Prescription drug abuse and pharmaceutical diversion continues to be a significant problem throughout Ohio . Prescription drugs are readily obtained illegally in most areas of Ohio . Some of the brand names of commonly diverted prescription drugs include Oxycontin ® , Vicodin ® , Percocet ® , Tylenol with Codeine No. 3, Valium ® , and Xanax ® . Oxycontin ® is particularly popular in southern Ohio where authorities believe it's been responsible for at least 15 deaths since 1999. Since this April, Cincinnati Drug and Poison Information Center has received over 180 calls related to the release of generic Oxycontin ® 80mg tablets.
Many young people mistakenly believe abusing prescription medications is not as dangerous as abusing “illegal drugs.” In truth, whether our children are getting these medications from a drug dealer, a classmate, or a family member's medicine cabinet, the consequences of misusing and abusing prescription medications may be life threatening.
The escalating availability and accessibility of prescription drugs and their subsequent use has prompted this alert.
Dangerous and addictive prescription drugs like Percocet ® , OxyContin ® , Valium ® , Xanax ® , and Ritalin ® are easy to obtain over the Internet. Anyone, including children can easily obtain highly addictive controlled substances online WITHOUT a prescription. All they need is a credit card. There are no mechanisms to block children from purchasing these drugs. The National Center on Addiction and Substance Abuse (CASA) has been engaged in an unprecedented national study of the diversion and abuse of controlled prescription drugs. They became concerned with the availability of prescription drugs on the Internet. They conducted an Internet search during a one-week period, and their findings were so alarming, they considered it their obligation to release this information prior to the completion of the study, in order to alert parents, teachers, and other caregivers of this immediate threat to our children and teenagers.
Many parents, educators, and other professionals, are unaware of the prescription drug threat to our children's safety and to their very lives. Clearly, there is a need to educate those involved in the lives of young people, and young people themselves, about the growing problems of prescription drug abuse, and the use of the Internet to obtain them.
Last year retail drug sales worldwide were $317 billion. In the United States alone, consumers spent $163 billion on drugs. The Centers for Disease Control and Prevention reported that 10 million children took prescription medication for three months or longer in 2002, and preschoolers, another study found, are now the fastest growing group of children receiving antidepressants. According to the DEA, the abuse of prescription drugs represents close to 30% of the overall drug problem in the United States , second only to cocaine.
Data from the 2002 National Survey on Drug Use and Health show the second most popular category of drug use among juveniles, after marijuana, is the non-medical use of prescription drugs. An estimated 6.2 million people, 2.6 percent of the population aged 12 or older are misusing prescription drugs. Of these, an estimated 4.4 million used narcotic pain relievers, 1.8 million used anti-anxiety medications (also known as tranquilizers), 1.2 million used stimulants and four hundred thousand used sedatives. The survey estimates that 1.9 million persons aged 12 or older used OxyContin non-medically at least once in their lifetimes. The most dramatic increases in new non-medical use of prescription drugs that act on the brain were among 12- to 17- and 18- to 25-year-olds.
Controlled Substances Act
The Controlled Substances Act (CSA), Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, is the legal foundation of the government's fight against the abuse of drugs and other substances. This law is a consolidation of numerous laws regulating the manufacture and distribution of narcotics, stimulants, depressants, hallucinogens, anabolic steroids, and chemicals used in the illicit production of controlled substances.
The CSA places all substances that are regulated under existing federal law into one of five schedules. This placement is based upon the substance's medicinal value, harmfulness, and potential for abuse or addiction. Schedule I is reserved for the most dangerous drugs that have no recognized medical use, while ScheduleV is the classification used for the least dangerous drugs. The act also provides a mechanism for substances to be controlled, added to a schedule, decontrolled, removed from control, rescheduled, or transferred from one schedule to another.
Schedule I:
- Drug has high potential for abuse.
- No current accepted medical use in treatment in the U.S.
- There is lack of accepted safety for use of drug.
