Use and abuse of prescribed drugs – includes related articles

This article discusses primarily medications that require a prescription as distinct from over-the-counter (OTC) products available in stores. Some products available over-thecounter in one form need a prescription in another. The amount of active drug in the medication usually determines whether a prescription is required. Examples: “222’s” (containing 8 mg codeine) can be purchased over-the-counter without a prescription, but “Tylenol No.3 ‘s” (containing 30 mg codeine) need a prescription; Advil (containing 200 mg ibuprofen) is available OTC, while Motrin(R) (white tablets, containing 300 mg ibuprofen) needs a prescription. Consumers are well advised to find out about the medications they use: what the drugs are intended for – to relieve symptoms (such as a headache or sleeplessness) or to cure disease (such as antibiotics to eradicate bacterial infection), when to take the drugs and possible adverse effects.

Prescription drug misuse a multifaceted problem

Many Canadians are exposed to a variety of compounds for which there may be no real or lasting need. Prescription drug misuse results in more North American injuries and deaths than all illegal drugs combined. Adverse drug reactions account for 15 per cent of hospital admissions in those over age 50. Hypnotics (sleep medications) result in almost 60 per cent of drug-related emergency room visits and 70 per cent of all drugrelated deaths. Prescription drugs may be misused even if taken in moderate amounts for the wrong reason (for example. codeine taken to solve psychological distress rather than to suppress a cough or mute pain).

There is no exact dividing line between moderate and excessive drug use. If drug use begins to disrupt social and family life, damages the user’s health. reduces work performance or causes financial burdens, use becomes “abuse.” The Addiction Research Foundatin, (ARF) states that “addiction or dependence exists when a drug is so central to someone’s thoughts, emotions, and activities that there’s a compulsive need to obtain and use it.” Physical dependence can occur without the addictive component, as happens with pain patients who hardly ever become addicted to their medications but readily give them up once the pain goes away.

According to one University of Toronto expert, “many substances are over-prescribed especially antibiotics, blood pressure medications, hypnotics (sleep-inducers) and narcotic analgesics (painkillers).” Among today’s most misused medications are the opiates such as codeine. The 1989 National Alcohol and Other Drugs Survey conducted by Health and Welfare Canada, reported that one in 20 adult Canadians regularly uses opiate painkillers. While correctly used, these medications are invaluable pain relievers. they’re sometimes inappropriately used in wrong doses and for too long.

The opiates include natural poppy derivatives such as codeine and morphine and related synthetics such as oxycodone, and meperidine (Demerol). Some are contained in combination products, for instance: Percocet (a mixture of oxycodone and acetaminophen), Percodan (with oxycodone and ASA), Tylenol No. 3 (containing codeine. ASA and caffeine) and Fiornal-C(containing codeine, ASA, caffeine and barbiturates).

Canada is currently the world’s top codeine consumer, with a per capita consumption twice that of the U.S. Codeine is not an innocuous substance. Those who habitually use it are apt to have impaired concentration and diminished peformance skills -risky when on the job, operating machinery or driving a car.

Studies show that drivers who take codeine have more collisions in simulated tests than those who took tranquillizers (e.g., diazepam) or alcohol (0.5 mg per kg body weight).

Physician mis-prescribing a key factor

The prescription pad has become as ranch a part of the modern physician’s paraphernalia as the stethoscope. A 1987 Canadian literature review entitled Drug Utilizatio, concluded that prescribers (physicians) and consumers are both to blame for prescription drug misuse. The report states that “physicians know too little about the correct use of the medications they prescribe and what they do know comes primarily from biased sources: the pharmaceutical companies. Practicing physicians are often inadequately prepared for good medicine prescribing.”

They may prescribe the wrong drug or faulty doses because of failure to keep up with medical advances, unfamiliarity with new medications and over-reliance nn the promotional material of pharmaceutical companies. It may seem easier (but is not safer) to rely on material put out by pharmaceutical companies instead of consulting scientific and pharmacological reviews.

To improve matters, more ongoing physician education in applied pharmacology (how to utilize drugs to best advantage) might help. Pharmacology courses in modern medical schools often pay too little attention to the clinical (practical) aspect of prescribing. There’s an ongoing need to update physician’s knowledge about new products whether genuine breakthroughs or copy drugs. Some new drugs offer few or no advantages over established products. There’s an equal call for consumers to become more knowledgeable medication-takers.

