Introduction

This commodity presents an analysis of the patterns of illicit use of prescription pain relievers, of the likely structure of the illicit market, and of the complexity of pain management. It suggests that a federal enforcement policy focused on physicians is unlikely to reduce the overall use of illicit drugs, but that it is likely to have an adverse impact on the ethical structure of medical intendance and to compromise the effectiveness of pain treatment.

Pain medications, such as OxyContin, Vicodin, and Methadone, take received increased regime and media attending over the last 2 or 3 years, as the growth of their application in the treatment of patients with acute and chronic pain has been accompanied by an increment in reported drug abuse and dependence, adverse medical events, and chemist's robberies. In response, the federal government announced a new initiative to control prescription drug abuse. 1 Diverse proposed measures, including heightened scrutiny of physicians' practices, increased prosecution of physicians, increased restrictions on a number of pain medications, drug monitoring programs to catch "doctor shoppers," and encouragement of more rigorous patient screening, will, it is claimed, limit the diversion of prescription medications from medical channels.

In its 2002 review of OxyContin diversion, the Drug Enforcement Administration (DEA) stated "Illegal acts past physicians and pharmacists are the primary sources of diverted pharmaceuticals available on the illicit marketplace." two The DEA report goes on to identify other sources of diversion, including doctor shopping, robberies, burglaries, thefts, illicit internet distribution, drug gang distribution, and foreign diversion. In view of the multiplicity of sources and the lack of quantitative data regarding the contribution of each source to the illicit market, information technology is non clear on what basis the DEA claimed that physicians and pharmacists are the main sources. All the same, the recently proposed measures to control diversion and corruption appear to exist predicated on the assumption that medications diverted to illicit use come primarily from prescriptions issued by criminal or inadequately vigilant doctors to inappropriate patients, who abuse or divert prescribed medications.

It would follow from this assumption that removal of the "bad apples" amid doctors and that greater precision by well-intentioned doctors in directing prescriptions to appropriate patients would reduce the quantities bachelor for misuse. It is farther assumed that restricting the supply of medications bachelor for diversion from medical practice will restrict the access of would-be illicit users to prescription medications, and that restricted admission will lower the overall burden of substance abuse. Whether the new enforcement policy will limit diversion or reduce substance abuse remains to be seen.

Who Misuses Prescription Drugs?

The 2002 National Survey of Drug Utilise and Wellness (NSDUH) provides basic epidemiological data on the scope and correlates of illicit drug use. iii The NSDUH distinguishes betwixt drug utilize and abuse or dependence according to DSM-IV 4 definitions and indicates the fourth dimension frame within which respondents had engaged in illicit employ. DSM-IV characterizes substance abuse and dependence as follows.

Substance Abuse

A pattern of substance use leading to significant impairment in functioning. One of the following must exist present within a 12-month menstruation: 1) recurrent use resulting in a failure to fulfill major obligations at work, schoolhouse, or home; 2) recurrent apply in situations which are physically chancy (e.g., driving while intoxicated); 3) legal issues resulting from recurrent use; or iv) continued use despite significant social or interpersonal issues caused past the substance use. The symptoms do non meet the criteria for substance dependence every bit abuse is a office of this disorder.

Substance Dependence

Substance use history which includes the following: 1) substance abuse (see beneath); 2) continuation of utilize despite related problems; 3) increase in tolerance (more than of the drug is needed to accomplish the same effect); and iv) withdrawal symptoms. v

Table 1 summarizes illicit drug utilise, in general, and illicit pain reliever use in the year prior to the survey for the U.Southward. population aged 12 and older. Information technology is estimated that well-nigh 11 meg people engaged in the nonmedical use of prescription pain relievers. It is axiomatic from Table 1 that illicit drug apply disproportionately affects the young. While those aged 12–17 are only x.five% of the population anile 12 or older, they business relationship for 16% of those who utilise illicit drugs and 17% of illicit users of pain relievers. Similarly, those aged 18–25 are simply 13.2% of the population; however, they account for 31% of illicit drug users and 32% of illicit hurting reliever users.

