Substance Abuse in WV - West Virginia State Medical Association

Special Issue CommentaryOpiate Addiction and Prescription Drug Abuse:A Pragmatic Approachby Khalid M. Hasan, MD andOmar K. Hasan, MDDuring this second decade ofthe 21st century, the UnitedStates is in the midst of amajor public health problem. At nearepidemic proportions, the abuse ofprescription drugs and especiallyopiates significantly contributesto escalating care costs, increasingpatient hospitalizations, and growingnumbers of untimely deaths.Although tobacco, alcohol,and marijuana traditionally haverepresented the drugs of choicefor adolescents, recreational use ofpharmaceuticals has the potential tobecome as prevalent. This is due toprescription medications’ relativelow cost, ready availability, andaccepted medical usage. In addition,the problem is exasperated by asmall percentage of unscrupulousproviders who for financial gainplay a major role in this epidemic.Some may question the usage ofthe term epidemic; however, statisticsbear the appropriateness of thisappellation. Approximately 14%of American adults are estimatedto be using pain medications fornonmedical purposes, and therecreational usage of opioids hassteadily risen during the past decade.From 2002 to 2006, the percentage ofyoung adults aged 18 to 25 abusingprescription opioids increasedfrom 4.1% to 4.6%. These figuressuggest that approximately 1.5million young adults are regularlyabusing these medications.Additionally, opioid-relatedemergency room visits increased126% from 2004 to 2008. Treatmentadmissions for non-heroin opioidabuse and dependence are alsoon the rise. From 1996 to 2006, thenumbers of these treatments nearlyquadrupled nationally from 16,605to 74,750. In West Virginia, thistrend especially has been severe.During the same ten-year period,non-heroin opioid treatments soaredin the Mountain State from twotreatments per every 100 thousandto 78 in every 100 thousand.Currently, West Virginia has thethird highest non-heroin opioidtreatment rate in the nation.While we believe that the majorityof physicians are treating patientpain appropriately, a numberindiscriminately prescribe opiates.This is done without a propertreatment plan of when and howto use the medications, withoutassessing the illness for the need ofsuch medications, and a lack of useof standardized pain assessmentinstruments. Some physiciansroutinely neglect alternativesto narcotics for treatment suchas psychosocial and behavioraltechniques as well as non-addictiveadjunctive medicines to reducedependencies on opioids. The resulthas created a culture of iatrogenicdrug addiction, and the offendingproviders are ascribed as being“legalized drug pushers.” It is ourintention to propose pragmaticchanges to physician practices toaddress this ever growing problem.Pain Management: Prescriptionof narcotics for non-cancer painshould be a treatment that is timelimitedand of a last resort. It shouldonly be used when non-narcoticand psychosocial interventionshave failed. Even when legitimatelyused, the prescriptions shouldinclude a dosage, quantity, andtreatment duration that is adequateto treat the pain. Monitoring theusage of these medications reducesthe risk of patient abuse anddependence, and it decreases thelikelihood of diversion through thedrug’s sale or theft. Since divertedprescription pain medications arethe leading source of opioid accessfor adolescents, the importance oflimiting quantities of prescribednarcotics cannot be overstated.Opioid Treatment Dependence:Although methadone and levaacetylmethadol(LAAM) havebeen used as agonist replacementtreatments for opioid dependence,the Substance Abuse and MentalHealth Services Administration arenow recommending buprenorphine(Subutex ® ) and Suboxone ® , acombination of buprenorphineand naloxone, as office-basedtreatment alternatives for opioidaddictions. Physicians can belicensed to prescribe buprenorphinewith minimal training and areonly required to be able to referpatients for adjunctive psychosocialtreatments. Unfortunately,buprenorphine has developed a streetvalue. The duration of treatmentdosage of Suboxone ® has beendebated, but the medication has beensuccessful in the treatment of opioidaddicts. We believe, however, thatunless these medications are properlycontrolled, they will meet the samefate and notoriety of methadone.Motivation: Another factorthat plays an important role inthe prognosis and treatment ofdrug addiction is motivation.Detoxification is not a cure. Whenutilized without adequate supportmeasures and proper follow-up,detoxification has proven to beineffective. While continuallyproblematic, assessing anindividual’s motivation is subjective.Although psychological tools exist,84 West Virginia Medical Journal