer C; Ulbricht S; Alte D. Sedative, hypnotic, anxiolytic and opioid medicament use and its co-occurrence with tobacco smoking and alcohol risk drinking in a community sample. BMC Public Health 7(e-article 337), 2007. (22 refs.)

Background: Sedative, hypnotic, anxiolytic and opioid medicament (SO) use and its relation to tobacco smoking and alcohol risk drinking is largely unknown. Prevalence data for SO intake and its co-occurrence with tobacco smoking and alcohol risk drinking considering age are presented. Methods: Random general population sample of individuals aged 20-79 drawn from a mixed rural and urban area in Germany (Study of Health in Pomerania, SHIP). All medicament intake during the past 7 days prior to the interview was assessed according to the Anatomical Therapeutic Chemical classification as part of an interview conducted in a health examination center. Results: Among men, 3.0%, and among women 5.0% took SO. The proportion of SO users was higher (odds ratio 1.9; 95% confidence interval 1.1-3.4) whereas the proportions of current cigarette smokers and alcohol risk drinkers without SO use were lower among individuals aged 60-79 compared to those aged 20-39. The proportion of individuals with smoking, alcohol risk drinking or SO use was also lower among those aged 60-79 compared to the 20-39 year olds. Conclusion: Although proportions of SO users in older adult age are higher than in younger adult age there are less subjects with any of the 3 substance use behaviors at older adult age compared to age 20-39.

Johnell K; Fastbom J; Rosen M; Leimanis A. Inappropriate drug use in the elderly: a nationwide register-based study. Annals of Pharmacotherapy 41(7-8): 1243-1248, 2007. (25 refs.)

BACKGROUND: Potentially inappropriate drug use (IDU) is an important and preventable safety concern, in the care of elderly patients and has been associated' with adverse drug reactions, hospitalization, and mortality. OBJECTIVE: To estimate the-prevalence of potentially IDU among the elderly in Sweden and investigate whether age, sex; arid number of dispensed drugs are associated with IDU: METHODS; We analyzed data on age; sex, and dispensed drugs for people aged 75 years and older who-were listed in the Swedish Prescribed Drug Register from October-December 2005 (N = 732 228). The main outcome measures of IDU were prescription of anticholinergics, prescription of long-acting benzodiazepines, concurrent use of 3 or more psychotropic drugs, and an indication of potentially serious drug-drug interactions. RESULTS: Prevalence for IDU was 17%; for anticholinergic drugs 6%, long-acting benzodiazepines 5%, 3 or more psychotropic drugs 5%,. and potentially serious drug-drug interactions 4 %. After adjustment for age and sex, number of dispensed drugs was strongly. associated with all 4 measures of IDU. After adjustment for sex and number of dispensed drugs, increasing age was moderately associated with a higher probability of IDU, long-acting benzodiazepines, and 3 or more psychotropic drugs, After adjustment for age and number of dispensed drugs; women had a slightly increased probability of IDU, anticholinergic drugs, long-acting benzodiazepines, and 3 or more psychotropic drugs. CONCLUSIONS: IDU was fairly common among the elderly in Sweden in 2005 and was strongly connected to the number of dispensed drugs they were taking. Older age and female sex were related to inappropriate use of psychotropic drugs, whereas the opposite relationship prevailed for potentially serious drug-drug interactions. Future research is needed to determine whether IDU will become more common due to increasing use of drugs among elderly persons. The challenge is to balance the problems related to IDU without denying older people potentially valuable drug therapy.

Kaloyanides KB; McCabe SE; Cranford JA; Teter CJ. Prevalence of illicit use and abuse of prescription stimulants, alcohol, and other drugs among college students: Relationship with age at initiation of prescription stimulants. Pharmacotherapy 27(5): 666-674, 2007. (20 refs.)

