Defining prescription painkiller misuse and abuse

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By Sam Hickman

 Editor’s note: This is the second story in a six-part biweekly series examining the prescription painkiller problem in Brunswick County. The first story in this series was published July 3.   


There’s a fine line between misuse and abuse. But both can be deadly.

Brunswick County leaders are working to combat a growing problem of prescription painkiller misuse and abuse.

Leaders gathered last month to discuss Project Lazarus, a secular public health nonprofit established in 2008 in response to extremely high drug overdose death rates in Wilkes County, which was four times higher than the state average at the time.

Wilkes County native Fred Brazon welcomed health professionals from across the southeast region of the Tar Heel State to Bolivia on June 25 for a presentation on Project Lazarus.

He came to Brunswick County because there has been a significant increase in opioid — or prescription painkiller — poisoning deaths here from 2008 to 2012, according to statistics from the Centers for Disease Control and Prevention.

In 2012, Brunswick County had the most prescription opioid overdose deaths — 18 per 100,000 people — in the region, which includes Bladen, Columbus, New Hanover, Pender and Onslow counties.


Defining misuse and abuse

Brazon, Project Lazarus CEO, said these accidental deaths stem from the misuse and abuse of prescription medications.

“If you have a prescription, because it doesn’t seem at the moment to be taking care of the pain, you self dose and take more than what’s prescribed. That’s misuse,” he said. “Abuse is defined as one who uses the medication for the possible benefits of the side effects. The side effects being a sense of euphoria, getting high. That’s what some people can experience from pain medication or obviously benzodiazepines, anti-anxiety drugs and so forth.”

Dr. Michael Klein of the Food and Drug Administration recently led a question-and-answer session detailing the difference in prescription pill misuse and abuse.

“When a person takes a legal prescription medication for a purpose other than the reason it was prescribed, or when that person takes a drug not prescribed to him or her, that is misuse of a drug,” he said. “Misuse can include taking a drug in a manner or at a dose that was not recommended by a health-care professional. This can happen when the person hopes to get a bigger or faster therapeutic response from medications such as sleeping or weight-loss pills.”

Klein said it “mostly has to do with the individual’s intentions or motivations.”

“For example, let’s see that a person knows that he will get a pleasant or euphoric feeling by taking the drug, especially at a higher dose than prescribed. That is an example of drug abuse because the person is specifically looking for that euphoric response.”

He said there’s a fine line between misuse and abuse.

“In contrast, if a person isn’t able to fall asleep after taking a single sleeping pill, they may take another pill an hour later, thinking, ‘That will do the job.’ Or a person may offer his headache medication to a friend who is in pain. Those are examples of drug misuse because, even though these people did not follow medical instructions, they were not looking to ‘get high’ from the drugs. They were treating themselves, but not according to the directions of their health-care providers.”

Brazon said more than 70 percent of prescription misuse and abuse in the United States is when people get the drugs from family members or friends.

“This happens in the home, workplace and in everyday life,” he said. “Normally, a practitioner is treating to who that person is — height, weight, condition, the reason why they need the medication. That’s not always the same for other individuals.

“The dangers are that if you’re taking someone else’s medication and you have a reaction to it, that can result in overdose. I’ve seen situations where someone wasn’t abusing the drug but died as a result of misuse. That’s been documented in a number of cases across the state.”

Brazon noticed a major problem when he was working as a hospice director in Wilkes County.

“Prescriptions were disappearing,” he said. “ We had family members taking it, stealing it, openly sharing — by percentage it was way over the top than anything I’d ever seen in my health-care career.”

It reached a point where prescribers told Brazon they didn’t feel safe keeping their own prescription in their house.

“That’s when it really opened my eyes,” he said. “But I’ve seen awareness grow exponentially. (Since I noticed the problem in 2004), awareness has grown probably three, four, five hundred percent. It’s because of bringing awareness to the situation but unfortunately so many more people having had a personal experience who have developed an issue surrounding prescription medication. People have experienced others having issues.”



Brazon said misuse and abuse have led to another serious problem: addiction.

“Misuse can lead to abuse. These individuals could become addicted down the road,” he said. “Most people aren’t going to gas station or behind the back alley (to get drugs). It’s happening in the home and between family and friends. No one intends to become addicted or develop a substance abuse problem. People are susceptible biologically and psychologically to addiction.”

Kenny House, vice president of clinical services with Coastal Horizons Center Inc., a treatment facility in Shallotte and Wilmington, agreed.

“It starts out all kinds of ways,” he said. “It starts out sometimes by someone starting out with heroin and going the other way, some times it starts out with pain medication that was prescribed legitimately and spirals out of control. It can happen either direction. Nobody starts out seeking to become addicted to any substance.”

House said many of the problems he sees with prescription painkiller misuse and abuse is with Vicodin and OxyContin.

“One of the big challenges, a couple of the most popular prescription drugs of abuse are OcyContin and Vicodin, which are very similar chemically to heroin,” he said. “Because of that, the addiction is very difficult to treat. It takes a long period of time and requires some medication to assist the person in their recovery.”

Brazon said addiction does not know demographics.

