The street value of a prescription drug is dependent on whether it is a brand or generic. Even abusers know that they get what they pay for when buying a brandname drug. Drugs that have a quick onset - immediate-release or injectable drugs -are more sought after, as well as those that have a greater intensity. The demand for drugs with a short duration of action is consistent with the rate hypothesis of reinforcement - the faster the drug enters the system, the quicker it causes the dopamine surge in the nucleus accumbens, which is associated with euphoria. Street value also depends on whether the product can be injected or snorted successfully.
Prescription drug abuse occurs because the controlled substances that work effectively for patients with legitimate need are commonly prescribed. As controlled substances are prescribed more often, their availability increases. As a result, opportunities for diversion increase because more people have access to the drug for abuse or diversion, either directly or indirectly because a family member is receiving it legitimately. An example was a woman who admitted under oath to giving M
& Ms® candy in place of pain medication to her grandmother who was dying of cancer, so that she could divert and abuse the pain medication.
There is a perception that abusing pharmaceutical drugs is safer than abusing street drugs. A pharmaceutical drug is easily identified (determined by the indicia on the pill), it is pure, and there is less risk of contracting HIV or hepatitis if not injecting and sharing needles. However, the risk of sexually transmitted disease may remain unchanged if a drug abuser with impaired judgment has sex with other abusers who are sharing needles.
There is often a correlation between the currently popular illicit drugs of abuse and the type of prescription drugs sought by diverters. Heroin is often interchanged with prescription opioids; benzodiazepines are used to soften the crash from cocaine withdrawal; methamphetamines are substituted with amphetamines; and cariso-prodol is reported to enhance the "high" of hydrocodone. In addition, there is a population that abuses only prescription drugs, as well as a population that primarily abuses illicit drugs, and a population that migrates from one to the other.
Another perception, particularly among the young, is that a prescription drug is safer because "it's just a prescription drug": "If my 80-year-old grandmother takes them, how bad can they be?" They don't realize that the grandmother, who has pain, has built up tolerance to the respiratory depressant effects of the medication over time. Healthy 18-year-olds who abuse their grandmother's pain medication are taking a big risk - they do not have the same pain condition and their bodies are not adapted to the presence of that drug.
There is also the issue of low or no acquisition cost for prescription drugs. For example, Workers' Compensation, the VA Health System, and Indian Health Services usually have zero acquisition costs; Medicaid has a small co-pay; and private insurance companies may have a small or no co-pay. This may motivate some individuals to profitably sell all or part of their medication.
Drug abusing individuals frequently develop medical sequelae of that behavior. Smoking or snorting cocaine and other drugs can cause respiratory problems, atrophy of the nasal mucosa, and perforation of the nasal septum . On the other hand, needle marks may be present on the skin from recent injections, or "tracks" may be present over veins from repeated injections. Injection is not always confined to the obvious sites. Many users will inject into the axilla, under the tongue, under the breast, in the legs, and even into the dorsal vein of the penis . Many heroin addicts begin with subcutaneous injections ("skin popping") and may return to this mode when extensive scarring makes their veins inaccessible (Figure V-4). As addicts become more desperate, cutaneous ulcers may be found in unlikely sites .
How can the medical practitioner protect himself from diversion? By being a good practitioner. Protecting yourself from diversion boils down to two basic tenets: be a
Hypo- J pigmentation
Figure V-4. Fresh, intermediate and old skin-popping scars resulting from subcutaneous injection of drugs careful, thoughtful practitioner, and document, document, document! Investigators accept that even the best practitioners are going to be fooled once in a while, but you don't want to be fooled routinely. You do want to be cautious because you want to protect your ability to serve your community and those patients in need.
Obtain a history and perform a physical examination that is appropriate to the complaint and do document all findings !!! Look for signs of drug abuse because some diverters are also abusers. They resort to diversion in order to feed their habit. Signs of drug abuse include inflamed nares and a perforated septum in individuals without a history of significant facial trauma. Tracks - multiple, linear, and often hyperpigmented scars - can be found over the arms, wrists, axillae, neck, groin, between the toes, on the breasts, and the dorsal vein of the penis.
When abusers run out of veins, they will resort to "skin popping," which is the subcutaneous injection of drugs. Skin-popping scars are irregular or round and look like small-pox vaccination scars, except they are multiple and not found where expected over the deltoid muscle. Skin-popping scars can be found all over the body and are a common cause of abscesses. In 1999, skin abscesses due to skin-popping heroin were the number one admitting diagnosis at San Francisco General Hospital's emergency department, for which the hospital provided more than $18 million in un-reimbursed medical care. The typical progress of drug abuse is from snorting or smoking, to intravenous injection, followed by skin-popping when no access to veins remains.