- Example: Heroin, LSD, Marijuana, GHB, and Ecstasy.
Schedule II:
- Drug has high potential for abuse.
- Has a currently accepted medical use in treatment in the U.S.
- Abuse may lead to severe psychological or physical dependence.
- Example: Morphine, Oxycodone, Cocaine, Demerol, and Methamphetamine.
Schedule III:
- Has less potential for abuse than drugs in schedule I and II.
- Has a currently accepted medical use in treatment in the U.S.
- Abuse may lead to moderate or low physical dependence or high psychological dependence.
- Example: Hydrocodone, Codeine, Anabolic steroids, some Barbiturates.
Schedule IV:
- Drug has low potential for abuse.
- Has a currently accepted medical use in treatment in the U.S.
- Abuse may lead to limited psychological or physical dependence.
- Example: Diazepam, Alprazelam, Propoxyphene, and Clonazepam.
Schedule V:
- Drug has low potential for abuse.
- Has a currently accepted medical use in treatment in the U.S.
- Abuse may lead to limited psychological or physical dependence.
- Example: Over-the-Counter cough medicine with codeine.
What are opioids and what are the potential consequences of their use and abuse?
Drugs classified as opioids include morphine, codeine, and related drugs such as oxycodone (OxyContin ® , Percocet ® ), hydrocodone (Vicodin ® ), and meperidine (Demerol ® ). These drugs are commonly prescribed for pain management. Opioids can produce drowsiness with therapeutic doses and may depress respiration in higher doses. Opioid drugs also can cause euphoria, which may contribute to abuse of these drugs. Taken as prescribed, opioids can be used to manage pain effectively without untoward side effects. Chronic use of opioids can result in tolerance, which means that users must take higher doses to achieve the same effects. Long-term use also can lead to physical dependence and addiction; withdrawal can occur when an individual discontinues use of the drugs. Withdrawal symptoms may include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps, and involuntary leg movements. Individuals who are addicted to opioids are more likely to overdose on the drugs, which could be fatal.
What are Central Nervous System (CNS) Depressants and what are the potential consequences of their use and abuse?
Central nervous system (CNS) depressants include any agent that can slow down the nervous system function and cause drowsiness, decreased breathing or heart rate, and slow reflex times down significantly. Among the most commonly prescribed CNS depressants are barbiturates , such as Butalbital (Fioricet ® , Fiorinal ® ) and Phenobarbital, which are prescribed to treat anxiety, tension, and sleep disorders; and benzodiazepines , such as diazepam (Valium ® ) and alprazolam (Xanax ® ), which typically are prescribed to treat anxiety, acute stress reactions, and panic attacks. Other benzodiazepines, such as clonazepam (Klonopin ® ) and lorazepam (Ativan ® ), are prescribed for short-term treatment of sleep disorders.
Although the various classes of CNS depressants work differently, they all produce a beneficial drowsy or calming effect in individuals suffering from sleep disorders or anxiety. If these drugs are used over a long period of time, the body develops tolerance, and larger doses are needed to achieve the initial effects. Continued use leads to physical dependence. When use is reduced or stopped, withdrawal can occur. Symptoms of withdrawal include: restlessness, loss of appetite, anxiety, nausea, blurred vision, muscle pain and convulsions. Both barbiturates and benzodiazepines have the potential for abuse and should be used only as prescribed. As with opioids, overdose of these drugs can be fatal.
What are Stimulants and what are the potential consequences of their use and abuse?
Stimulants enhance brain activity, increasing alertness, attention, and energy, raising blood pressure, and elevating heart rate and respiration. Stimulants such as methylphenidate (Ritalin ® ) and dextroamphetamine (Dexedrine ® ) are prescribed for the treatment of narcolepsy, attention-deficit/hyperactivity disorder, and depression that has not responded to other treatments. They also may be used for short-term treatment of obesity. Individuals may become addicted to the sense of well being and enhanced
energy that stimulants can generate. Taking high doses of stimulants repeatedly over a short time, however, can lead to feelings of hostility or paranoia. Additionally, taking high doses of stimulants may result in dangerously high body temperatures and an irregular heartbeat. Click here to view chart...
