Educate Patients on the Risks of Prescription and Non-Prescription Drugs

Introductory Paragraph

There is a common misperception that prescription drug use is without risks because they are legal and used for medical purposes. Pain relievers, along with other prescription drugs such as sedatives, stimulants, and tranquilizers, are highly prescribed in the United States and have the potential for misuse, dependence, overdose, and even death when used inappropriately. In the late 1990s, healthcare providers began to prescribe opioid pain relievers at high rates due to reassurance by pharmaceutical companies that patients would not likely become addicted to this medication. However, the increase in prescription use soon led to misuse of prescription and to nonprescription opioid use. By 2015, the National Survey on Drug Use and Health reported that over 90 million adults were using prescription pain relievers. The individuals who reported misuse of prescription pain relievers stated that they did so in order to relieve pain, relax, help with sleep, and relieve tension. The two most commonly reported sources of obtaining pain relievers that were misused came from friends or relatives and healthcare providers. For this reason, prevention efforts began to encourage physicians to speak with their patients about:

• potential risks of misusing medication
• not sharing prescription medication with friends or family members
• keeping medication out of reach from others
• appropriately disposing of remaining dosages

These educational strategies continue to be focal themes for effective prevention of misuse of prescription medications.

Key Information

In 2018, over 50 million people over the age of 12 reported having used illegal non-prescription drugs and/or prescription medication in a way not intended or that was not prescribed to them. In 2019, over 60,000 people died from a drug overdose in the United States. Even more people continue to live with harmful impacts, such as loss of family members, loss of relationships, employment issues, loss of child custody, and destroyed finances. The United States has experienced a rise in emergency room visits, overdoses leading to death, and increased drug treatment admissions. Fatality rates from overdose rose from 3,442 in 1999 to 17,029 in 2017. It can be especially difficult for people in rural communities to gain access to treatment. Substance use comes with a myriad of social stigmas and criminal repercussions which typically keep who people are struggling with substance use from seeking help.

The most common types of prescription medication that are misused are: opioids used to treat pain, depressants used to treat anxiety and sleep issues, and stimulants used to treat attention deficit disorders. In 2020, the most commonly misused prescription drugs were psychotherapeutic medication. That year, almost 17 million people, or about 6% of people 12 and older, attested to misusing this type of medication within the past 12 months. Also in 2020, SAMHSA reported 9.5 million people ages 12 and older had misused opioids (both prescription and non-prescription). Clearly, prescription and non-prescription substance use is beginning to spiral out of control, causing personal, financial, physical, and mental health issues for victims of addiction and those close to them.

Many times, individuals can become addicted to non-prescription narcotics after being prescribed medication to treat a condition. For example, prescription opioids used to treat pain are highly addictive the longer an individual uses them. One can take prescription opioids and develop a tolerance over time. Physicians are aware that it may be difficult for some patients to continue to receive a prescription or be prescribed an increased dosage. In some cases, this can lead to patients trying to seek out medication not prescribed to them or non-prescription narcotics like heroin or other opioids.

Risk Factors for Prescription and Non-prescription Drug Misuse

The misuse of prescription medication far surpasses the rate of misuse of illicit substances, except for marijuana usage, with the largest users being adolescents and young adults. For this reason, it is important that care providers provide adequate education on prescription drug use and screen patients for common risk factors before prescribing addictive medication. Individuals are at a heightened risk for misusing drugs if they have experienced or are currently experiencing the following:

• Stressful circumstances
• Poverty
• Unemployment
• Family history of substance use
• Personal history of substance use
• Mental disorders
• History of criminal activity or DUIs
• Contact with high-risk environments or individuals who use substances

The Role of Physicians and Primary Care Providers

Physicians are in a unique position to provide valuable information which could prevent misuse, because they frequently come into contact with people at risk for misusing substances. It is vital to identify ways to improve patient education about the risks and consequences of misusing substances. One survey found that 87% of U.S. adults visited a healthcare professional at least once during 2018, with 53% of Americans seeing a primary care provider during the same year. This information lends itself to the potential for physicians to incorporate approaches that educate individuals on the risks of misusing substances, incorporate effective screening practices, and develop other ways to reduce the harmful effects of prescription and non-prescription misuse. SAMHSA reports that doctors are continuing to prescribe highly addictive painkillers with increased frequency. Thus, it the responsibility of physicians to increase their monitoring of when and how often addictive drugs are prescribed to patients. Pharmacists can aid in this effort by regularly checking prescription drug registries.