Signs and symptoms to look for in order to detect a past or a present abusive behavior.
1. Inflamed, ulcerated, or perforated nasal septum (Figure V-5).
2. Continual sniffing
3. Needle tracks along venous access sites (Figure V-6)
4. Poor venous access
5. Multiple small skin ulcerations
6. Subcutaneous use - "skin popping" (Figure V-4)
7. The typical "pin-point" pupil (Figure V-7)
Figure V-5. Looking into the left nares one can see the left turbinate, as expected, and also the right turbinate, which you should not be able to see because a wall - the septum - should be present. Instead there is a healed hole. One can also see some ulceration present
Old track marks
Needle tracks on external, jugular
Figure V-6. Needle tracks at accessible veins are typical for the injection of illicit drugs
Figure V-7. A jaundiced eye with a small pupil is suggestive of hepatitis C resulting from intravenous drug abuse. Constricted pupils are a characteristic of opioid use. The photograph was taken in normal light, so the small pupil is not an artifact of flash photography
Such a perforated septum may be the result of piercing, trauma, or repeated snorting of cocaine, which is both vasoconstrictive and locally irritating to the nasal mucosa.
In addition, injecting drug users are at risk for infective endocarditis and valvular murmurs .
Alcohol or drug addiction problems often lead to a disturbance of lifestyle in which adequate nourishment is neglected. Absorption and metabolism of nutrients are also impaired. Drug addicts are often emaciated . Cocaine causes intense coronary arterial spasm and users may present with cocaine-induced angina or MI .
Inconsistent information provided by the patient, a history of substance abuse, past or present participation in detoxification or other treatment programs (AA, NA), history of adverse consequences related to substance abuse, including legal issues, and a family history of substance abuse are all red flags for problematic substance abuse [42, 9, 36]. The physician should be sensitized in case of:
1. Inconsistent information provided
2. History of substance abuse
3. Past or present participation in treatment programs (AA, NA)
4. History of adverse consequences related to substance abuse, including legal issues
A history of problems with employers, family, or school, such as frequent change of jobs for no apparent reason or unexplained financial problems, may be indicative of impulsivity, and can be the result of substance abuse . Some patients' manipulativeness can be detected by observation. For example, when a physician has the impression that his or her responses are being intensely studied by the patients. Patients with pseudologica fantastica or Munchhausen's syndrome, or those who are adept at deceit, can be persuasive to a degree that is unusual in comparison to ordinary clinical encounters. When the interaction with the patient creates unease or discomfort for the physician, suspicion that a manipulator may be present is justified .
In summation, aberrant drug related features characterize behaviors, which are more likely to be predictive. Adapted from :
• Prescription forgery
• Concurrent abuse of related illicit drugs
• Repeated prescription losses
• Selling prescription drugs
• Multiple unsanctioned dose escalations
• Stealing or borrowing another patient's drugs
• Injecting oral formulations
• Obtaining prescription drugs from non-medical sources
• Concurrent abuse of alcohol and illicit drugs
• Repeated episodes of prescription "loss"
However, there are aberrant drug related behaviors, which are less predictive. Adapted from :
• Drug hoarding during periods of reduced symptoms
• Acquisition of similar drugs from other medical sources
• Aggressive complaining about the need for higher doses
• Unapproved use of the drug to treat another symptom
• Unsanctioned dose escalation one or two times
• Reporting psychic effects not intended by the clinician
• Requesting specific drugs
Also, when prescribing drugs with abuse liability, for his own safety the physician should observe the following:
1. Set clear rules and expectations for the patient; have them sign an agreement.
2. Begin the dose of medication at the appropriate level to treat the condition and titrate as necessary; get feedback from the patient.
4. Give sufficient medication to last between appointments, plus rescue doses.
5. Ask the patient to bring any remaining drugs to the next meeting in original bottles - provides information on pharmacies used, alterations of prescription, other prescribing physicians, and patterns of use.
6. Monitor for lost or stolen prescriptions.
7. Obtain random UDS (urine drug screens); know what drugs laboratory screens actually identify.
8. Use adjunctive medications as necessary.
9. Document your decision-making process.
10. Evaluate the patient at appropriate intervals.
11. Involve significant others in treatment plan.
12. Know how to safely discontinue medications.
13. Know the pharmacology of the drugs used.
When interpretating aberrant drug-related behavior, realize that none are pathog-nomonic, and could indicate
3. Psychiatric diagnosis, with a. Depression b. Personality disorder c. Anxiety d. Mild encephalopathy e. Social stressors
4. Other medical diagnosis
5. Inadequate instruction by healthcare provider
6. Non-restorative sleep
7. Criminal activity
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