Abuse of Over-the-Counter Cough and Cold Medication:
Some young people are abusing over-the-counter medicines containing dextromethorphan (DXM). DXM is a safe and effective cough suppressant ingredient found in over-the-counter (OTC) cough medicines. When used according to directions, products containing DXM produce few side effects and have a long history of safety and effectiveness. Some teens are attempting to get high by taking much larger than recommended doses of DXM in the form of OTC cough syrup, tablets and gel caps. In these high doses, DXM can produce hallucinogenic and dissociative effects. Dissociative effects include distorted perceptions of sight and sound as well as feelings of detachment or separation from the environment and self. The effects of DXM abuse vary with the amount taken. DXM abusers describe a set of distinct “ plateaus ” ranging from a mild stimulant effect or excitement with distorted visual perceptions to a sense of complete dissociation from one ' s body.
Physical signs of abuse can include nausea, vomiting, diarrhea, abdominal pain, confusion, poor coordination, rapid heart rate and dizziness. At very high doses, DXM can cause inability to move arms or legs or to talk, slowed breathing and even death (from stopped breathing). DXM is also sometimes abused with other drugs or alcohol, which can increase the dangerous physiological effects. There are over 100 different products that contain DXM (not including generic brands). Most cough remedies contain DXM since the ingredient dextromethorphan safely and effectively suppresses coughs brought on by the common cold or flu. DXM works by raising the coughing threshold in the brain.
Products that contain DXM come in several forms -- liquid, tablets, and gelcaps. Some common brand names include: Alka-Seltzer Plus Cold & Cough Medicine, Comtrex Multi-Symptom Cold, Coricidin Cough & Cold Tablets, Dimetapp DM, Robitussin cough products, Sudafed cough products, Triaminic cough syrups, Tylenol Cold products, Vicks 44 Cough and Vicks NyQuil LiquiCaps.
A number of web sites promote the abuse of DXM. The information on these sites ranges from recommending how much to take, suggesting other drugs to combine with DXM, instructing how to extract DXM from cough medicines, and even selling a powder form of DXM for snorting. Other sites display art, movies and music produced by people promoting DXM and other forms of drug abuse. You should be aware of what your teen is doing on the Internet, the web sites he or she visits and the amount of time he or she is logged on.
What is Pharmaceutical Diversion?
Diversion is the removal of a drug from the intended route from manufacturer to Pharmacy to patient. The purpose is to resell the drug to a different market that will use the drug for abuse purposes, or to be used directly by the abuser.
Why Pharmaceuticals are Diverted:
- Less risk of overdose. (Known dosage)
- Easier to obtain. (Through “legal” prescription, Internet, theft, etc.)
- Cheaper than cocaine and heroin. (Paid by insurance)
- Less risk of detection. (Lack of enforcement)
- Not viewed as “serious” or as “dangerous” as other illicit drugs.
- Profitable business. (Easy money)
How Pharmaceuticals are Diverted:
The diversion for pharmaceuticals and prescription drugs range from the simple scam, to complex and organized operations. Below are samples of typical diversion scams, and are limited only by the creativity of the abuser.
The abuser visits several doctors in a short span of time, and deceives them by denying seeing any other doctor, or receiving any prescriptions from them. Uses drugs for themselves, or can “Wholesale” some on the street.
The abuser visits several emergency rooms, sometimes in the same day, and seeks narcotics for an alleged injury. Gives false information to the doctor in order to obtain pills.
- Phony Prescription Call- In:
The abuser or an accomplice calls in a prescription to a pharmacy, acting as a nurse or other office worker. They will then pick up the prescription. They will give a different phone number other than the doctors' office for the call back, or if they are employed in the office, will give their direct line.