Table ane

Illicit drug and illicit pain reliever employ in the past yr

Numbers and Percent of Population of Users
12 or Older 12–17 18–25 26 or Older
U.Southward. population 235,143,000 24,753,000 31,024,000 179,366,000
Pct of population 100% 10.five% 13.2% 76.iii%
Any illicit use 35,132,000 5,495,166 eleven,013,520 xviii,654,064
Percent of all users 100% 16% 31% 53%
Illicit pain reliever use 10,992,000 ane,881,228 3,536,736 5,560,346
Percent of all users 100% 17% 32% 51%
Numbers and Percent of Population of Users
12 or Older 12–17 18–25 26 or Older
U.South. population 235,143,000 24,753,000 31,024,000 179,366,000
Pct of population 100% 10.v% 13.2% 76.3%
Any illicit utilise 35,132,000 5,495,166 xi,013,520 18,654,064
Percent of all users 100% sixteen% 31% 53%
Illicit pain reliever use x,992,000 1,881,228 iii,536,736 5,560,346
Percent of all users 100% 17% 32% 51%

Information recompiled from Tables H.one through H.5 referenced in footnote 3.

Table i

Illicit drug and illicit hurting reliever use in the past year

Numbers and Percent of Population of Users
12 or Older 12–17 xviii–25 26 or Older
U.Due south. population 235,143,000 24,753,000 31,024,000 179,366,000
Percentage of population 100% 10.5% 13.2% 76.iii%
Any illicit use 35,132,000 5,495,166 11,013,520 18,654,064
Percent of all users 100% 16% 31% 53%
Illicit pain reliever use ten,992,000 i,881,228 3,536,736 5,560,346
Percentage of all users 100% 17% 32% 51%
Numbers and Percent of Population of Users
12 or Older 12–17 xviii–25 26 or Older
U.South. population 235,143,000 24,753,000 31,024,000 179,366,000
Per centum of population 100% ten.v% 13.2% 76.three%
Whatsoever illicit utilize 35,132,000 5,495,166 11,013,520 18,654,064
Percent of all users 100% sixteen% 31% 53%
Illicit pain reliever apply ten,992,000 one,881,228 3,536,736 5,560,346
Percentage of all users 100% 17% 32% 51%

Data recompiled from Tables H.1 through H.5 referenced in footnote 3.

The increased prevalence of illicit drug use among younger users is not unique, simply corresponds to the historic period distribution of use of alcohol and cigarettes, every bit Figure i half-dozen illustrates. The percent of individuals who utilize illicit drugs rapidly rises through adolescence and remains at a height of approximately 40% from age 18 to 22, after which information technology gradually declines (Effigy ane).

Figure 1

Alcohol, cigarette, and illicit drug use by age.

Alcohol, cigarette, and illicit drug use past age.

Effigy one

Alcohol, cigarette, and illicit drug use by age.

Alcohol, cigarette, and illicit drug use by historic period.

The preceding data presented a picture of the American population at one betoken in fourth dimension, non a longitudinal written report of the same people passing through different stages of life. It is possible that the college rates of employ among the younger age groups now will be reflected in higher rates among older groups in the future, as these individuals historic period. But information technology is every bit plausible that the design of drug use is age specific, reflecting changes in life circumstances.

This notion of age- and circumstance-specific determinants of drug use is supported by a study of drug employ amidst Vietnam veterans. The study revealed that "earlier arrival, hard drug use was largely casual, and less than 1% had always been addicted to narcotics. In Vietnam, almost half of the full general sample tried narcotics and xx% reported opiate addiction. Afterwards return, usage and addiction essentially decreased to pre-Vietnam levels."[1]

Part of what has prompted the government initiative is a recent rapid growth in illicit prescription drug use and related adverse medical events. One index of that growth is the change in drug-related emergency department visits reported through the Drug Abuse Alert Network (DAWN). DAWN collects data on drug abuse-related emergency department visits, and specifies, when possible, the drug or drugs involved in the drug-abuse related visit. 7 Table 2 records the alter from 1997 to 2002.