Study Objective. To examine associations between age at initiation of prescription stimulants and illicit use and abuse of prescription stimulants, alcohol, and other drugs among college students in the United States. Design. Web-based survey of college students. Setting. A large (full-time undergraduate population > 20,000) university. Intervention. A Web-based survey was sent to a random sample of 5389 undergraduate college students plus an additional 1530 undergraduate college students of various ethnic backgrounds over a 2-month period. Measurements and Main Results. Alcohol abuse was assessed by including a modified version of the Cut Down, Annoyance, Guilt, Eye-opener (CAGE) instrument. Drug use-related problems were assessed with a slightly modified version of the Drug Abuse Screening Test, short form (DAST-10). The final sample consisted of 4580 undergraduate students (66% response rate). For the analyses, five subgroups were created based on age at initiation of prescription stimulant use: no prescription stimulant use, grades kindergarten (K)-4, grades 5-8, grades 9-12, and college. Undergraduate students to whom stimulants were prescribed in grades K-4 reported similar rates of alcohol and other drug use compared with that of the group that had no prescription stimulant use. For example, students who started prescription stimulants in grades K-4 were no more likely to report coingestion of alcohol and illicit prescription stimulants (odds ratio [OR] 1.4, 95% confidence interval [CI] 0.2-11.5, NS] than the group that had no prescription stimulant use. However, undergraduate students whose prescription stimulant use began in college had significantly higher rates of alcohol and other drug use. For example, students who started a prescription stimulant in college were almost 4 times as likely (OR 3.7, 95% CI 1.9-7.1, p < 0.001) to report at least three positive indicators of drug abuse on the DAST-10 compared with the group that had no prescription stimulant use. Conclusions. In concordance with results of previous research, these results indicate that initiation of prescription stimulants during childhood is not associated with increased future use of alcohol and other drugs.

Kapadia N; Fox D; Rowlands G; Ashworth M. Developing primary care services for high-dose benzodiazepine-dependent patients: A consultation survey. Drugs: Education, Prevention and Policy 14(5): 429-442, 2007. (19 refs.)

Aim: To survey healthcare workers and high-dose benzodiazepine-dependent patients and obtain views on service improvement for managing high-dose benzodiazepine dependency. Methods: Two focus groups were conducted-one consisting of drug workers and high-dose benzodiazepine users and one of drug workers and general practitioners. Groups discussed gaps in service provision for benzodiazepine dependency. Based on a thematic analysis of the discussion, a pilot questionnaire was developed. The final version was sent to all GPs and drug workers in one inner-London borough. Findings: Five themes emerged from the focus groups: definition, impact on society, fear of withdrawal, attitudes and future service developments. The questionnaire was sent to 210 GPs and 21 drug workers. Response rate: 105 (50%) and 13 (62%), respectively. GP respondents had seen 482 high-dose benzodiazepine dependent patients in the preceding month; drug workers had seen 90. Benzodiazepines were considered an important cause of social and physical problems (69% and 75%, respectively). Just 9% of GPs thought that users wanted to withdraw, 23% were not encouraging them to withdraw and only 45% felt confident in carrying out withdrawal. The Department of Health, 'Orange Guidelines', had only been read by 53% of GPs. Three service priorities were identified: specialist benzodiazepine drug workers (preferably based in general practices), educational support (including up-to-date guidelines) and clinical psychologist input. Conclusions: Our consultation has identified service development priorities for high-dose benzodiazepine users.

Karbakhsh M; Zandi NS. Pattern of poisoning in the elderly: An experience from Tehran. Clinical Toxicology 46(3): 211-217, 2008. (30 refs.)

Introduction. Poisoning is considered a significant health problem in the elderly. This study aimed to portray the pattern of poisoning in the elderly population of Tehran. Methods. This cross-sectional study included all patients aged 60 years and older with acute poisoning who attended the emergency department of the Loghman-Hakim hospital over a six-month period (n=299). Results. Episodes of poisoning were more common in men (70.9%) and the majority of incidents took place in the patient's own home (84.3%). Most episodes were accidental (53.2%) followed by attempted suicide (32.4%). Opioids and opiate products accounted for 54.02% of the non-pharmaceutical substances that were involved in episodes of poisoning. Overdose with opioids and opiate products, was higher in male patients than in female patients. The most frequently involved drug groups were benzodiazepines, antidepressants, and analgesics. The most common cause of accidental poisoning was overdose by drug abusers. The Poisoning Severity Score was minor in 25.4%, moderate in 52.2%, and severe in 17.1% of patients. Asymptomatic patients accounted for 5.4% of the total. Unfortunately, 11.7% of patients died. The main agents involved in the fatal cases were opioids and opiate products. Conclusion. The commonest method of accidental poisoning was overdose in opioid and opiate abusers. Attempted suicide was also very common comprising about one third of all cases. The high mortality observed in this study warrants attention to the risk factors and prognostic factors of poisoning in elderly.

