Burns Woodward, MD
Private practice of psychiatry, Norwood and Newton, Massachusetts
Dr. Woodward has disclosed that he has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.
We’ve all been taught not to prescribe addictive drugs to patients who will abuse them, but in the real world it is not always easy to tell who those patients are or to manage the resulting problems. The stakes are high: unintentional overdoses of prescription medication account for 27,000 deaths in the United States each year, more than heroin and cocaine combined (Morb Mort Wkly Rep 2012;61(1):10–13). Prescription drug abuse leads to suicides, auto accidents, unemployment, violence, and drug-related crime.
In treatment, patients who abuse medication usually get worse rather than better. They may engage in demanding, manipulative, and threatening behavior or quit treatment altogether. Although benzodiazepines, stimulants, and opioids are among our most effective drugs for anxiety, ADHD, and pain, respectively, psychiatric patients are at increased risk of abuse because of comorbid substance use disorders; cognitive, affective, and behavioral instability; and difficulties managing relationships with their treaters.
Patients misuse medication for many reasons: stress, personality problems, histories of trauma and abuse, latent mood or anxiety problems, and exposure to addiction in their environments. But the strongest factors involve medication altering the brain’s reward and stress response systems in individuals vulnerable to addiction (Kalivas PW and Volkow NE, Am J Psychiatry 2005;162:1403–1413.) Such a patient might tell you, “I know I can’t use, but I think about it all the time. When I relapsed I felt guilty, and scared it would happen again. Since then the cravings have been even stronger.” With this neurobiology in mind, you can approach your patients with an empathic understanding of the potential medication abuser’s struggles.
Evaluating the Risk of Medication Abuse The first step is to get your patient’s family and personal histories of alcohol, illicit drug, and medication abuse. You can start with a screening tool such as the Two-Item Conjoint Screen (available at bit.ly/JpYUTU); the Relax, Alone, Friends, Family, Trouble questions (bit.ly/Ig7CaZ); or the Opioid Risk Tool (bit.ly/fo5Cns) to help identify problematic use. Risk factors in addition to substance abuse include age between 15 and 45, peers who abuse substances, and a preadolescent history of sexual abuse pros and cons of medication. Is your patient on a complex regimen? Is he or she dependent on or possibly already abusing a drug given for a supposedly therapeutic purpose? Are there nonaddictive or nonpharmacologic alternatives? Have you overlooked any psychological, social, or medical problems that might need treatment? A patient whose ADHD you medicate with a stimulant, for example, might misuse the drug to self-treat mood instability that slipped under your radar. Is your patient willing to cooperate with steps to reduce the risk of abuse? (Webster LR and Webster RM, Pain Med 2005;6(6):432–42.)
If you suspect a problem, ask open-ended, nonjudgmental questions to flesh out the substance use history, looking especially at the patient’s efforts to maintain control of drug use: loss of control may be a red flag. Consider interviewing a family member, too. If your state has a prescription monitoring program, you can check online for prescriptions your patient may be filling from other prescribers.
With a picture of your patient’s abuse risk, you are ready to weigh the At this stage, you will be wise not to give too much credence to a patient’s denial of risk or promises to be careful, even if your patient is otherwise trustworthy. Similarly, don’t rely solely on your alliance with the patient: addictive cravings can and often do overcome such therapeutic values as trust and openness.
Prescribing Precautions If you decide to start your patient on a medication carrying abuse risk, you will want to tailor an individualized set of precautions and monitoring procedures. Begin with the treatment setting: do you have the resources to meet this patient’s needs for visit frequency, medical monitoring, substance abuse counseling, or urine testing? Some patients you will be able to treat yourself, but others might need substance abuse programs or detoxification facilities. Spell out with your patient the specific symptoms, behaviors, and functional abilities the drug is expected to improve. Include nonmedication plans such as psychotherapy, support groups, and exercise whenever possible. Plan how you will monitor treatment response; this might include rating scales and reports from the family. Be sure the patient understands your policies for follow-up visits, refills, and the consequences of aberrant medication behavior, which may include referral for more intensive care.
There is some evidence that slow-onset, longer-acting preparations such as clonazepam (Klonopin) are less likely to be abused (O’Brien CP, J Clin Psychiatry 2005;66[suppl 2]:28–33), and stimulants are available in abuse-deterrent formulations, for example methylphenidate extended release (Concerta) and transdermal (Daytrana).
Since a patient who loses control of medication may take a large amount in a short period of time, you may decide to write smaller prescriptions until you see how the patient responds. Electronic prescribing of controlled substances is available in some states and can prevent loss, alteration, and theft of prescriptions. Additional safety measures include asking a family member to dispense the medication, requiring the patient to bring in bottles for pill counts, and urine tests to be sure the patient is taking the medication you prescribe and not using other substances.
It’s important to know the medication your patient receives from other prescribers. If any of these seem inappropriate, be sure to get the other providers’ input and make sure they are aware of the possibility the patient is abusing the drug, if you suspect this. You may need to devise a solution that takes into account the overall medical and psychiatric picture. For example, a patient with a mood disorder and opioid dependence stable on buprenorphine/naloxone (Suboxone), whose addiction is activated by a prescription for oxycodone from an unwitting orthopedist, might need a family meeting, referral back to a 12-step program, and an increase in Suboxone dose in addition to cancelling the oxycodone prescription.
Monitoring Prescription Drug Use Watch for dosage escalation, nonadherence to other treatment recommendations, deteriorating functional status, obtaining drugs from other prescribers or illegal sources, and concurrent abuse of alcohol or illicit drugs. If your patient shows such behavior, consider whether the drug you prescribed has activated addiction, or whether something else is going on. The prescribed dose may be too low; the medication may simply be ineffective; or the patient may have developed tolerance or be self-medicating an unrecognized disorder. The patient may even be giving away or selling the drug.
Your response to aberrant medication behavior will be guided by your evaluation of the underlying cause. If you are dealing with an emerging addiction, assess the severity of the problem. Motivational interviewing is a good, non-confrontational way to do this (See TCPR, May 2010) and is best done when you first suspect a problem. Sometimes stopping the addictive drug is enough. Other patients will need additional measures such as relapse prevention psychotherapy, regular urine testing, 12-step groups, or substance abuse programs.
TCPR Verdict: Both you and your patients will be more confident with prescriptions for abusable medication if you evaluate your patients’ vulnerabilities to addiction, tailor your treatment plans to manage the risk of abuse, and recognize and respond to signs of inappropriate medication use.