Table 2

DAWN emergency department mentions for selected prescription medications 1997–2002

DAWN 1997 2002 % Change
Hydrocodone xi,570 25,197 117.viii
Oxycodone five,012 22,397 346.9
Methadone iii,832 11,709 205.6
Morphine ane,300 2,775 113.five
DAWN 1997 2002 % Modify
Hydrocodone 11,570 25,197 117.8
Oxycodone 5,012 22,397 346.9
Methadone 3,832 11,709 205.six
Morphine 1,300 two,775 113.5

Tabular array 2

DAWN emergency section mentions for selected prescription medications 1997–2002

DAWN 1997 2002 % Change
Hydrocodone xi,570 25,197 117.8
Oxycodone 5,012 22,397 346.nine
Methadone 3,832 xi,709 205.6
Morphine i,300 2,775 113.5
DAWN 1997 2002 % Change
Hydrocodone xi,570 25,197 117.eight
Oxycodone 5,012 22,397 346.9
Methadone 3,832 eleven,709 205.6
Morphine i,300 2,775 113.5

The percentage increase in DAWN mentions for prescription hurting relievers has been greater than the increase for marijuana, cocaine, and heroin. Information technology has been exceeded only by the per centum increase in Ecstasy mentions. Tabular array three records change in DAWN mentions for these nonprescription drugs over the same interval.

Table 3

DAWN emergency department mentions for selected nonprescription medications 1997–2002

DAWN 1997 2002 % Modify
Marijuana 64,720 119,472   84.6
Cocaine 171,894 207,395   twenty.seven
Heroin 70,712 93,519   32.iii
MDMA (Ecstasy) 637 4,026 532.0
DAWN 1997 2002 % Alter
Marijuana 64,720 119,472   84.6
Cocaine 171,894 207,395   20.7
Heroin 70,712 93,519   32.3
MDMA (Ecstasy) 637 4,026 532.0

Table iii

DAWN emergency section mentions for selected nonprescription medications 1997–2002

DAWN 1997 2002 % Change
Marijuana 64,720 119,472   84.six
Cocaine 171,894 207,395   20.vii
Heroin lxx,712 93,519   32.3
MDMA (Ecstasy) 637 4,026 532.0
DAWN 1997 2002 % Modify
Marijuana 64,720 119,472   84.6
Cocaine 171,894 207,395   xx.vii
Heroin lxx,712 93,519   32.3
MDMA (Ecstasy) 637 4,026 532.0

Information technology should also be noted that the number of DAWN mentions for the selected illicit drugs (with the exception of Ecstasy) is v–10 times college than for prescription drugs in 2002. However, NSDUH data for 2002 reflect a greater prevalence of employ and of dependence on or abuse of pain relievers than of heroin, as illustrated in Table four. This disproportionate representation of DAWN mentions for heroin every bit compared with prescription pain relievers confirms that heroin is much riskier. One measure out of the relative adventure of these substances is the ratio of the rates of DAWN mentions to the prevalence of utilise or abuse. For users in the past year, heroin users were 21.3 times more likely than pain reliever users to generate DAWN mentions, and heroin abusers were 5.v times more likely than pain reliever abusers to generate DAWN mentions (Table 4).

Table 4

Prevalence data of past year use and dependence or abuse versus DAWN mentions for pain relievers and heroin in 2002

Past Year Use Dependence/ Abuse DAWN DAWN Mentions per Hundred
Users with Past Year Utilise		 DAWN Mentions per Hundred
Users with Dependence/Abuse
Hurting relievers 10,992,000 1,509,000 119,185   1.08   7.ix
Heroin      404,000    214,000   93,519 23.ii 43.7
Past Yr Employ Dependence/ Abuse DAWN DAWN Mentions per Hundred
Users with By Twelvemonth Apply		 DAWN Mentions per Hundred
Users with Dependence/Corruption
Hurting relievers 10,992,000 ane,509,000 119,185   1.08   7.9
Heroin      404,000    214,000   93,519 23.2 43.7

Table 4

Prevalence information of past year apply and dependence or abuse versus DAWN mentions for pain relievers and heroin in 2002

Past Year Utilise Dependence/ Abuse DAWN DAWN Mentions per Hundred
Users with By Twelvemonth Use		 DAWN Mentions per Hundred
Users with Dependence/Corruption
Pain relievers 10,992,000 1,509,000 119,185   1.08   7.9
Heroin      404,000    214,000   93,519 23.2 43.vii
By Year Employ Dependence/ Abuse DAWN DAWN Mentions per Hundred
Users with By Year Use		 DAWN Mentions per Hundred
Users with Dependence/Abuse
Pain relievers ten,992,000 1,509,000 119,185   1.08   7.nine
Heroin      404,000    214,000   93,519 23.two 43.7

