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Closing the loop on youth prescription drug abuse

by Joseph Lee, M.D., child and adolescent psychiatrist/adolescent addiction specialist at Hazelden

Joseph Lee, M.D., child and adolescent psychiatrist/adolescent addiction specialist at HazeldenThink twice before storing your medications haphazardly in your medicine cabinet.  Home is the most likely place where teens can obtain access to addictive prescription medications.

I did an interview for a newspaper recently about the increase in the number of young people needing residential treatment for opiate dependence, particularly regarding heroin.  I surmised that opiate dependence was rather difficult to treat in young persons, and that the surge in admissions possibly signaled the subpopulation's response or lack thereof to lower levels of outpatient care. 
Of course, when you think of a teenager's choice of substances, heroin doesn't seem as though it should be at the top of the list.  And statistically, this is correct.  The number of heroin users between the ages of 12 to 25 pales in comparison to the number for marijuana or alcohol.  Monitoring the Future reports that 32.8% of 12th graders used marijuana in the past year, as opposed to 0.7% for heroin. 
So how does heroin relate to the topic of prescription drug abuse?  Heroin is relevant because it is a probable endpoint for opiate dependence.Though a gateway drug hypothesis may not hold water from a neurochemical viewpoint, there is something to be said for the progression of a teenager’s indiscretions. What the statistics can’t flesh out is the evolution of the same young person struggling with addiction over the years.  

I can't tell you the number of times an addicted teenager in residential care has told me about accessing their relatives' prescription drugs for the first time.  Or how they successfully "doctor shopped" and faked symptoms in order to receive their drug of choice.  Or how their initial use of prescription medications went unchecked for ADHD, or wisdom teeth surgery, or a sports injury.
Soon the stories of the young adults at Hazelden's treatment facility in Plymouth, Minn. begin to merge and take shape.  Many of them tell of a lack of supervision, general misinformation, and the inability of the medical community to address a systematic dysfunction.  It is an unwavering reality we see before us on a daily basis.
Prescription drugs of abuse

There are a number of prescription medications that can be abused.  Pain medications, stimulants for ADHD, and benzodiazepines are just a few.  Ten percent of twelfth graders reported abusing vicodin, a pain medication, over the past year.  Another five percent abused Oxycontin, five percent abused Adderall, and the list goes on. 
Did you know that outside of marijuana, teenagers abuse prescription medications more than any other illegal substance?  This information isn't new and has remained consistent for at least a decade.  Looking at prescription drug abuse nationally, the data suggests that the prevalence of teenagers abusing prescription drugs has stayed relatively the same over the past couple of years.  But other information suggests the trend may be getting worse.
For example, the incidences of accidental poisonings (overdose) from prescription drugs have skyrocketed since the early 2000s.  To be fair, this statistic includes anyone over the age of 15, but it is alarming nevertheless. A recent rash of celebrity overdoses may confirm the attitude of some young people who believe prescription "medicines" are safer to abuse than illicit substances.
So what can be done?  Curbing the prescription drug problem for the youth in this country will take a concerted effort by clinicians, teachers, parents, and relatives. 
Seven ways we can turn the problem around

  1. Health care clinicians need to communicate with each other about patient care.
    Thirty-four states have some type of operational monitoring system for prescription drugs with varying levels of implementation.  On the ground level, however, communication between clinicians is often lacking.  If your teenager has multiple health care providers, insist on consistent correspondence between all clinicians involved.  I know of someone who was diagnosed with a serious but treatable medical condition.  Pain was a hallmark of the disease, as were frequent visits to a slew of specialists.  None of the specialists communicated with one another, and each asked him if he wanted more opiates.  Within two days, he had prescriptions for over 200 pills!  A variety of minimal efforts could have prevented this. Fortunately, this person was quite conscientious, but others in similar situations have been far more "entrepreneurial."

  2. Clinicians need to educate themselves about addiction.
    Many physicians come in contact with addicted patients frequently (through primary care, pain clinics, surgical clinics, etc.) but are not equipped to recognize or triage properly.  Physicians are often trained to flag patients who ask for unusually high dosages or quantities of addictive medications, those who run out or lose prescriptions often, or those who look visibly impaired.  Given the sophistication of prescription drug abusers and relatively easy accessibility to the drugs, none of the warning flags above may be visible in young people.   If you have a strong family history of addiction, or are otherwise concerned, ask your clinician about his or her familiarity with chemical dependency.  If expertise is lacking, you can seek out another provider or supplement the provider with another resource such as an addiction counselor.

  3. Dispose of unused prescriptions.
    Most youth obtain prescription drugs from their family and loved ones.  Although parents are generally vigilant about where they keep prescription drugs in the home, this vigilance needs to extend to other family members the teenager may visit. Securing access to medications in the home is one thing, but we don't often think about disposing of our prescription drugs safely. Certain medications, including many addictive substances, can be disposed via flushing down the toilet.  If you are concerned about medications in the water, most local governments offer a prescription disposal program.  Most medications can be thrown away if placed in a sealed container along with some absorptive material such as cat litter.

  4. Know who dispenses the medications.  
    If your teen has been prescribed a medication that is potentially addictive, make sure that responsible individuals dispense it.  That usually means parents or schools.  This is especially true for stimulant medications which are used to treat ADHD.  Some teens may try to obtain your child's prescription drugs.  Given the street value of certain medications and adolescent relationship dynamics, it's best to dispense only the necessary dosage. 

  5. Ask questions if your child abuses a medication.
    If you discover that your teen has abused prescription medication, ask more questions.  A National Survey on Drug Use and Health Report from 2008 showed that youth who abused stimulant medications were more likely to abuse other illicit substances, more likely to be depressed, and more likely to engage in delinquent behaviors. Do not dismiss experimentation as harmless.  Many teens who take a prescription medication for nonmedical purposes will not develop and addiction, but you have more than a right to ask some follow up questions.  Why did they take it?  Are there other issues you need to be concerned about?  Some teens may use abuse prescription medication to cram for a test, others may snort medications for a high.  Girls may experiment with stimulants to lose weight.  Parents should also inquire about a teenager's friends and their potential access to prescription medications.

  6. Don't overreact.
    The fact is that most young people who are prescribed medications do not abuse them.  Some parents take an "anti medication" stance in order to avoid the potential of prescription drug abuse.  Depending on the teenager's clinical needs, however, this may do more harm than good.  Unfortunately, there are no black and white solutions here.

  7. Talk to your teens. 
    Though adolescents often prize luxuries like privacy and autonomy, these virtues cannot be sustained without a safe foundation and certain parameters.  Make your values and guidelines clear when it comes to the use of drugs.

May 2010

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