Misuse and abuse of noncontrolled drugs: It’s not just prescription opioids anymore

What pharmacists should be aware of and steps to take

With so much attention directed toward preventing and curtailing prescription opioid abuse, pharmacists should be careful not to miss the signs of misuse and abuse of noncontrolled medications as well, say experts at two state poison control centers. Case studies appearing in the literature note misuse and abuse of drugs ranging from prescription anticonvulsants, antidepressants, and second-generation antipsychotics to OTC antidiarrheals, antihistamines, and cough suppressants. Furthermore, data from the defunct Drug Abuse Warning Network noted sharp increases in emergency department visits owing to nonmedical use of noncontrolled substances between 2004 and 2011, including 82% for diphenhydramine, 78% for muscle relaxants, and 48% for psychiatric medications.

Yet pharmacists may be largely unaware of the issue because there’s a dearth of current large-scale data, according to Lisa Booze, PharmD, CSPI, clinical coordinator at Maryland Poison Center at University of Maryland School of Pharmacy in Baltimore.

“If a drug isn’t included in a drug monitoring program, we don’t have a lot of information about trends,” Booze said. I do pharmacy continuing education webinars, and many pharmacists comment that they have no idea these drugs are being abused.”

DEA’s distinction between “controlled” and “noncontrolled” substances also plays a role, said William Eggleston, PharmD, DABAT, clinical toxicologist and assistant professor at SUNY Upstate Medical University in Syracuse. “We equate controlled substances with abuse, so a lot of times if a substance is not controlled, we consider it not abusable. But it’s really that it’s less abusable. Certainly the potential for abuse is still there.”

Collateral damage

The war on prescription opioid abuse may have the unexpected adverse effect of prompting misuse and abuse of noncontrolled substances, Eggleston said, noting that those who grapple with withdrawal from prescription opioids may turn to medications like loperamide as a “poor man’s methadone.”

“We’ve seen a pretty impressive increase in the reported cases of abuse of loperamide in the last 5 years or so. As we crack down on prescription opioids to prevent addiction, we haven’t done enough to take care of the people who were already addicted,” Eggleston said.

Prescribing certain medications in lieu of controlled drugs—i.e., as a way of following CDC recommendations for limiting prescription opioids for pain management—may be another silent driver. Here, Eggleston points to gabapentin. “That’s one of the biggest [prescription drugs] we’ve seen being misused. Although some seek it out specifically, a lot of those who misuse gabapentin were originally prescribed it as an alternative to controlled substances.”

What pharmacists can do

Learning which noncontrolled medications have been frequently reported as misused and staying on the lookout for falsified prescriptions are easy first steps for pharmacists to take in detecting possible misuse and abuse of noncontrolled drugs. But getting to the heart of the matter requires pharmacists to build relationships with patients in their communities, Booze said.

“It’s hard for community pharmacists unless they know the person. Look for changes in behavior, early refills, or coming up with stories about why they need their drugs earlier,” Booze said. “If their record indicates a history of substance abuse, think of other ways of treating them other than these drugs.”

Pharmacists should be prepared to offer assistance if a patient could be misusing a noncontrolled substance, just as they would for patients who may be misusing controlled substances, Eggleston said.

“Bring up a discussion of services that are available and who they can contact if they are struggling with addiction. Far too often we feel it’s our job only to cut them off, but that’s not the best path for the patient. Work as an advocate.”

To read the full article, please visit www.pharmacytoday.org for the upcoming June 2017 issue of Pharmacy Today.