The growth in nonprescription illicit drug reports suggests that prescription drug abuse is part of a more general tendency in drug abuse. Information from the NSDUH indicate both the dimension of illicit drug utilize and commonalities in the patterns of employ that illicit use of prescription drugs share with other illicit drugs, alcohol, and tobacco. Figure 2 8 below traces the proportion each yr of 18- to 25-year-olds reporting prior use of marijuana, cocaine, Ecstasy, and the nonmedical use of prescription pain relievers from 1970 to 2002.

Effigy 2

Lifetime use 18- to 25-year-olds—selected drugs 1970–2002.

Lifetime use 18- to 25-year-olds—selected drugs 1970–2002.

Figure 2

Lifetime use 18- to 25-year-olds—selected drugs 1970–2002.

Lifetime employ 18- to 25-year-olds—selected drugs 1970–2002.

Every bit illustrated in Effigy 2 and Figure 3, 9 tracking new users of selected drugs, there has been a general increase in illicit drug use since the early on 1990s. The parallel paths for marijuana and cocaine suggest common epidemiological determinants of the fluctuation in employ of these established drugs. The rapid rising from relatively low levels of pain reliever and Ecstasy use may indicate a common pattern for new fad drugs.

Figure 3

Initiates of selected drugs—all ages.

Initiates of selected drugs—all ages.

Effigy 3

Initiates of selected drugs—all ages.

Initiates of selected drugs—all ages.

For all classes of drug, the proportion reporting abuse or dependence is dramatically lower than those reporting use alone. Table five presents these information for pain relievers.

Table 5

Illicit utilise of and abuse/dependence on hurting relievers

Numbers (×1000) and Per centum of Each Historic period Accomplice
12 or Older % 12–17 % 18–25 % 26 or Older %
U.S. population 235,143 24,753 31,024 179,366
Illicit pain reliever use (lifetime)   29,611 12.half-dozen   ii,772 eleven.two   vi,856 22.1   19,910 11.1
Illicit pain reliever employ (past year)   10,992   four.7   1,881   7.6   3,537 11.4     5,560   three.1
Illicit pain reliever use (past month)     4,377   1.9     792   3.ii   1,272   4.i     2,332   1.three
Pain reliever abuse/Dependence-by twelvemonth     i,509   0.6     237   one.0      419   1.4        853   0.5
Numbers (×g) and Percent of Each Age Accomplice
12 or Older % 12–17 % 18–25 % 26 or Older %
U.S. population 235,143 24,753 31,024 179,366
Illicit pain reliever utilize (lifetime)   29,611 12.6   ii,772 11.2   half dozen,856 22.ane   nineteen,910 11.1
Illicit hurting reliever use (past yr)   x,992   4.7   i,881   7.6   3,537 11.iv     5,560   3.1
Illicit hurting reliever use (past month)     4,377   1.9     792   3.2   i,272   4.1     2,332   1.3
Pain reliever abuse/Dependence-by year     ane,509   0.half dozen     237   ane.0      419   1.four        853   0.5

The data were extracted and recompiled from the tables summarizing NSDUH data as follows:

Table H.1 (i.1B) Illicit Drug Apply in Lifetime, Past Year, and Past Month amid Persons Anile 12 or Older: Numbers in Thousands, 2002

Table H.2 (1.2B) Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older: Percentages, 2002

Tabular array H.3 (1.3B) Illicit Drug Employ in Lifetime, Past Year, and Past Month among Persons Anile 12–17: Percentages, 2002

Table H.iv (1.4B) Illicit Drug Use in Lifetime, Past Twelvemonth, and Past Month among Persons Aged 18–25

Table H.5 (1.19B) Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 26 or Older: Percentages, 2002

Tabular array H.43 (five.25B) Substance Dependence or Corruption for Specific Substances in the By Year, by Historic period Group: Numbers in Thousands, 2002

Table H.44 (5.27B) Substance Dependence or Abuse for Specific Substances in the By Year, by Age Group: Percentages, 2002

Table G2 Numbers (in Thousands) of Persons Aged 12 or Older, by Gender and Detailed Historic period Categories: 2002.