Consumer expectations compound medication misuse

In a society that believes “there’s a pill for every ill,” some people seek a remedy for every little twinge, expecting every doctor visit to terminate with a prescription whether or not they need one. Having got the prescription, some may not properly follow directions, discontinue the medication too soon, take wrong amounts, skip or forget a pill, and then take two or three to “make up.” Some go on the mistaken theory that “if one dose is good, two or three must be better.” Conversely, some carry a treasured prescription around without ever getting it filled, as a talisman or symbol of recovery. Not knowing (or checking) the patient’s failure to follow drug-taking instructions, physicians may be misled into believing that the medication didn’t work and prescribe more or other drugs.

Physicians like to appear “actively helpful” and sometimes handing out a prescription seems a satisfactory way to end the visit. “The act of transmitting a prescription from doctor to patient has non-pharmacological dimensions.” comments one University of Toronoto expert. “It symbolizes an act of healing and the psychological reaction can facilitate recovery.” In many cases. the mere anticipation of relief, the sense of “help on the way” exerts a neurohormonal effect on the mind. Up to one third of patients respond with a placebo effect by feeling better, even if no medication is taken. But if used as a coping mechanism for unresolved or everday problems, medications may expose people 10 needless risks. The dangers may arise not only from the drugs (chemicals)themselves but because reliance upon them undermines coping skills.

Doctors may feel pressured to prescribe drugs even when nondrug interventions without adverse side effects – such as a diet change, relaxation therapy, biofeedback exercise or counselling – might be as good or better. Trying to find out what’s causing a problem and discussing both medication and non-drug alternatives can help people decide which to choose. For example, while some might opt for sedatives to combat insomnia, others may decide to try relaxation therapy. In order to make informed decisions. people need adequate knowledge.

Who are the chief prescription drug misusers?

It’s a common misconception that medication misusers are fringe people, unemployed drop-outs or stressed-out professionals. It may be true for example that the job stress of stock market traders, intensive care nurses or businessmen encourages a few to over-use tranquillizers or become addicted to painkillers, but not most. Anyone can develop a drug over-use problem, although there are no good “markers” to identify those likely to do so. Some fall into the trap following legitimate use of prescription medication(s) for conditions such as migraine or arthritis. They may become dependent on the medication, seek multiple prescriptions and use too much for too long. Others likely to overuse prescribed medicines are the inveterate worriers, people with chronic anxiety or those who demand instant relief of the slightest distress.

It’s hard to obtain accurate figures on prescription drug misuse because of widespread under-reporting. Statistics only depict those who have been caught as abusers. But surveys conducted by Health and Welfare Canada and Toronto’s Addiction Research Foundation give a rough picture. Such as they are, studies show that those convicted of prescription drug abuse average 35 years of age, three quarters are employed and women account for almost half the cases.

Elderly particularly “endangered” by drug misuse

Adverse drug reactions among the elderly account for many hospital admissions, especially as they often take several different medications, sometimes prescribed by different physicians. Older people are al special risk of harmful drug reactions because doses suitable for younger adults may be too high for aging bodies that absorb, metabolize and eliminate drugs differently. The elderly require specialized prescribing tactics, better supervision and accurate records of all drugs taken. On medical visits they’re encouraged to “brown bag” it to put all medications (including over-the-counter products) in a bag to show the physician everything being taken. Older people should beware of taking drugs that are only marginally useful. They can ask their doctor(s) what the medication is for and whether there’s any non drug alternative or a substitute with fewer side effects.

Ways to improve prescription drug use

Responsible use of prescribed medication ideally involves a partnership between the consumer with a problem (bodily discomfort, pain, stress, anxiety or illness) and the physician who diagnoses and treats the disorder. In the Hippocratic tradition and to the best of their ability, physicians follow the tenet of “primum non nocere” above all, do no harm” But the safe administration of substances considered too dangerous for over-the-counter availability is no easy matter. Prescribing today’s vast array of medicalions requires considerable pharmacological knowledge. What’s needed is more continuing education for physicians about new products and better educated consumers who follow drug-taking instructions.

Consumers need to ask about their medicines – whether they are supposed to relieve symptoms (e.g., remove pain) or cure disease (e.g., kill the bacteria causing infection). Informed consumers use their medicalion correctly, know when and how to take it, for how long and side effects to watch for. The key is to weigh the benefits against possible risks.