Kelly BC; Parsons JT. Prescription drug misuse among club drug-using young adults. American Journal of Drug and Alcohol Abuse 33(6): 875-884, 2007. (25 refs.)

Nonmedical prescription (Rx) drug use has recently increased, particularly among young adults. Using time-space sampling to generate a probability-based sample of club-going young adults (18 - 29), 400 subjects provided data on Rx drug misuse. Club-going young adults misuse Rx drugs at high rates. An overwhelming majority of the sample indicated lifetime use of pain killers, sedatives, and stimulants. A majority indicated recent pain killer use. Variations by gender and sexuality exist in this population. Young lesbian/bisexual women emerged as the group most likely to abuse Rx drugs. Research into the contexts influencing these patterns is imperative.

Kisa C; Bulbul DO; Aydemir C; Goka E. Is it possible to be dependent to Tianeptine, an antidepressant? A case report. Progress in Neuro-Psychopharmacology & Biological Psychiatry 31(3): 776-778, 2007. (14 refs.)

Tianeptine, an atypical tricyclic antidepressant, is one of the first chemical agents, like tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), which are employed for the treatment of anxiety and depressive disorders. It is believed that tianeptine, unlike the SSRIs, is enhancing serotonin re-uptake the velocity of the cortical neurons in the lymbic system and hippocampal neurons. In literature, there are more examples of dependence cases of antidepressants, which have amphetaminergie effects, such as amineptine and tranylcipromine, than amitriptyline, fluoxetine and tianeptine. Contrary to the reports about using high dosages of tianeptine, case reports about misuse and dependence have revealed that the most common reason of dependence is the psychostimulant effect. In these cases, tolerance to tianeptine and the symptoms of depreviation in absence of the drug have been seen, and the history of dependence or abuse of any drug or alcohol, treatment for mood and/or personality disorders are mentioned as possible risks for the dependence to tianeptine. This report discusses the diagnosis and treatment of a tianeptine dependence case. The 34 year-old patient, who is in conflict with her own family members, does not have the history of dependence or abuse of any substances, except for smoking, had been using excessive doses of 750 mg/day of tianeptine for a year.

Kokkevi A; Fotiou A; Richardson C. Drug use in the general population of Greece over the last 20 years: Results from nationwide household surveys. European Addiction Research 13(3): 167-176, 2007. (25 refs.)

The evolution of the drug use epidemic in Greece (prevalence and incidence of use of illicit drugs and illicit use of psychoactive pharmaceuticals) over a 20-year period is presented taking into account the sociocultural context and policies. Data were drawn from face-to-face household surveys carried out in 1984, 1998 and 2004 on national stratified probability samples of approximately 4,000 participants aged 12-65 years. After a large increase in lifetime illicit drug use prevalence from 4.0% in 1984 to 12.2% in 1998, the phenomenon seems to have taken a downward turn, to 8.6% in 2004. The incidence of illicit drug use remained unchanged between 1998 and 2004 in adolescents, declined in the young adult group (18-24 years) and dropped sharply at older ages. Cannabis accounts for almost all the total prevalence of illicit drug use; other illicit drugs have lifetime prevalence below 1%. The large gender differences in illicit drug use have narrowed over the years, especially in the younger age groups, although males remain far more heavily involved in illicit drug use than females. The lifetime prevalence of unprescribed use of pharmaceuticals has decreased markedly over the last 20 years from 13.5 to 9.1% following a stricter policy on prescribing. A narrowing of gender differences was also observed here, although females continue to predominate. Findings from the Greek general population surveys have had an impact on drug policy in the past and continue to represent an important input to policy formulation.

Lake AE. Screening and behavioral management: Medication overuse headache - The complex case. Headache 48(1): 26-31, 2008. (17 refs.)

The new appendix criteria for a broader concept of chronic migraine from the International Headache Society no longer require headache resolution or return to the previous headache pattern to confirm the diagnosis of medication overuse headache (MOH). MOH can be subdivided into simple (Type I) and complex (Type II). Complex cases may involve long-term use of daily opioids or combination analgesics, multisourcing, multiple psychiatric comorbidities, and/or a history of relapse. Daily use of opioids for other medical conditions, psychiatric comorbidity including borderline personality disorder, prior history of other substance dependence or abuse, and family history of substance disorders are risk factors for MOH. Relapse for analgesic overusers can be as high as 71% at 4-year follow-up. A case illustration spans 20 years from initial presentation through multiple periods of recovery and relapse to illustrate issues in the screening and management of complex MOH patients.