Table five

Illicit employ of and abuse/dependence on pain relievers

Numbers (×thou) and Percentage of Each Age Cohort
12 or Older % 12–17 % eighteen–25 % 26 or Older %
U.S. population 235,143 24,753 31,024 179,366
Illicit pain reliever apply (lifetime)   29,611 12.6   two,772 11.2   6,856 22.1   19,910 eleven.1
Illicit pain reliever use (past year)   10,992   4.7   1,881   7.half dozen   iii,537 11.4     five,560   3.1
Illicit pain reliever employ (past month)     four,377   1.9     792   three.2   one,272   4.1     2,332   i.3
Pain reliever abuse/Dependence-past yr     1,509   0.six     237   i.0      419   1.4        853   0.five
Numbers (×1000) and Pct of Each Age Cohort
12 or Older % 12–17 % eighteen–25 % 26 or Older %
U.S. population 235,143 24,753 31,024 179,366
Illicit pain reliever apply (lifetime)   29,611 12.6   2,772 xi.two   6,856 22.1   19,910 11.1
Illicit hurting reliever utilize (past year)   10,992   4.7   one,881   seven.6   3,537 11.4     5,560   three.i
Illicit pain reliever use (past month)     4,377   i.9     792   3.2   i,272   4.1     two,332   1.3
Pain reliever abuse/Dependence-past twelvemonth     1,509   0.6     237   1.0      419   1.4        853   0.v

The data were extracted and recompiled from the tables summarizing NSDUH data equally follows:

Tabular array H.i (1.1B) Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older: Numbers in Thousands, 2002

Table H.two (i.2B) Illicit Drug Use in Lifetime, By Year, and By Month amid Persons Aged 12 or Older: Percentages, 2002

Table H.iii (i.3B) Illicit Drug Use in Lifetime, Past Twelvemonth, and Past Month among Persons Anile 12–17: Percentages, 2002

Table H.4 (1.4B) Illicit Drug Utilise in Lifetime, Past Year, and Past Calendar month among Persons Aged 18–25

Table H.5 (1.19B) Illicit Drug Apply in Lifetime, By Yr, and Past Calendar month among Persons Anile 26 or Older: Percentages, 2002

Tabular array H.43 (5.25B) Substance Dependence or Abuse for Specific Substances in the Past Year, by Age Group: Numbers in Thousands, 2002

Table H.44 (5.27B) Substance Dependence or Abuse for Specific Substances in the Past Twelvemonth, by Age Group: Percentages, 2002

Table G2 Numbers (in Thousands) of Persons Aged 12 or Older, past Gender and Detailed Age Categories: 2002.

Table half dozen presents the percentage of individuals who had discontinued pain reliever utilize after some exposure, likewise every bit those whose use is designated abuse or dependence, calculated from the information in Tabular array 5. Opposite to commonly held beliefs, mere exposure to pain relievers among those using the medicine for nonmedical purposes does not pb to corruption or dependence in the bulk of those exposed. In each historic period category, discontinuation of utilise after some period of exposure is a mutual upshot, and the proportion of those discontinuing apply increases with age, from a low of 32.1% in the 12–17 historic period group to 72.ane% among those 26 and older. Even amid those who accept used in the past year, the charge per unit of abuse/dependence is 15.3% or less.

Tabular array 6

Percent who discontinue pain relievers and percent of abuse/dependence among users in past year and amidst those who had e'er used

12 or Older 12–17 18–25 26 or Older
Percentage of users who discontinue 62.nine% 32.i% 48.four% 72.1%
Percent abuse/dependence amid users in past year 13.7% 12.half dozen% 11.8% 15.3%
Percent abuse/dependence among those who had ever used   5.one%   8.v%   vi.one%   4.3%
12 or Older 12–17 18–25 26 or Older
Percent of users who discontinue 62.9% 32.1% 48.iv% 72.1%
Percent abuse/dependence amidst users in past year thirteen.7% 12.six% 11.8% 15.3%
Percent corruption/dependence among those who had ever used   5.1%   eight.5%   6.1%   4.iii%

The pct who discontinue hurting relievers is calculated by subtracting the number of past yr users from those who had always used and dividing the result by the number who had ever used for each historic period cohort (users in lifetime − past yr users)/(users in lifetime). The percentages of corruption/dependence among past year users and amid users in lifetime are calculated direct from the data entered in the designated categories in Table v.