“If people are misusing without a prescriber’s instruction, it can lead to dependence and then it can lead to addiction,” he said. “Those people need to turn their lives around. It’s a cross sectional issue that deals with all population groups. It doesn’t matter what ethnicity you are or where you live. It’s across all title areas.”

Additional problems are created when someone becomes addicted to the drugs, Brazon said.


Treatment options

“This is why we view this as a public health issue. We’re talking about people who have developed the disease of addiction,” Brazon said. “Part of the age-old problem with addiction is the perception from the general public that it’s completely behavior-oriented. If they’d just change their behavior, they wouldn’t be in the position they are in.

“The general public is keeping individuals at arm’s length away and treating these individuals poorly who have substance abuse issues. Because of denial, because of the stigma of what people would think, they hide it, they conceal it, and they reject treatments, whereas recovery should be celebrated and not stigmatized.”

One of the most accessible ways to prescription medication is through a family member’s medicine cabinet, House said.

“It’s a combination of things that result in addiction; one of them certainly that contributes to it is easy access,” he said, “especially if nobody is counting the (number of pills in the bottle). It’s just something that people don’t think about doing, but we actually need to. It has to be a communitywide education process as well as making sure treatment is, we have specialized treatment for people who suffer from opioid prescriptions. We need to do a communitywide project to help doctors with self-prescribing of this medication and to help families store and secure these medications.

“The No. 1 opportunity to get one of those prescription drugs I mentioned is in the medicine cabinet of a family member. You went to the doctor, had some minor surgery, got X amount of OxyContin, you used a few of them, plenty left in the bottle, and there’s several left. Those are very dangerous and they are very addictive. Sons, daughters, grandsons, granddaughters, aunts, uncles, every one knows in the medicine cabinet you can find these substances.”


A doctor’s take

Abuse can certainly be lethal, especially when painkillers are mixed with other drugs or alcohol, House said.

“One of the big challenging pieces, nationally, statewide and locally, is people are getting these prescriptions from primary doctors,” he said. “They aren’t primarily getting them from the drug dealer, or the Internet — it’s small amounts from that. Most are coming from primary care doctors. They are getting it from families or friends that come from those doctors.”

Dr. Timothy Gibble of Atlantic Internal Medicine in Supply said doctors prescribe medicine based on the best information available.

“I think it’s very hard to get people to be completely honest about what they are taking.” Gibble said. “That’s difficult to regulate for a doctor. Even when we try to pin them down to get specifics, they’re pretty vague about what they’re taking. We have to trust our patients to do what’s right and tell us what’s important, so we still prescribe based on the best information available.”

Painkillers in particular are more dangerous than anti-anxiety medications, although the two are equally habit-forming, he said.

House said the community needs to help families dispose of medications they won’t use. “We also need to reduced the demand for these substances across the board. All of that is part of a communitywide effort that needs to happen to reduce what we’ve seen with people getting addicted and participating in unlawful behavior, winding up in the ER and at times, winding up dead,” he said. “Prescription opioids have a very high potential for overdose and risk of death especially in combination with alcohol or anti-anxiety medications. When you put those drugs in combination, they are potentially lethal. Alcohol and any combination with any depressant can produce respiratory failure and put someone in overdose potential, primarily by slowing the heart rate down to dangerous levels.”

Klein said there are many ways for people to overdose on prescription medications.

“However, when a person misuses or abuses a prescription drug, there is no medical oversight of the risks,” he said. “A person can die from respiratory depression from misusing or abusing prescription painkillers — for example, opioids.

“Prescription sedatives like benzodiazepines can cause withdrawal seizures. Prescription stimulants such as medications for attention deficit hyperactivity disorder (ADHD) can lead to dangerous increases in blood pressure. The risks from these drugs are worse when they are combined with other drugs, or alcohol.”


Facts and figures

Drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs, according to the Centers for Disease Control and Prevention.

Although many types of prescription drugs are abused, there is a growing deadly epidemic of prescription painkiller abuse. Nearly three out of four prescription drug overdoses are caused by prescription painkillers, also called opioid pain relievers. The unprecedented rise in overdose deaths in the United States parallels a 300 percent increase since 1999 in the sale of these strong painkillers. These drugs were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined, according to the CDC.

The misuse and abuse of prescription painkillers was responsible for more than 475,000 emergency department visits in 2009, a number that nearly doubled in just five years, according to the National Vital Statistics System.

Brazon’s message to those with prescriptions is simple: Take correctly, store securely, dispose properly and never share. Those are the simple practices that will save lives.

How close are we to combating the problem of prescription misuse and abuse?

“I mean we’re close enough to where it’s already happening,” Brazon said. “Individuals and families are changing their behaviors and their perception of medication. There again, we’re 10 years behind in doing this, at least. We’re talking about a whole generation that has had easy access and consequences to the misuse and abuse of prescription medication.

“We’re gaining ground on the behavior surrounding medication; we have a lot of ground to gain on those getting into treatment and recovery.”


Sam Hickman is a staff writer for the Beacon. Reach him at 754-6890 or shickman@brunswickbeacon.com