Prescription drug abuse has increased significantly in India due to overprescription of drugs like benzodiazepines without proper warnings, unlawful over-the-counter selling of prescription drugs, and legislation that lumps all drugs together. Commonly abused prescription drugs include opioids, CNS depressants, stimulants, and steroids. Doctors are uniquely positioned to screen for prescription drug abuse during routine exams and help patients receive treatment, which may involve behavioral therapies and medication to manage withdrawal symptoms and prevent relapse. Prevention requires vigilance about false prescriptions, educating pharmacists, and considering alternative means of dispensing potentially abusable drugs.

1. Prescription Drug Abuse
Dr Madhu Oswal
What is prescription drug abuse? It is the use of a prescription medication in a way not
intended by the prescribing doctor -the nonmedical use or abuse of prescription drugs.
Has the problem of prescription drug abuse increased, and if so, why? In 1999, the Ministry
of Social Justice and Empowerment, Government of India (MSJE, GOI) and the United Nations
International Drug Control Programme, Regional Office for South Asia (UNIDCP, ROSA)
decided to undertake a large-scale national survey to obtain information on extent, pattern and
magnitude of substance abuse in the country. Results show that nationally about 10 per cent of
drug abuse involves prescription drugs. We have a huge population that knowingly or
unknowingly is hooked on to prescription drugs. What’s the reason? First reason is the way in
which drugs like benzodiazepines are prescribed as anxiolytics or sedatives right and left without
giving patient enough warning about its dependence potential. Secondly, in India we have
rampant unlawful selling of these drugs without prescription. Thirdly it’s the very act which was
enacted to prevent this menace, is fuelling this problem. We in India have always had a tradition
of substances like ganja and charas which did not do any great harm. The Narcotic Drugs and
Psychotropic Substances Act (NDPS), 1985 put all of them at a par with hardcore drugs making
all drugs illegal and equally punishable. This led to a surge in heroin and increase in intravenous
drug use. During the late 1980s and early 1990s, the pharmaceutical buprenorphine became
popular and its availability in ampoule form made it injectable - this drug and mode of
administration became popular throughout most major cites of India and adjoining states. They're
cheaper too, at only Rs 20 per cocktail ampoule, compared to Rs 80-150 for the same amount of
heroin. The other main advantage of prescription drugs for addicts is their easy and lawful
availability. These are also difficult to detect. Even better, when caught-one just needs to feign a
cough or headache convincingly and explain the need for possessing that drug
Which are the commonly abused prescription drugs?

2. Opioids, which are most often prescribed to treat pain;
CNS depressants, which are used to treat anxiety and sleep disorders;
Stimulants, which are prescribed to treat the attention-deficit hyperactivity disorder
(ADHD) and obesity.
Steroids (Anabolic-Androgenic steroids) used to treat conditions resulting from steroid
hormone deficiency, such as delayed puberty, or to increase lean muscle mass esp. cancer
and AIDS.
Most of these drugs are schedule H drugs- that is these are to be sold only on prescription of a
registered medical practitioner. But there is rampant over the counter(OTC) sell of these drugs.
Opioids like morphine, codeine, and related drugs are commonly prescribed because of their
effective analgesic, anti-tussive and anti- diarrheal properties. Commercially available
preparations include propoxyphene (Darvocet), pentazocine (Fortwin) injections, fentanyl
(Duragesic), dextropropoxyphene (Proxyvon), dextromethorphan (Dexcof) buprenorphine
(Tidegesic), codeine (III/IV) and diphenoxylate (Lomotil). Cough syrups such as Corex and
Phensedyl have opiates, and antihistamines as well as alcohol. Opioid drugs cause euphoria by
affecting the brain regions that mediate what we perceive as pleasure and that’s the reason of it
being abused.
CNS depressants like benzodiazepines and barbiturates are the class of drugs most frequently
abused. Commonly used molecules are diazepam (Valium), chlordiazepoxide HCl (Librium),
alprazolam (Restyl), lorazopam (Larpoze), and nitrazepam (Nitrosun). Barbituarates are
available as phenobarbital( Gardinal). Benzodiazepines should not be taken for more than 2-3
weeks and then the drug should be tapered off gradually. But patients often easily acquire the
medicines without prescription or re-fill their prescriptions from a chemist. Also, they suffer
withdrawal symptoms when they try to reduce or stop the drugs and the withdrawal symptoms
are very similar to the illness for which they started the drug. So they again take the drug and in
progressively higher doses falling in a vicious cycle
Stimulants like dextroamphetamine (Dexedrine) and methylphenidate (Ritalin) are drugs causing
an increase in alertness, attention, and energy. Stimulants are prescribed for the treatment of only