Table half dozen

Per centum who discontinue hurting relievers and percent of abuse/dependence among users in past yr and amongst those who had always used

12 or Older 12–17 18–25 26 or Older
Per centum of users who discontinue 62.9% 32.1% 48.iv% 72.one%
Percent corruption/dependence among users in past year 13.7% 12.vi% eleven.eight% xv.3%
Per centum abuse/dependence amongst those who had e'er used   5.one%   eight.5%   six.1%   4.3%
12 or Older 12–17 eighteen–25 26 or Older
Percent of users who discontinue 62.9% 32.1% 48.4% 72.1%
Percentage abuse/dependence among users in past year 13.seven% 12.six% 11.8% fifteen.three%
Percent abuse/dependence among those who had always used   5.1%   viii.5%   6.1%   4.3%

The percent who discontinue pain relievers is calculated by subtracting the number of past twelvemonth users from those who had always used and dividing the result past the number who had always used for each age cohort (users in lifetime − by year users)/(users in lifetime). The percentages of abuse/dependence among past year users and among users in lifetime are calculated directly from the data entered in the designated categories in Table 5.

Well-nigh individuals who engage in illicit use of hurting relievers exercise and then infrequently. NSDUH asked respondents to estimate the number of days in the prior year that they had used hurting relievers. As noted in Table 7, slightly fewer than i quarter of those reporting use in the prior yr used on only 1 or 2 days. The bulk (52.4%) had used these medications on 10 days or fewer in the prior yr. The predominance of depression frequency use further supports the proposition that mere exposure does not inevitably pb to corruption and dependence. Information technology also suggests the informal and opportunistic, rather than deliberately planned, pattern of well-nigh youthful drug use (Table 7).

Table 7

Frequency of pain reliever use amid 18–25 years olds—percent using for the specified number of days or fewer in prior yr (2002)

Days 1 ii 3 5 10 15 30 60 xc
Percent 12.ix 24.1 32.3 42.4 52.4 60.seven 71.three 85.two 86.7
Days 1 2 3 5 ten 15 xxx 60 90
Percentage 12.ix 24.1 32.3 42.4 52.four 60.seven 71.iii 85.2 86.7

Tabular array 7

Frequency of pain reliever apply among 18–25 years olds—percent using for the specified number of days or fewer in prior yr (2002)

Days 1 two 3 5 ten 15 30 60 90
Percent 12.9 24.one 32.three 42.4 52.four threescore.seven 71.3 85.ii 86.7
Days i 2 3 v 10 15 xxx sixty 90
Percent 12.nine 24.ane 32.3 42.4 52.iv 60.7 71.three 85.2 86.vii

At that place has been no detailed analysis of the sources of supply to this predominantly young market for prescription hurting relievers. Data from an earlier household survey of drug use, presented in Table viii[two], reported that the bulk of users of illicit nonprescription drugs obtained their drug from friends, oft, as a souvenir. From information gathered in the course of investigation the Section of Justice has concluded that "young people rarely obtain prescription drugs using methods commonly associated with pharmaceutical diversion such as pharmacy theft, prescription fraud, or dr. shopping—visiting numerous doctors to obtain multiple prescriptions. Instead, adolescents typically obtain prescription drugs from peers, friends, or family members." 10

Table 8

How past-month users obtained their drug [2]

Drug Source Marijuana Cocaine Crack
None avowed   7.two%   7.8%   viii.8%
Bought from dealer 18.0% 32.8% 45.4%
Bought from friends but not from dealer 31.9% 22.7% 18.9%
Gifts, did not buy 41.7% 34.6% 24.4%
Other   1.2%   two.1%   2.6%
Drug Source Marijuana Cocaine Crack
None avowed   7.2%   vii.8%   viii.8%
Bought from dealer xviii.0% 32.8% 45.4%
Bought from friends but not from dealer 31.nine% 22.vii% eighteen.ix%
Gifts, did not buy 41.7% 34.six% 24.4%
Other   i.ii%   2.1%   ii.half-dozen%

