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Drug Abuse, Prescription

Basics

Description

  • Controlled substances are prone to misuse, dependence, and diversion.

  • Misuse may include:

    • Taking medication for nonmedical reasons (e.g., to get high)

    • Using medications intended for someone else

    • Performance enhancement misuse

  • Common drug classes: opioids, stimulants, benzodiazepines, barbiturates

  • Diversion = redirection of medications for recreational or criminal use

Epidemiology

  • ED visits for substance use ↑ from 2.9M (2013) to 4.1M (2018)

  • Overdose deaths quadrupled (1999–2019); >91,000 deaths in 2020 alone

  • Opioids responsible for 78.4% of 2020 drug overdose deaths

  • 1 in 4 patients on long-term opioids develop addiction

  • Highest risk: age 18–25, followed by 12–17, then ≥26 years

Etiology & Pathophysiology

  • Euphoric effects → tolerance, dependence, addiction

  • Genetic predisposition involves opioid, dopamine, serotonin, GABA receptor variants

Risk Factors

  • Psychiatric illness, chronic pain, family history, genetics

  • Opioid use ≥3 months increases overdose risk:

    • 4x at 1 year

    • 30x at 5 years

General Prevention

  • Nonopioid pain treatments first-line

  • Avoid prescribing controlled substances at initial visit

  • Limit opioid quantity to a few days

  • Use PMPs, UDSs, and thorough history

  • Avoid benzodiazepines in anxiety; try SSRIs, CBT, or buspirone

  • Provide naloxone to all chronic opioid users

  • Identify and treat SUD

Commonly Associated Conditions

Opioids

  • Hyperalgesia, constipation, low testosterone, depression, overdose, HCV/HIV

Benzodiazepines/Barbiturates

  • Withdrawal seizures, psychosis, cognitive decline, falls in elderly

Stimulants

  • HTN, MI, arrhythmias, psychosis, hallucinations

Diagnosis

Screening Tools

  • Ask: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

  • Use DAST, AUDIT, CAGE

  • Use DSM-5 for formal SUD diagnosis

History

  • Look for doctor shopping, early refill requests, drug-specific demands

  • Behavior: hostile, manipulative, flattering

Physical Exam

  • May show signs of sedation, intoxication, or withdrawal

  • Opioid withdrawal: dilated pupils, yawning, piloerection

  • Benzo withdrawal: tremors, tachycardia

Differential Diagnosis

  • Depression, mania, psychosis, anxiety

Diagnostic Tests

Urine Drug Screen (UDS)

  • Check for:

    • Semisynthetics: hydrocodone, oxycodone

    • Synthetics: fentanyl, methadone

    • Others: tramadol, buprenorphine, benzodiazepines

  • Watch for false positives (e.g., poppy seeds, energy drinks)

  • GC/MS for confirmation

Other Labs

  • CBC, renal, liver, glucose, lipids

  • Screen for HIV, hepatitis, syphilis

Special Considerations

  • Random pill counts

  • Random UDS

  • Consider rehabilitation referral

Treatment

General Approach

  • Inpatient/residential/outpatient detox, MAT, behavioral therapy

  • Buprenorphine/naloxone, methadone, naltrexone

MAT

Buprenorphine/Naloxone

  • Up to 24 mg/day

  • Can be prescribed by any provider with training

  • Available as monthly injection

Naltrexone

  • Oral or injectable

  • Must be opioid-free for ≥7 days before starting

Methadone

  • Dispensed at certified OTPs by addiction specialists

Medication Notes

  • Benzos must be tapered slowly

  • Stimulants can be stopped abruptly

Issues for Referral

  • Refer to:

    • Addiction specialists

    • Pain management

    • Psychiatry

Additional Therapies

  • 12-step programs (AA/NA)

  • SMART Recovery

  • Family support: Al-Anon, Learn to Cope

  • Mindfulness, yoga, acupuncture

Admission Considerations

  • Admit if:

    • Failed outpatient treatment

    • Co-use of benzos/alcohol

    • Psychosis, SI, poor support

Ongoing Care

  • Continue MAT as long as beneficial

  • Frequent follow-ups early (e.g., weekly)

  • Monitor via PMPs, UDS, and in-person visits

Diet

  • For opioid-induced constipation:

    • Taper dose, high fiber, hydration, stool softeners

Patient Education

  • Store meds in locked containers

  • Warn against diversion

  • Educate about cravings, overdose signs, stress coping strategies

Prognosis

  • Most SUD patients achieve remission with treatment

Complications

  • Overdose

  • Cardiac events

  • Seizures (benzos)

  • Psychosis (stimulants)

References

  1. Onwuchekwa Uba R, et al. J Am Pharm Assoc. 2020

  2. Manchikanti L, et al. Pain Physician. 2012

See Also

ICD-10 Codes

  • F19.10 – Other psychoactive substance abuse, uncomplicated

  • F11.10 – Opioid abuse, uncomplicated

  • F15.10 – Other stimulant abuse, uncomplicated

Clinical Pearls

  • Addiction is treatable; MAT can be offered by most licensed providers

  • Stop opioids if no pain/function improvement or if UDS is positive, overdose, early refill

  • PMPs help detect doctor shopping, but don’t reduce ED visits/deaths alone