- Prescription Forgery / Alteration:
The abuser will forge or alter a prescription by either creating a prescription on the computer, photocopying, using white out, or nail polish remover. Forging or altering a prescription is a felony in Ohio . This includes changing the dose, refills, or strength of the medication.
Theft and robbery of pharmaceuticals from individuals and pharmacies. Pharmacy robbed for controlled substances. Most of the time demands certain drug. Also break in after hours. This is a Federal offense. Abuser may also just walk out of pharmacy with out paying for the prescription.
- Doctor's office or Phone Service scam:
The abuser, or accomplice actually works for the doctor, or his answering service and either calls in a phony prescription, or approves it if the pharmacy calls to verify the prescription. A phone service scam involves someone working for the service that knows which doctors will not, or do not return calls from the answering service. They then know which doctors name to use on the phony prescriptions.
Diversion by Health Care Professionals:
- Theft (Take from patient drawer, or falsify drug wastage)
- Substitution (substitute the controlled drug for a non-controlled drug)
- Alteration (dilute drug after taking some or all of the controlled substance out)
- Falsification of drug documents (not recording or intentionally incorrectly recording drug transaction, falsifying doctors orders.)
- Doctor intentionally writing an illegal prescription for himself, or another.
Other Deceptive Criminal Activity :
- In-home workers (carpet layers, cleaners, plumbers, etc.)
- Realty open house scam (go to open house and check cabinets for drugs.)
- In-home health care providers, service personnel.
- Parties
Internet Pharmacies:
Prescription drugs are easy to obtain over the Internet. Anyone, including children can obtain highly addictive controlled substances online WITHOUT a prescription. All they need is a credit card. There are no mechanisms to block children from purchasing these drugs. The National Center on Addiction and Substance Abuse (CASA) conducted an Internet search during a one-week period, with the assistance of Beau Dietl & Associates, and their findings were so alarming, both considered it their obligation to release this information prior to the completion of the study, in order to alert parents, teachers, and other caregivers of this immediate threat to our children and teenagers. 495 web sites were identified as selling schedule II-V controlled drugs, 68% were portal sites , which act as a conduit to other sites selling the drugs, and 32% were anchor sites , where the drug is sold directly from the site. Of the anchor sites selling the drugs (157), 90% did not require a prescription. 47 % stated the drugs would be coming from outside the United States, 28% stated the drugs would come from within the United States, and 25% did not indicate where the drugs would come from.
The licensing and regulation of pharmacist and clinicians have traditionally taken place at the state level. Internet pharmacies, however, transcends state laws making it difficult not only to identify online pharmacies, but also to take action against those engaged in illegal practices. To date, federal law and regulatory practice have not caught up with Internet technology, and no new legislation has been enacted. This lack of control threatens the health and safety of millions of Americans, including our children.
Counterfeit drugs that may not contain the exact amount, or type of drug portrayed are also an issue. Someone ordering drugs from the Internet may not be receiving the same dosage as the medication they receive from a regular pharmacy. This could have deadly results. These drugs may look the same, but may not be formulated exactly the same.
Verified Internet Pharmacy Practice Sites (VIPPS):
The National Association of Boards of Pharmacy (NABP) was established to assist state licensing boards in developing, implementing, and enforcing uniform standards to protect the public health. Pharmacy boards from 50 states, the District of Columbia , three U.S. territories, nine Canadian provinces, and four Australian states make up the association membership.
In response to public concern of the safety of pharmacy practices on the Internet, the association developed the Verified Internet Pharmacy Practice Sites ( VIPPS ) program in the spring of 1999. A coalition of state and federal regulatory associations, professional associations, and consumer advocacy groups provided their expertise in developing the criteria that VIPPS-certified pharmacies follow.