Lessenger JE; Feinberg SD. Abuse of prescription and over-the-counter medications. (review). Journal of the American Board of Family Medicine 21(1): 45-54, 2008. (46 refs.)

The nonmedical use of prescription or over-the-counter (OTC) medications implies that the user is using them for reasons other than those indicated in the prescribing literature or on the box label. The abuse of these medications is a national issue. Intentional drug abuse of prescribed and OTC medicines has climbed steadily. Data from the 2005 National Survey on Drug Use and Health demonstrated that 6.4 million (2.6%) people aged 12 or older had used prescription drugs for nonmedical reasons during the past month. Of these, 4.7 million used pain relievers, 1.8 million used tranquilizers, and 1.1 million used stimulants. The nonmedical use of prescription drugs in the past month among young adults aged 18 to 25 increased from 5.4% in 2002 to 6.3% in 2005, primarily because of an increase in the abusive use of pain relievers. Physicians need to watch for prescription and OTC medication abuse. Treatment strategies include (1) inquiring about prescription, OTC, and herbal drug use at the initial examination (even though many individuals are drug-abuse savvy, some are naive and do not realize that OTC medications can be problematic); (2) inquiring about drug use during office visits; (3) providing disposal containers that patients can use to dispose of their unused or unneeded prescription or OTC medications; (4) treating pain aggressively and appropriately; (5) practicing careful record keeping of prescription refills and controls over prescription blanks; (6) referring patients who are addicted to medications to 12-step programs such as Alcoholic Anonymous, Narcotics Anonymous, and Pills Anonymous; and (7) considering detoxification.

Levin FR; Adamson JJ; Antshel KM; Biederman J; Faraone SV; Kollins SH. ADHD and substance abuse update. (editorial). American Journal on Addictions 16(Supplement 1): 1-4, 2007. (0 refs.)

Levine DA. 'Pharming': The abuse of prescription and over-the-counter drugs in teens. (review). Current Opinion in Pediatrics 19(3): 270-274, 2007. (27 refs.)

Purpose of review Prescription and over-the-counter cough and cold medication abuse is rapidly becoming a national health concern for adolescents. Increased awareness of this growing epidemic is essential toward diagnosing, treating and preventing this type of substance abuse. Recent findings Data from surveys and poison control center records demonstrate an increased nonmedical use of prescription and over-the-counter cough and cold preparations, particularly those containing dextromethorphan. The nonmedical use of prescription medications may result in serious clinical effects with potential life-threatening complications, dependence and withdrawal syndromes. Dextromethorphan causes alterations in mental status that may contribute to judgment impairment leading to injury or fatality. Coingestion of other substances found in over-the-counter medications may also cause significant morbidity. Alcohol and illicit drug use is highly associated with the abuse of these medications. The incentive for abuse, such as easy accessibility, low cost and decreased perception of potential for harm, and potential interventions are described, Summary: The recent trend of prescription and dextromethorphan-containing over-the-counter medication abuse in adolescents is alarming. Improved awareness for these readily available, seemingly benign yet highly dangerous medications is essential. Prevention and early education on substance abuse in young teens are critical in combating this recent epidemic.

Levy MS. An exploratory study of OxyContin use among individuals with substance use disorders. Journal of Psychoactive Drugs 39(3): 271-276, 2007. (13 refs.)

This study surveyed 422 individuals being treated in a substance abuse treatment program that offers various levels of care in order to learn about OxyContin (R) use among this population. Focus areas included exposure and use of OxyConfin, how this medication was obtained, reasons for initial use, and whether users of OxyContin were drug naive or experienced users of opiate or non-opiate drugs. Whether OxyContin users who previously had never used opiates would report migrating to heroin was also explored. Findings revealed that 48% of the population had used OxyContin and of this population, only 1 % had no history of prior substance use. Seventy percent of this sample obtained them from friends and 14% obtained them directly from physicians. Many reported that their friends obtained their OxyContin from physicians, bringing the percentage of people who directly or indirectly obtained OxyContin through a physician to 37%. While most users of OxyConfin had a history of past opiate use, a small percentage had not, and of this later group, 73% migrated to using heroin. The majority of individuals who obtained OxyContin from a physician had a history of recreational or problematic opiate or non-opiate drug use. Finally, over time, 90% had stopped using this drug, although other drug use continued.

