MIXED MESSAGE ON PRESCRIPTION DRUG ABUSE

The National Institute on Drug Abuse (NIDA) broadened its focus in April
by launching a campaign against abuse of legally prescribed drugs.
According to NIDA, 4 million people aged 12 years and older misused pain
relievers, sedatives, tranquilizers, and stimulants in 1999.

At a press conference announcing the effort to raise awareness about
the dangers of these drugs, representatives from pharmacies and drug
manufacturers joined NIDA director Alan I. Leshner, PhD, at the
podium. All offered obligatory support for the endeavor, which at the
moment amounts to a collection of pamphlets, Web sites, and other
educational materials. Lacking any fixed agenda other than drawing the
attention of the Washington media the parade of spokespersons balked at
questions about the true scope of the problem and how to remedy it.

"Determining illegitimate use is challenging," said Thomas Menighan,
RPh, president of the American Pharmaceutical Association. "We can't
view every patient as a potential abuser." Leshner himself seemed to
undermine the message of the rally by forcefully stating, "Very, very
few people who use prescription drugs develop addiction."

So what exactly is the problem?

Leshner said he is alarmed by the increasing number of people who use
prescription drugs nonmedically. Data from the National Household
Survey on Drug Abuse, administered by the Substance Abuse and Mental
Health Administration, show the number of new abusers of prescription
drugs is on the rise. In 1998, an estimated 1.6 million Americans used
prescription pain relievers nonmedically for the first time. In the
1980s, the survey reported there were generally fewer than 500 000
first-time users each year. "We're pretty confident the increase is
real" and not an artifact of data collection, said Lucinda Miner, PhD,
chief of science policy at NIDA.

But teasing out precise trends is difficult.

The 1999 survey incorporated major changes that make it incompatible
with earlier surveys, said Jim Colliver, PhD, a NIDA statistician.
Colliver also said there is confusion about the figures presented at
the press conference. Leshner stated that 4 million people used
prescription drugs nonmedically during 1999, while the survey report
actually places that figure at 9.3 million.

The 4 million figure refers to past-month, not past-year, usage, said
Colliver.

In any case, the survey does a poor job of tracking the severity of
abuse, as the 1999 report does not distinguish between fleeting and
chronic users.

Of the 4 million -- or 9.3 million, depending on the time frame --
prescription drug abusers, it is unclear how many used pills once, 10
times, or 100 times.

For solutions to the ill-defined problem, the press conference
organizers presented a variety of views.

Leshner said that he hoped "raising awareness" would lead to a
decrease in prescription drug abuse and an increase in research into
the issue.

Other participants want better physician, patient, and pharmacist
education.

Ray Bullman, of the National Council for Patient Information and
Education, called for the development of the "medical education team"
concept, with physicians and pharmacists working together to help
patients better understand their medications. Bert Spillker, MD, PhD,
of the Pharmaceutical Research and Manufacturers Association, said
that drug companies are committed to developing products, such as
slow-release drugs, with less potential for abuse.

While some of these long-acting drugs are already on the market, they
do not eliminate the potential for abuse.

Front-line responders, namely pharmacists, are the ones who confront
the problem most directly.

They are trained to spot the signals of abuse, such as a patient
filling prescriptions from multiple physicians, said Edith Rosato,
RPh, of the National Association of Chain Drug Stores. But Menighan
added that pharmacists need better ways to help potential abusers.
"Despite our best efforts to balance our roles as health care
providers and gatekeepers, we struggle with the lack of a formal
process for dealing with incidents of suspected abuse," he said.

At the same time that NIDA is raising alarm bells about abuse
potential, new studies point to chronic underprescribing of
appropriate pain relief and a low ris of addiction to prescription
drugs.

At a scientific symposium following the press conference, pain
management experts presented their case. "There is widespread
acknowledgment that acute pain and cancer pain have been
undertreated," said Richard Brown, MD, MPH, associate professor of
family medicine at the University of Wisconsin Medical School. He said
that upward of 17% of Americans have serious chronic pain and that
many go untreated.

To gauge the extent of the problem, Brown and his colleagues developed
a survey (unpublished as yet) that measured physicians' prescribing
tendencies for benzodiazepines and opioids.

The survey presented several variations of a single case and compared
physicians' prescription decisions with recommendations from a panel
of pain management experts. In all cases, the physicians
underprescribed.

The most egregious underprescribing occurred with idiopathic back
pain, the most common kind. While the expert panel recommended that
virtually all patients with such pain -- and who do not respond to
other treatments -- be given an opioid analgesic, only 20% of
physicians said they would actually write that prescription.
Orthopedic surgeons were the most prescription-averse, while
oncologists were quicker with the pen. "It suggests there's a lot of
unnecessary suffering," said Brown. To combat the problem, he called
for increasing the amount of medical school education devoted to pain
management, from the typical 2 to 4 hours to 16 or 20. Brown added
that there have been strides toward greater acceptance of pain
management, particularly for patients with cancer. About 95% of
surveyed physicians said they would give an opioid for cancer-related
pain. "That's much better than 5 or 10 years ago," he said.

The second presentation focused on the frequency of abuse among
patients taking pain relievers.

In contrast to myths of yore, codeine, morphine, and their chemical
cousins rarely drive patients into the ever-tightening grip of
tolerance and dependency, said Steven Passik, PhD, director of
Community Cancer Care Inc, Indianapolis.

A major issue, said Passik, is sorting out truly abusive or addictive
behavior from borderline cases. "There is tremendous misunderstanding
about the risk of addiction," he said. Preliminary data from a survey
of physicians who treat chronic pain suggest that the frequency of
abuse and addiction among those taking prescription drugs is the same
as in the general population about 6%.

His survey also showed that, on average, patients had 58% of their
pain relieved by opioid analgesics. "They're not a panacea, but a lot
of patients would take 58% to the bank," he said. And the physicians
he surveyed said that they saw real improvements in overall
functioning in about 80% of such patients.

With these real gains in quality of life available, putting the
prescription drug abuse issue into perspective becomes a matter of
numbers. NIDA says that somewhere between 4 and 9 million people
misuse prescription drugs.

According to Wisconsin's Brown, the number of people who could benefit
from the drugs, but never get the chance to, could be even higher.