To be VIPPS certified, a pharmacy must comply with the licensing and inspection requirements of their state and each state to which they dispense pharmaceuticals. In addition, pharmacies displaying the VIPPS seal have demonstrated to NABP compliance with VIPPS criteria including patient rights to privacy, authentication and security of prescription orders, adherence to a recognized quality assurance policy, and provision of meaningful consultation between patients and pharmacists.
A recent search on the Internet identified only (14) sites of pharmacies that were VIPPS certified.
Warning Signs of Drug Abuse:
Most drug users are usually pretty secretive about their dependency. Watch your child or friend for any of the following signs:
- Person avoids you.
- Grades start to drop.
- Less time spent on schoolwork, more time hanging out with friends.
- Lies about drug use, or amount of drugs they use.
- Stops doing things that used to be a big part of their life (sports, homework, or hanging out with friends who don't do drugs).
- Plans drinking or drug use in advance, hides drugs, and uses them when alone.
- Doesn't think they can have fun unless drunk or stoned.
- They have a lot of hangovers.
- Seems withdrawn, depressed, tired, and cares less about personal grooming and physical appearance.
- Eating and sleeping patterns have changed; rapid loss of weight.
- Having difficulty concentrating.
- Red-rimmed eyes or runny nose not related to cold or allergies.
- Pressures other people to drink or use other drugs.
- Has "blackouts" and forgets what they did while under the influence.
- Feels run-down, hopeless, depressed, or even suicidal.
- Sounds selfish and doesn't care about others.
- Constantly talks about drinking or using other drugs.
- Gets in trouble with the police.
- Gets suspended from school for drug-related problems.
Addiction Treatment:
Prescription drugs can be just as addictive as cocaine or heroin. Years of research have shown that addiction to any drug, illicit or prescribed, is a brain disease that can, like other chronic diseases, be effectively treated. But no single type of treatment is appropriate for all individuals addicted to prescription drugs. Treatment must take into account the type of drug used and the needs of the individual. To be successful, treatment may need to incorporate several components, such as counseling in conjunction with a prescribed medication, and multiple courses of treatment may be needed for the patient to make a full recovery. The two main categories of drug addiction treatment are behavioral and pharmacological . Although a behavioral or pharmacological approach alone may be
effective for treating drug addiction; research shows that a combination of both, when available, is most effective.
Behavioral Treatment:
Behavioral treatments teach people how to function without drugs, how to handle cravings, how to avoid drugs and situations that could lead to drug use, how to prevent relapse, and how to handle relapse should it occur. When delivered effectively, behavioral treatments - such as individual counseling, group or family counseling, contingency management, and cognitive-behavioral therapies - also can help patients improve their personal relationships and ability to function at work and in the community.
Pharmacological Treatment:
Some addictions, such as opioid addiction, can also be treated with medications. These pharmacological treatments counter the effects of the drug on the brain and behavior. Medications also can be used to relieve the symptoms of withdrawal, to treat an overdose, or to help overcome drug cravings.
Treating Addiction to Prescription Opioids :
Several options are available for effectively treating addiction to prescription opioids. These options are drawn from experience and research regarding the treatment of heroin addiction. They include medications, such as methadone, Buprenorphine, Naloxone, and LAAM (levo-alpha-acetyl-methadol), and behavioral counseling approaches. A useful precursor to long-term treatment of opioid addiction is detoxification. Methadone is a synthetic opioid that blocks the effects of heroin and other opioids, eliminates withdrawal symptoms, and relieves drug craving. It has been used successfully for more than 30 years to treat people addicted to opioids.
Treating Addiction to CNS Depressants:
Patients addicted to barbiturates and benzodiazepines should not attempt to stop taking them on their own, as withdrawal from these drugs can be problematic, and in the case of certain CNS depressants, potentially life threatening. Although no extensive body of research regarding the treatment of barbiturate and benzodiazepine addiction exists, patients addicted to these medications should undergo medically supervised detoxification because the dose must be gradually tapered off. Inpatient or outpatient counseling can help the individual during this process. Cognitive-behavioral therapy also has been used successfully to help individuals adapt to the removal from benzodiazepines.