Lin JJ; Alfandre D; Moore C. Physician attitudes toward opioid prescribing for patients with persistent noncancer pain. Clinical Journal of Pain 23(9): 799-803, 2007. (22 refs.)

Objectives: Physicians frequently express dissatisfaction about caring for patients with chronic pain and frequently report that inadequate training and concern about addiction are impediments to prescribing opioids. Elderly patients with chronic pain may be at increased risk of experiencing uncontrolled pain and this patient population is increasingly being cared for by geriatricians rather than internists. We sought to determine if there is a differential impact on internists and geriatricians of the factors that adversely affect attitudes toward opioid prescribing. Methods: Anonymous survey of geriatric and internal medicine physicians at a large urban academic medical center about their beliefs and behaviors regarding opioid prescribing. Results: One hundred thirty-two of 187 physicians completed the survey for an overall response rate of 71 %. Controlling for level of training, internists were more likely to be concerned about illegal diversion (adjusted odds ratio = 10.0, P = 0.004), were more concerned about causing addiction (38% vs. 0%, P < 0.00 1), and were more likely to be concerned about their inability to prescribe the correct opioid dose (adjusted odds ratio = 11.1, P = 0.020). Discussion: Factors shown to have an adverse affect on opioid prescribing disproportionately impact on the attitudes of internists compared with geriatricians. Further research is needed to determine if there is also a differential impact on how internists care for their elderly patients with chronic pain.

Martins SS; Ghandour LA; Chilcoat HD. Profile of dependence symptoms among extramedical opioid analgesic users. Addictive Behaviors 32(10): 2003-2019, 2007. (34 refs.)

Little is known about the extent of problems due to extramedical opioid analgesic use ('analgesic misuse') in the US general population. This study explores the distribution of the seven DSM-IV-defined past-year dependence symptoms in a total household sample of 78 10 past-year extramedical opioid analgesic users using the 2002-2003 National Survey on Drug Use and Health (NSDUH). We tested for differences in opioid analgesic dependence symptom profiles across four subgroups of opioid analgesic users, different levels of deviant behaviors, and presence/absence of serious mental health problems quantified by the Composite International Diagnostic Interview Short Form (CIDI-sf). Generalized Estimated Equations (GEE) models were used to analyze the data. The most common opioid analgesic dependence symptoms were 'tolerance' (17.0%) and 'salience' (13.3%). Opioid analgesic dependence symptom profiles were 'parallel' across the groups of past-year opioid analgesic users, across deviant behavior groups and across presence/absence of serious mental health problems. Extramedical use of opioid analgesics associated with prescription drug use, having high levels of deviant behaviors, and having serious mental health problems were more strongly associated with endorsement of opioid analgesics dependence symptoms.

McCabe SE; Cranford JA; Boyd CJ; Teter CJ. Motives, diversion and routes of administration associated with nonmedical use of prescription opioids. Addictive Behaviors 32(3): 562-575, 2007. (31 refs.)

Objectives: The main objectives of this study were to assess the motives, diversion sources and routes of administration associated with the nonmedical use of prescription opioids as well as to examine substance use related problems associated with the nonmedical use of prescription opioids. Method: A self-administered, cross-sectional Web survey was conducted in 2005 at a large public Midwestern 4-year university in the U.S. using a probability-based sampling approach. The final sample included 4580 full-time undergraduate students. Results: The three most common motives associated with the nonmedical use of prescription opioids were to relieve pain, get high, and experiment. The leading sources of prescription opioids were friends and parents although there were gender differences in reports of primary sources. More than I in every 10 nonmedical users reported intranasal administration. Multivariate analyses indicated nonmedical users of prescription opioids who used for motives other than to relieve pain, obtained these drugs from non-parental sources, or used these drugs via non-oral routes of administration were significantly more likely to experience substance use related problems. Conclusions: These results indicate that nonmedical use of prescription opioids represents a considerable problem for particular subgroups of college students. While additional research is needed, the present study offers important new directions for policy and research regarding prescription opioid misuse.

