For most of us, the phrase “drug addiction and abuse” probably makes us think about street drugs like heroin and cocaine. But another culprit — prescription drugs — is driving an epidemic-sized crisis across communities throughout America. According to the National Institute on Drug Abuse, annual overdose deaths from prescription opioid pain relievers have more than tripled since 1991.

To get insights on the problem, and advice to help reduce the risk of abusing or becoming addicted to prescription drugs, we talked with Steven Capuzzi, senior pharmacist for the Highmark health plans’ care management team (see sidebar for bio). For more than 10 years, Capuzzi has helped people take medications safely, including educating people about the dangers of prescription drug abuse.

Understanding the Problem

Corey Florindi (CF): What are the most commonly abused prescription drugs that people should know about?

Steven Capuzzi (SC): The opioids are what’s making the news — and rightfully so. Over the past eight years, drug overdose deaths have outnumbered deaths from motor vehicle crashes in the U.S. — and a lot of that involves opioids.

Opioids include heroin, but the commonly abused prescription drugs we’re talking about are pain medications like morphine, codeine, oxycodone, and fentanyl. People may also know opioids better by certain brand names, including Vicodin, Dilaudid, Demerol, OxyContin, and Percocet.

Other commonly abused drugs include medications for anxiety and panic attacks; medications intended for people having difficulty sleeping; and medications for attention deficit and hyperactivity disorder (ADD/ADHD) or to help people stay awake (see sidebar for list).

I’ll add that when we talk about prescription drug abuse and addiction, we’re not just talking about buying those drugs illegally or taking them outside the intended use. People can become addicted to some drugs even while seeing a doctor and getting legal prescriptions.

CF: Is prescription drug abuse more common with any specific demographics?

SC: Part of what makes the word “epidemic” appropriate when we talk about opioid abuse and addiction is that it’s everywhere — from suburban neighborhoods to inner city streets to rural areas. Affluent, poor, men, women, all races and ages and backgrounds — this is a growing problem that’s hitting Everytown, USA.

CF: Any thoughts on what’s led the opioid epidemic to become so “epidemic”?

Hand holding a pill bottle with second hand holding label outSC: Availability and overprescribing are certainly causes. Unfortunately, drugs are part of American culture. You need relief of pain or an ailment? Just take a pill. Many cultures do not turn to drugs as quickly as we do in America. All the information available online and pushed out through advertising can reinforce that mindset. Patients walk into a doctor’s office, describe their issue, and know exactly what they want prescribed — and some doctors have been pretty quick to write the script, when maybe it would be better to explore alternatives that don’t involve addictive drugs. You also have people actively exploiting this by telling doctors they have certain symptoms or problems they don’t have in order to get a drug they want to use or sell.

That said, probably the leading cause of the epidemic is drug diversion. Broadly defined, drug diversion is when the legal supply chain of prescription analgesic drugs is broken, and drugs are transferred from a licit to an illicit channel of distribution or use. What does that mean? It includes something as common as a child taking a medicine intended for a parent or guardian because it wasn’t safely locked away. Redistribution of unused opioids from dental or medical procedures is also common. For example, someone gets a prescription for OxyContin but doesn’t use the pills. Instead of properly disposing of the extras they give them to a friend or relative who’s complaining about back pain. Another common diversion is opioids being stolen from the originally prescribed patients. Think about someone suffering from cancer who may have a prescription for these medications — you can imagine how easy it is for anyone near that person to take some or all of their medication.

So there are really multiple contributing factors to the epidemic. And that’s why you’re seeing tighter controls now, including from insurance companies. We want to make sure these drugs are only prescribed when they’re truly needed, and that dosages and refills are monitored to minimize the risk of abuse and addiction.

Awareness Can Lower the Risk for Addiction or Abuse

CF: Is part of the problem that people are misinformed or believe certain myths about drug abuse and addiction?

SC: Sure, probably the biggest myth is thinking prescription drugs are safer than illegal drugs because they came from a doctor, were dispensed by a pharmacist, and were manufactured by a company regulated by Food and Drug Administration (FDA) standards. The truth is that prescription drugs can be just as dangerous as any illegal drugs; statistically speaking, more people die each year overdosing on prescription opioid pain relievers than any illegal drug.

Another myth is that addiction can’t happen to you, or in your home or community. There’s the stereotype that addicts are folks you see in the city streets begging for money, so it can’t happen to a successful professional living in the suburbs. The truth is that people from all walks of life can end up struggling with addiction.

Thought cloud with pills in the centerCF: Going back to that “just take a pill” mindset — I wonder if people don’t always realize how much stronger, and more dangerous, some pills are?

SC: It is definitely a mistake to think of all drugs as the same. It might help to look at how the FDA categorizes drugs. Since 1970, the FDA has assigned a schedule number from 1 to 5 (designated by Roman numerals I, II, III, IV, V) for all controlled substances, which includes the drugs that, by law, require special parameters to write or dispense a prescription. The lower the schedule number, the higher the potential for abuse or harm.