• Improved Screening Methods for Misuse in Primary Care Setting. Many times, observation alone can not aid in identifying intoxication or someone under the influence of substances. Therefore, it is extremely important for primary care physicians to routinely ask all patients about substance use, amount, and frequency. Physicians offer a safe space to open the dialogue for patients to disclose any issues they are facing, as well as providing an opportunity for professionals to offer helpful information. For many people, a long-standing relationship with their doctor may feel like the best place to disclose information they may not feel comfortable bringing up to family members. A positive screen might give someone a better chance at recovery with early intervention. A negative screening allows the care provider to remind patients about the risks of misusing substances.

• Referring at Risk or In-Need Patients to Community Resources. Emergency Rooms that provide counseling, medication, and referrals to treatment centers have a significant and positive impact on the patients who come in for drug-related issues or complaints. A doctor can identify and screen for all types of drug use and assist their patients in recognizing any risky behavior or existing drug addiction. In conjunction with Prescription Drug Monitoring Programs (PDMP), doctors can begin to identify patients who have drug-seeking behaviors and refer them to community resources. See the SAFE wiki on PDMPs. This approach may reduce escalation of prescription drug misuse to illicit non-prescription drug abuse, such as dangerous street narcotics.

Relevant Research

Scientific evidence shows that substance use treatment, screening, and education programs that are integrated into mainstream health care in rural communities have promising impacts on patients. By integrating physical health care, mental health care, and substance use treatment, effective and efficient health care can be available for those who struggle with or are at risk for substance use. Many primary care offices can begin to implement screening, education, and case management services as the first step toward integration.

Impactful Federal, State, and Local Policies

In 2022, the Biden Administration released the National Drug Control Strategy in an effort to address addiction and overdoses in the United States. A major focus of this strategy emphasizes the need to develop stronger data collection systems to implement better public health interventions. The administration’s effort to build trust and engagement with those struggling with addiction should lead to more individuals seeking help, gaining education, and reducing overdose and drug dependency.

Available Tools and Resources

SAFE Project:

• SAFE Project Online Courses are SAFE Project original online trainings that focus on harm reduction techniques such as: Narcan administration and navigating Fentanyl use safely.

"Words Matter - Preferred Language for Talking about Addiction" This NIDA article discusses how language can impact those living with substance use disorders. It provides valuable information for care providers and loved ones to become informed about how language can cause people to feel stigmatized and therefore may prevent them from starting treatment.

Promising Practices

Connecticut -- Primary Care Development Corporation Through the Transformation Loan Fund, the Community Health and Wellness Center of Greater Torrington serves rural communities by providing an opioid treatment program that combines medication-assisted treatment, patient education, counseling, and other behavioral therapies to prevent overdose. It has also aided in the implementation of integrated substance abuse treatment into the primary care setting, aligning to a growing body of research which shows promising results when substance use treatment and prevention is added to mainstream healthcare.

Minnesota. The Little Falls Program to Reduce Opioid Prescriptions for Pain launched when doctors organized a response to the increasing number of opioid prescriptions and drug-related arrests. They worked with community partners in schools, local health departments, law enforcement, and health alliances to increase addiction treatment options and to monitor prescriptions. They were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse. Law enforcement alerts doctors if opioids they prescribed are found in possession of someone other than their patient. Rather than punish patients caught selling and abusing opioids, they are given access to Suboxone and to a support team which including a nurse and a mental health specialist. Although the program started off as an abstinence-based program, opioid fatalities led the doctors to changed to a medically-assisted program. This program has gained national attention of national policymakers. Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little FallsThe aim is to establish and fund opioid abuse prevention pilot projects throughout the state. Each pilot project has a multidisciplinary controlled substance care team to:

• deliver health care services and care coordination to reduce inappropriate use of opioids
• address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes
• provide prescriber and dispenser education
• promote best practices related to opioid disposal
• engage community partners outside the health care system in such efforts.