3. a few health conditions like narcolepsy, attention-deficit hyperactivity disorder, and recalcitrant
or severe depression. Stimulants may be used as appetite suppressants for short-term treatment of
obesity.
Steroids (Anabolic-Androgenic) like nandrolone ( Durabolin), testosterone (Testoviron depot)
are demanded by patients or prescribed by doctors to enhance performance and/or improve
physical appearance. Patients on these drugs feel good about themselves but mood swings can
also occur, including manic-like symptoms that could lead to violence. Users may also suffer
from paranoid jealousy, irritability, delusions, and impaired judgment.
Who is at risk? Although prescription drug abuse can affect anyone, older adults, adolescents,
women and we medical professional, are at highest risk. Older adults are prescribed these drugs
for their ailments like osteoarthritis, insomnia, depression, etc. In women- without dealing with
the underlying cause of the problem, we doctors prescribe anti-anxiety drugs like diazepam
(Calmpose), alprazolam (Alprax), for their anxiety and depression. And in adolescent- use of
drugs can be an experimentation, occasional recreational drugs or may provide a way of coping
with the stress of modern world and its expectations. Others are abusers, popping a pill along
with alcohol or marijuana for an added "kick". Some see prescription drugs as back-up, to be
used when their main source like of addiction drugs heroin, Ecstasy are not available or
feasible. Unlike the pills, injected drug use is common among this age group and so they are at
risk of infections like HIV, hepatitis B and C, and other problems like cellulitis,
thrombophlebitis, endocarditis, septicaemia, etc. Also, health care professionals - including
physicians, nurses, pharmacists, dentists, anesthesiologists, and veterinarians are at increased
risk of prescription drug abuse because of easy availability with self-prescription. Overall, men
and women have roughly similar rates of abuse of prescription drugs, though young women are
more likely than young men to use benzodiazepines.

4. What is our role as doctors? We are in a unique position to identify prescription drug abuse,
help the patient recognize it and then manage the problem. Screening for any type of substance
abuse can be incorporated into routine history taking. Eg. ASSIST questionnaire developed by
WHO or Drug Abuse Screening Test (DAST). Discussing and motivating our neighboring
chemists about this issue with can play a key role in preventing prescription drug abuse, as these
are the places where the drugs are procured from. They should be vigilant about false or altered
prescriptions and should not unlawfully refill prescriptions. Other alternative could be dispensing
from our clinics the drugs that can be potentially abused, instead of prescribing them.
How to treat? The two main categories of drug addiction treatment are behavioral and
pharmacological. Brief interventional therapy takes not more than few minutes and has found to
be effective. The A-FRAMES model is the core structure of a brief intervention: Assessment,
providing objective Feedback, emphasizing that Responsibility for change belongs to the patient,
How to diagnose this disorder? We need to have a high level of clinical suspicion to diagnose
prescription drug abuse disorder in our busy practice. We should take notice if a patient demands
to increase the dose these prescribed drugs or comes frequently to us for refills before the
quantity prescribed should have been used. This may indicate the development of tolerance. We
should also be aware of “doctor shoppers” patients, those moving from doctor to doctor to get
multiple prescriptions for the drug they abuse. We can also diagnosis if we are aware of
withdrawal symptoms of these abused prescription drugs. Symptoms of opiate withdrawal
include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose
bumps ("cold turkey"), and involuntary leg movements. Taking a large single dose of an opoid
could cause severe respiratory depression and can also lead to death. Benzodiazepines in
withdrawal state cause sleeplessness, restlessness, tremors of the hand, slurring, irritability,
vomiting, sadness, altered appetite, and abnormal behavior, even delirium in extreme cases.
Although the use of stimulants may not lead to physical dependence and risk of withdrawal, they
can be addictive in that individuals begin to use them compulsively. Taking high doses of some
stimulants repeatedly over a short time can lead to feelings of hostility or paranoia. Withdrawal
symptoms of anabolic steroids include mood swings, fatigue, restlessness, loss of appetite,
insomnia, reduced sex drive, and depression, all of which may contribute to continued abuse.

5. giving clear Advice about the benefits of change, providing a Menu of options for treatment to
facilitate change, using Empathic listening, and emphasizing and encouraging Self-efficacy with
the patient.
Medications are used to relieve the symptoms of withdrawal, to treat an overdose, or to help
overcome drug cravings. For withdrawal symptoms of opioid, buprenorphine (Tidigesic) 1.2-4.0
mg or 6-12capsules of dextropropoxyphene (Proxyvon) are given initially and tapered off after
the third day. Usually, detoxification medicines are required for 2-3 weeks. Methadone
(60mg/day), or buprenorphine 4 mg and 8 mg /day) are used as maintainance therapy.
Naltrexone( Naltima) (antagonist) given three times a week(100mg on 1
t
and 3
rd
day and 150mg
on 5
h
day or 50mg/day), act as anti-craving agent for abstinence. In cases of mild to moderate
benzodiazepine dependence, an outpatient detoxification by tapering of the drug, with weekly
reduction in doses can be carried out. In patients with severe dependence, particularly with
dependence on short acting benzodiazepines, indoor detoxification is preferred. In indoor setting,
the drugs can be tapered off at a rate of 10% a day. In patients dependent on short or
intermediately acting benzodiazepine (oxazepam, alprazolam, etc), risk of withdrawal seizures
should be kept in mind and to prevent the seizures, detoxification is started with equivalent doses
of long acting benzodiazepines (diazepam, chlordiazepoxide ), which then should be tapered off as
usual. Usually, detoxification in indoor set-ting is over within 2 weeks. In cases where only
insomnia persists, non-benzodiazepine hypnotics like zopiclone alone should be tried. Treatment
of addiction to prescription stimulants, such as Ritalin, is often based on behavioral as 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. For steroids, if withdrawal symptoms are severe or prolonged, symptomatic
medications or hospitalization may be needed.
To summarize, we as general practitioners are in a unique position to prevent, diagnose and
manage the problem of prescription drug abuse- what we need is a little awareness and
motivation!!
REF: APA Practice Guidelines: Practice Guideline for the Treatment of Patients With Substance Use
Disorders, Second Edition