McCabe SE; Teter CJ. Drug use related problems among nonmedical users of prescription stimulants: A web-based survey of college students from a Midwestern university. Drug and Alcohol Dependence 91(1): 69-76, 2007. (32 refs.)

This college-based study compared nonmedical users of prescription stimulants to other types of drug users regarding drug use related problems. A Web survey was self-administered in 2005 by a probability sample of 3639 full-time undergraduate students (68% response rate) at a large public Midwestern 4-year university in the United States. The survey consisted of measures to assess substance use and misuse, including a modified version of the Drug Abuse Screening Test (DAST-10). Nonmedical users of prescription stimulants were more likely than other drug users to report polydrug use. Nonmedical users of prescription stimulants had over four times greater odds than other drug users to experience three or more DAST-10 items in the past 12 months (AOR = 4.61, 95% CI = 3.28-6.48). Among nonmedical users of prescription stimulants, those who used prescription stimulants via intranasal and other non-oral routes of administration had greater odds than oral only users to experience three or more DAST-10 items in the past 12 months. The findings of the present study suggest that the majority of nonmedical users of prescription stimulants are polydrug users and should be screened for potential drug abuse or dependence, especially those who report non-oral routes of administration.

McCabe SE; West BT; Wechsler H. Alcohol-use disorders and nonmedical use, of prescription drugs among US college students. Journal of Studies on Alcohol and Drugs 68(4): 543-547, 2007. (26 refs.)

Objective: The purpose of this study was to examine the association between Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), alcohol-use disorders (AUDs) and nonmedical use of prescription drugs (NMPD) among U.S. college students. A secondary aim of this study was to identify individual-level and college-level characteristics associated with the co-occurrence of AUDs and NMPD. Method: Data were collected from self-administered mail surveys, sent to a random sample of approximately 14,000 college students from a nationally representative sample of 119 U.S. colleges and universities. Results: Among U.S. college students, those with AUDs represented approximately 75% of nonmedical users of prescription drugs. Multivariate logistic regression analyses indicated that college students with past-year DSM-IV alcohol abuse only (adjusted odds ratio [AOR] = 4.46, 95% confidence interval [CI] = 3.59-5.55) and students with past-year DSM-IV alcohol dependence (AOR = 9.17, 95% Cl = 7.05-11.93) had significantly increased odds of NMPD in the past year compared with students without AUDs. The co-occurrence of AUDs and NMPD was more likely among college students who were male, white, earned lower grade point averages, and attended co-ed colleges and institutions located in Southern or Northeastern U.S. regions. Conclusions: The findings provide evidence that NMPD is more prevalent among those college students with AUDs, especially individuals with past-year DSM-IV alcohol dependence. The assessment and treatment of AUDs among college students should account for other forms of drug use such as NMPD.

McCabe SE; West BT; Morales M; Cranford JA; Boyd CJ. Does early onset of non-medical use of prescription drugs predict subsequent prescription drug abuse and dependence? Results from a national study. Addiction 102(12): 1920-1930, 2007. (40 refs.)

Aims: The present study examined the associations between early onset of non-medical use of prescription drugs (NMUPD) (i.e. sedatives, tranquilizers, opioids, stimulants) and the development of prescription drug abuse and dependence in the United States. Design Data were collected from structured diagnostic interviews using the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Alcohol Use Disorder and Associated Disabilities Interview Schedule: Diagnostic and Statistical Manual version IV (DSM-IV). Setting National prevalence estimates were derived from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, n = 43 093). Participants: A nationally representative cross-sectional sample of civilian non-institutionalized adults aged 18 years or older in the United States, of whom 52% were women, 71% white, 12% Hispanic, 11% African American, 4% Asian and 2% Native American or of other racial background. Findings A higher percentage of individuals who began using prescription drugs non-medically at or before 13 years of age were found to have developed prescription drug abuse and dependence versus those individuals who began using at or after 21 years of age. Multivariate logistic regression analyses indicated that the odds of developing any life-time prescription drug abuse among non-medical users was reduced by approximately 5% with each year non-medical use was delayed [adjusted odds ratio (AOR) = 0.95, 95% CI = 0.94, 0.97], and that the odds of developing any life-time prescription drug dependence were reduced by about 2% with each year onset was delayed (AOR = 0.98, 95% CI = 0.96, 1.00) when controlling for relevant covariates. Conclusions: The results of this study indicate that early onset of NMUPD was a significant predictor of prescription drug abuse and dependence. These findings reinforce the importance of developing prevention efforts to reduce NMUPD and diversion of prescription drugs among children and adolescents.