Treating Addiction to Prescription Stimulants:
Treatment of addiction to prescription stimulants, such as Ritalin, is often based on behavioral therapies proven effective for treating cocaine or methamphetamine addiction. At this time, there are no proven medications for the treatment of stimulant addiction. However, antidepressants may help manage the symptoms of depression that can accompany the early days of abstinence from stimulants. Depending on the patient's situation, the first steps in treating prescription stimulant addiction may be tapering off the drug's dose and attempting to treat withdrawal symptoms. The detoxification
process could then be followed by one of many behavioral therapies. Contingency management, for example, uses a system that enables patients to earn vouchers for drug-free urine tests. The vouchers can be exchanged for items that promote healthy living. Another behavioral approach is cognitive-behavioral intervention, which focuses on modifying the patient's thinking, expectations, and behaviors while at the same time increasing skills for coping with various life stressors. Recovery support groups may also be effective in conjunction with behavioral therapy.
Prevention Strategies:
Health care providers, pharmacists, nurses, parents, other caregivers, and teachers, play a vital role in preventing and detecting prescription drug abuse. Become aware of diversion tactics, and suspicious activity. Monitor patient /children activity. Review records. Parents keep drugs locked up and out of reach of children. Educate them to respect drugs and chemicals and their effects. Some poison centers have reported the particularly dangerous party activity called “salad bowl” or “bowls” where adolescents divert from medicine cabinets and combine at a party thinking everything is either an upper or downer.
What is being done to help prevent the abuse of prescription drugs:
Manufacturers: Research and Development on ways to make drugs less abused (reformulating), Working with law enforcement and other agencies, Funding studies, promoting abuse awareness.
Law Enforcement : Work with pharmacists, doctors and other health professionals to increase awareness of abused prescription drugs. Increase enforcement of drug laws. Increase public awareness of prescription drug laws.
Health Care Professionals: Monitor patients drug use closely. Monitor and control drug dispensing and prescription pads. Educate health care workers on proper procedures and laws related to drug dispensing. Ensure proper documentation. Monitor staff.
Become aware of diversion tactics and activities. Have patient sign a “prescription drug contract”. Work with police.
Court System: Screens candidates for “Treatment in lieu of Conviction” Drug Court .
Identifies and differentiates between addiction vs. criminal intent. Enforces drug laws and prosecutes aggressively.
Family Members, and other Care Givers: Educate your children about the dangers of drug abuse. Get to know their friends. Monitor your child's behavior. Establish “Blame Free” communications. Become aware of warning signs of drug abuse. Keep drugs out of site and locked up.
First Aid Treatment:
Call your poison control center at 1-800-222-1222 for assistance in treating overdose victims, identifying medicines or information about adverse drug reactions, interactions, and or dosage.
References / Resources:
This warning is being sent to inform parents, prevention and treatment professionals, law enforcement and educators of this emerging trend. Please distribute this information through list serves, newsletters or bulletin boards, etc. using the Ohio Early Warning Network as your source.
For additional information on the above alert contact: The Ohio Resource Network for Safe and Drug Free Schools and Communities, P.O. Box 210109, 2624 Clifton Ave Cincinnati, Ohio 45221-0109 Phone # 1-800-788-7254 (opt#2) or fax# 1-513-556-0782.
To participate in this OEWN initiative, visit www.ebasedprevention.org and fill out the OEWN registration form. Anyone in Ohio can report an issue to the Ohio Early Warning Network by calling the toll-free non-emergency InfoLine at 1-866-OhioEWN.
This alert is brought to you by the Ohio Early Warning Network initiative sponsored by: the
Ohio Department of Alcohol and Drug Addictions Services, the Ohio Department of Education and the Ohio National Guard.
The information appearing on this alert is presented for educational purposes only. While the information published is believed to be accurate, it is not intended to substitute for your own informational gathering or professional medical advice.