Schedule C-I drugs have the highest levels of abuse and no currently accepted medical use — that  includes heroin. Most of the commonly abused pain medications and ADHD medications are Schedule C-II — so that tells you there is a very high risk to be aware of. On the other end of the spectrum, a Schedule C-V drug is something like Robitussin AC, which has a low dose of codeine and can be abused, but there’s lower potential for addiction or abuse than the C-II drugs.

CF: What should patients ask their doctors and/or pharmacists to reduce the risks?

SC: This is an important point, because sometimes patients aren’t having that conversation and there’s not enough education or counseling. You could think of it as a series of steps:

  • First, any prescription, ask the prescriber about the risk potential for abuse or harm, as well as potential side effects.
  • If we’re talking about pain management, ask whether there are ways to manage your pain without prescription drugs.
  • For any drug, ask whether there are therapeutic alternatives that have lower risk of being habit-forming.
  • If you are taking a prescription, there may be a treatment plan that it will be important for you to understand; this may include benchmarks or time periods where you’re going to check in to see if the dosage can be reduced or if medication is still needed at all.
  • Make sure the prescriber, pharmacist or both have explained exactly how to take the medication and whether you need to be aware of any risks while taking it.
  • Be vigilant in monitoring yourself to make sure you don’t begin using more than what is prescribed.
  • Always call your prescriber immediately if something doesn’t feel right or you think you might be developing a problem.

My best advice is talk to your doctor and pharmacist as often as necessary. Some prescribers also use pain management contracts, which can be helpful. You sign these contracts, like any other contract, and requirements may include agreeing that you will only get your pain control prescription from that specific doctor or at a specific pharmacy.

When and How to Get Help

Overlapping yellow and black WARNING tape lines

CF: If someone is prescribed one of the higher-risk drugs, what warning signs should they and their families and friends watch for to help prevent abuse and addiction?

SC: How people obtain drugs is one indicator — if someone isn’t using the correct prescription with the correct amount, or is getting additional prescribers to write prescriptions, those are signs of a possible problem. Similarly, some people who are addicted or abusing prescription drugs will go to multiple pharmacies in hopes of getting more medication. Another warning sign is someone consuming a drug in a manner other than directed — chewing a pill or crushing a pill and snorting it through the nose instead of swallowing it, for example.

Going back to the issue of drug diversion or medication diversion — it’s a major flag if anyone is taking a drug they don’t have a strong medical reason to use. That ranges from someone using another person’s prescription, to someone getting a prescription and then selling the drugs, to someone lying about or exaggerating a medical condition to try to get drugs. Highmark has a Financial Investigation and Provider Review team that, among many other things, helps combat prescription drug addiction and abuse by investigating suspicious claims and prescription activities. You can learn more about their work on their web pages, and they also have a form you can use to report suspected fraud.

CF: What about visible warning signs that someone may be abusing or addicted to drugs?

SC: Physical and behavioral symptoms will differ depending on the drug. For instance, if someone is abusing ADHD medication, their anxiety level may increase, they may have flushed skin, or have an increased heart rate. With pain medications, one thing to watch for is becoming delusional about the pain — believing and saying the pain is constantly worse, and therefore that more medication is needed. Other symptoms with pain medications, as well as sedative and hypnotic drugs, would be increased drowsiness, confusion, nausea, or being constipated. Warning signs for potential drug abuse related to behavior changes include:

  • Withdrawal from family and friends, spending more time alone than usual
  • Loss of interest in normal activities and hobbies
  • Increased hostility, anger, and aggression
  • Failure to keep up personal appearance and cleanliness
  • Decreased quality of work (on the job or with tasks at home)
  • Changing sleep patterns — for example, sleeping during the day and staying up all night or staying awake or sleeping for extremely long periods at a time
  • Disregarding family rules, being unusually disrespectful toward others, etc.

CF: If a problem develops, or someone is worried about a possible problem, where should they seek help?

SC: First, depending on the situation, consider talking with the doctor prescribing the drug. Drugs don’t always effect everyone the same way; a dosage that is safe for most people may cause trouble for an individual, but the doctor won’t know that or be able to help unless the patient or a family member tells them what’s going on.

In terms of professional help for addiction, The American Addiction Centers is one resource at the national level. They guarantee privacy, and you can call them at (888) 966-8152 or live chat with an advisor on the website 24/7. There are local and regional resources as well. Here in western Pennsylvania, the Allegheny Health Network has one of 45 Center of Excellence for Opioid Use Disorder programs funded by the Pennsylvania Department of Human Services.

Finally, for Highmark health plan members, I’m part of a team of pharmacists, behavioral health counselors, nurses, social workers and other professionals who are available through Blues on Call at 1-888-258-3428, or by calling the Member Service phone number listed on your member ID card (see sidebar). Whether it’s helping you understand a new prescription, answering questions about potential problems, or discussing options like in-house rehabilitation or detox programs, we are here to help.