Morasco BJ; Dobscha SK. Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain. General Hospital Psychiatry 30(2): 93-99, 2008. (47 refs.)

Objective: The goal of this paper was to examine the relationship between history of substance use disorder (SUD) and self-reported prescription medication misuse in 127 primary care patients who receive opioid medications for treatment of chronic pain. Method: Participants completed measures of pain location, pain intensity, disability due to pain, and misuse of prescription medications. Other measures included demographic characteristics, psychiatric symptomatology and quality of life. Results: Seventy-eight percent of participants reported at least one indicator of medication misuse in the prior year. After adjusting for age and clinical factors (pain severity, depression severity, current alcohol or substance use disorder), participants with SUD history were significantly more likely than participants without SUD history to report borrowing pain medications from others (OR=6.62, 95% CI=1.430.7) and requesting an early refill of pain medication (OR=3.86, 95% 0=1.5-9.6). Conclusions: Misuse of prescription medications is a concern among primary care patients with chronic pain. Participants with a lifetime history of SUD are more likely to endorse some aberrant medication-related behaviors. Patients with SUD histories should be carefully evaluated for medication misuse potential and may require more intense assessment and follow-up.

Morgado BM; Leal FJV; Peralvarezi MB; Macias JAG. Efficacy of bupropion in the treatment of pemoline dependence. Actas Espanolas de Psiquiatria 35(4): 277-278, 2007. (10 refs.)

We present the case of a woman who requested psychiatric evaluation because she had been taking pemoline for six months at a dose between 100-150 mg/day, and was finding it difficult to discontinue taking this substance. Initiation of 300 mg/day of bupropion solved the patient's dependence problem. We propose using antidepressants such as bupropion for the treatment of addictive behaviors due to central nervous system stimulants.

Nakada N; Komori K; Suzuki Y; Konishi C; Houwa I; Tanaka H. Occurrence of 70 pharmaceutical and personal care products in Tone River basin in Japan. Water Science and Technology 56(12): 133-140, 2007. (6 refs.)

The occurrence of 70 pharmaceutical and personal care products (PPCPs) was investigated in the Tone River. The river has the largest basin in Japan, and the water is utilized not only for farming, but also as a source of water supply. One day in both January and October 2006, surface waters in the river and its tributaries and effluents from sewage treatment plants (STPs) directly discharging into the Tone River were collected, the location of which ranged over 150 km along the river. The 70 PPCPs in the samples were concentrated by solid phase cartridge and were measured by LC-MS/MS using three analytical methods. Fifty-seven PPCPs were detected in one or more samples. Bezafibrate, caffeine, carbamazepine, clarithromycin, crotamiton and sulpiride were frequently detected. Mass flow profiles of some PPCPs (e.g., crotamiton) were comparable to cumulative inhabitants in the basin, suggesting that these PPCPs could be markers of population. Total load of each PPCP into the basin from upstream, the tributaries, and the STPs were calculated. The contribution of selected PPCPs from the tributaries with lower sewerage system coverage was dominant compared to those from upstream and the STPs, suggesting the installation of sewerage systems is necessary to reduce the load of PPCPs in the Tone River basin.

Noble M; Schoelles K. Opiate treatment for chronic back pain and its association with addiction. (letter). Annals of Internal Medicine 147(5): 348-349, 2007. (4 refs.)

Novak S; Kroutil LA; Williams RL; Van Brunt DL. The nonmedical use of prescription ADHD medications: Results from a national Internet panel. Substance Abuse Treatment, Prevention, and Policy 2(e-article 32), 2007. (61 refs.)