Workplace drug abuse – the high cost to industry

Prescription anti other drug misuse can be a costly workplace problem leading to considerable injury and absenteeism. An estimated four to seven per cent of the workplace has a drug problem sufficient to impair performance at some time or other.

An ARF survey of nearly 2,500 workers found that two to 12 per cent were regularly overusing prescription medication several times a week. In Alberta, where toxicology tests on workers killed in industrial accidents are required, nine per cent of the victims had traces of prescription drugs in the body and 4.7 per cent had blood alcohol levels equal to or greater than the legal limit of 0.08 per cent. The costs of medication overuse to industry include not only high absenteeism rates but also rehabilitation expenses, paid in part by employers. Moreover, the cost of the employee’s prescription medications is often picked up by the company via a drug insurance plan. As with the general population, the prescription drugs most likely to affect performance are the opiate painkillers, hypnotics (sleep aids) and tranquillizers. Psychoactive medications impair the ability to perform tasks that require concentration and swift decisions – such as walking downstairs, driving a car or crossing the street. Such substances impair the ability to perform well, safely and reliably. Skills and judgment can be undermined, leading to poor performance, lower productivity and faulty workmanship. Drug-impaired workers can undermine safety, particularly if they operate complex machinery. By the same token, appropriate medication for specific disorders can enable workers to continue doing a good job. Medication users are not necessarily misusers or abusers: some need medication to function well. Tell employers about any medications needed.

Experts at Ontario’s Addiction Research Foundation predict that workplace drug testing, either before employment or on the job, is likely to be a big issue in labour relations during the ’90s. While some companies vigorously promote workplace (even random) drug tests, others call it an “intrusive witch hunt,” an infringement of civil liberties. The current climate around human rights dictates extreme caution when endorsing drug tests. The Canadian Medical Association has issued a 1992 policy statement, suggesting that “random drug testing among employees be restricted to safety-sensitive positions, only undertaken when measures of performance and peer or supervisory observation are unavailable.” The author of Drug Testing in the Workplace: Where to Draw the Line, points out that “drug tests only show past not present drug use and can indict lifestyle, not job efficiency.” Workplace drug tests only show that someone was using drugs in the past, not when, how much or what kind, nor whether an individual is “fit” for work.

Many drug misusers abandon their habit once they realize that it’s affecting their health, work performance, social or family life. But those who find it hard to give up, or fear they are dependent, should seek professional help. People can consult a family physician who may refer them on for specialized therapy. Ernplo.Vee Assistance Programs (EAPs) are another good place to get help in companies that have them. The EAP uses trained professionals for assistance and counselling. Many large companies now operate EAPs and find that about five per cent of the workers use it in any one year. The modem EAP takes a comprehensive approach to health and wellness, examining all areas of lifestyle and the work environment. EAP counsellors maintain full confidence. Outside agencies generally bill the company through an insurance company, not the personnel department, so the employer only knows the numbers attending not the names. As one ARF organizer says, “My impression of senior management is that they do not snoop or pry in this area.

Reasons for medication misuse

* Strong social expectation of “a pill for every ill,” a prescription to alleviate every little discomfort – possibly even those due to normal everyday life ! * Mis-prescribing by physicians, perhaps because of insufficient knowledge about medications, inability to keep up with new products, over-reliance on drug company promotion and sometimes because a prescription is easier (given little time) than unravelling the root of problems (such as anxiety disorders).

* Too little joint decision-making by physicians and medication consumers, inadequate explanation given about what a drug does, how it should be taken, side effects to watch for, addictive potential, possible interactions with alcohol and other substances. (Pharmacists are often better sources of information about medications).

* Lack of consumer knowledge about what prescribed medications are for – to allay symptoms or cure disease.

* Non-compliance by consumers, who don’t take the medications as prescribed and fail to report adverse effects.

* Exaggerated publicity about “drug wonders.”

* Pharmaceutical company advertising that persuades physicians and consumers to try new products that may be no better or cheaper than older “trusted and tried” remedies.

* Failure to take account of self-medication with OTC products and drug interactions. Physicians may not ask, and patients often don’t tell the doctor about other medications, including OTC products, being taken.

* Diversion of prescription drugs from physicians’ offices, hospitals and pharmacies through illegal channels to the street.

COPYRIGHT 1992 Strategic Inc. Communications Ltd.

COPYRIGHT 2004 Gale Group

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