Background: Emerging evidence suggests that nonmedical use (NMU) of prescription attention deficit/hyperactivity disorder (ADHD) medications is rising, but many previous investigations have used clinical or regionally based samples or limited their investigations to stimulants rather than to medications specifically used to treat ADHD. Using an Internet-based epidemiological survey, this paper advances understanding of the prevalence and correlates of NMU of medications used to treat ADHD, sources of diverted medications, motivations for use, and consumption patterns. Methods: The study used a self-administered Internet survey of civilian, noninstitutionalized adults (N = 4,297) aged 18 to 49 in the United States. National-level estimates were created using propensity scoring methods and weighting procedures using data from three nationally representative probability surveys: a random-digit dialed telephone survey, the current U.S. Census, and the National Survey on Drug Use and Health (NSDUH). Results: Past-year prevalence of NMU of ADHD medications was approximately 2%, with 4.3% reported among those aged 18 to 25 and 1.3% among those aged 26 to 49. Most respondents reporting NMU used on multiple occasions. Receipt of medications for ADHD was a significant correlate of past-year NMU, though most nonmedical users never had a prescription. Among persons who had never been prescribed medication to treat ADHD, friends or family members were the most common source. Productivity was the most frequently endorsed reason for NMU. Alcohol was the substance most commonly used in combination with ADHD drugs. Conclusion: Because most prescription ADHD medications currently are highly regulated, policy options for supply-side reduction of nonmedical use may include identifying those medications with lower abuse liability for inclusion on insurance formularies. Patient and physician education programs also may be useful tools to heighten awareness of intentional and unintentional diversion of ADHD medications for nonmedical purposes.

2007, BioMed Central

Office of Applied Studies; Colliver JD; Kroutil LA; Dai L; Gfroerer JC. Misuse of Prescription Drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health. Analytic Series A-28. Rockville MD: Substance Abuse and Mental Health Services Administration, 2006. (60 refs.)

This report presents findings from the 2002, 2003, and 2004 National Surveys on Drug Use and Health (NSDUHs) on the nonmedical use of prescription psychotherapeutic drugs. NSDUH, an annual survey of the civilian, noninstitutionalized population of the United States aged 12 or older, covers four broad classes of prescription psychotherapeutic drugs: pain relievers, tranquilizers, stimulants, and sedatives. Attention also is given to two specific drugs within these general classes: methamphetamine, a stimulant, and OxyContin(r), a pain reliever. This report presents findings from the 2002, 2003, and 2004 National Surveys on Drug Use and Health (NSDUHs) on the nonmedical use of prescription drugs. Four broad classes of prescription drugs are considered -- pain relievers, tranquilizers, stimulants, and sedatives, and the specific drugs OxyContin(r) (a pain reliever) and methamphetamine (a stimulant). Among the major findings are that the nonmedical use of prescription drugs generally remained stable from 2002 through 2004. The nonmedical use of prescription pain relievers was second only to marijuana use among the as the most common illicit drug use. Annually 11.3 million persons aged 12 or older (4.8 percent) had used prescription parin relievers compared to about 25.5 million users of marijuana. Young adults, those ages 18 to 25 have the highest rates of nonmedical use. In the overall population males generally had higher rates than females for the use of pain relievers (5.2 percent for males and 4.3 percent for females), stimulants (1.3 vs. 1.1 percent), and methamphetamine (0.7 vs. 0.5 percent). However, among those ages 12 to 17, the rates of nonmedical use in the past year was higher among females than males for any prescription psychotherapeutic drug (9.9 percent for female youths and 8.2 percent for male youths), pain relievers (8.1 vs. 7.0 percent), tranquilizers (2.6 vs. 1.9 percent), and stimulants (2.6 vs. 1.9 percent). Misuse of prescription drugs was higher in the West (7.3 percent) than in the South (6.3 percent), Midwest (5.8 percent), and Northeast (5.2 percent). Despite overall stable patterns of prescription drug misuse, significant increases in the prevalence of lifetime misuse from 2002 through 2004 were observed among persons aged 12 or older for pain relievers in the hydrocodone and oxycodone categories (5.9 percent in 2002 to 7.4 percent in 2004 for hydrocodone and 4.3 to 5.0 percent for oxycodone). Specific drugs that were most prevalent among persons who initiated nonmedical use in the past year differed from those that were most prevalent among lifetime misusers overall. For example, Vicodin(r), Lortab(r), or Lorcet(r) as a group was the pain reliever with the highest prevalence (50.3 percent) among past year initiates of pain reliever misuse, but Darvocet(r), Darvon(r), or Tylenol(r) with codeine as a group had the highest prevalence (62.7 percent) among lifetime misusers of pain relievers overall. Most lifetime nonmedical users of prescription