Table 8

How past-month users obtained their drug [2]

Drug Source Marijuana Cocaine Crevice
None avowed   7.2%   7.8%   8.8%
Bought from dealer 18.0% 32.8% 45.four%
Bought from friends only not from dealer 31.9% 22.7% 18.9%
Gifts, did not buy 41.7% 34.vi% 24.iv%
Other   ane.two%   two.i%   two.vi%
Drug Source Marijuana Cocaine Crack
None avowed   7.2%   7.8%   8.viii%
Bought from dealer 18.0% 32.viii% 45.4%
Bought from friends but non from dealer 31.9% 22.7% xviii.ix%
Gifts, did not buy 41.7% 34.vi% 24.four%
Other   1.two%   2.1%   two.6%

Taken together, data presented in this section suggest that the illicit demand for prescription pain relievers is function of a broader upward trend in the demand for illicit drugs. This increase is a component of larger cultural trends in drug misuse, which wax and wane over time. That the employ of prescription medications for nonmedical purposes is merely one component of the more full general phenomenon of illicit drug use is confirmed by commonalities in the historical trends and age distribution of illicit prescription and other illicit drug use and by the ancillary apply of multiple nonprescription illicit drugs past illicit prescription drug users. 11 Drug misuse typically includes licit and illicit drugs, is initiated at a young historic period, and declines with age. Most users do non satisfy medical criteria for dependence or abuse, merely engage in haphazard and incidental use. If the design of drug distribution observed among illicit drug users is applicable to illicit prescription drug users, the majority obtain their medications from nonphysician intermediaries (who may or may not obtain medications from physicians).

The Relationship Betwixt Medical Prescription and Diversion

Dissimilar other illicit substances, prescription medications are subject to federal government-monitored product and distribution from designated manufacturers through licensed wholesalers, to licensed pharmacies or healthcare facilities for final distribution to patients via valid prescriptions from licensed practitioners. This system of federal drug control implicitly recognizes that there is a risk of diversion at every level of the concatenation of distribution. At each stage in the distribution process, there are opportunities for diversion by theft or fraud.

An assessment of the contribution of nonphysician sources is critical to the success of drug control policy. Every bit reported in the Wall Street Periodical, the General Bookkeeping Function (GAO) has institute that massive quantities of pharmaceuticals enter the U.South. daily. "John F. Kennedy Drome in New York receives a whopping xl,000 drug packages each day, while some 30,000 pharmaceutical shipments land in Miami and Chicago receives at least 4,300 packages containing drug products every day"[3]. The article goes on to report that nearly xxx% of the packages contained controlled substances, and that the GAO was able to buy controlled substances without a prescription and without visiting a md.

The limitations of a strategy focused on medico prescribing have been implicit in proposals to suppress net sales of prescription medications directly to consumers. But fifty-fifty this focus may have footling bear on on illicit access to prescription medications if diversion from higher levels in the distribution chain contributes substantially to black marketplace supplies, allowing dealers and users only to obtain supplies from alternative sources.

Information technology is unlikely that prescriptions written by dishonest doctors or those easily duped institute a significant black market place supply. This is then, considering the size of the illicit market, approximately 11 meg illicit users of prescription painkillers in 2002, 12 is simply too big to be supplied by a small grouping of doctors. If, for case, in that location were one,000 active criminal or highly negligent doctors, on average they would have to outcome enough bogus or excessive prescriptions yearly to provide for distribution to ane,100 individuals each. While DEA enforcement policy may fail to discover physicians who consequence small numbers of prescriptions destined for illicit use, one would await that those who issue large prescriptions or large numbers of small prescriptions destined for the illicit market would be highly visible and targeted for investigation. As evident from Table 9[4], the rate of adverse deportment confronting physician registrants over the interval 1999 through the tertiary quarter of 2003 has been depression and declining during a period of significant increase in prescription drug abuse. It is theoretically possible that big numbers of loftier volume prescribers are ignored by regulatory authorities and criminal prosecutors, simply information technology is far more likely that intentional distribution by doctors represents a very minor proportion of those in practice—too few to furnish a meaning fraction of the illicit market. At that place are but non enough "bad" doctors to account for distribution to xi million people.

Table 9

Adverse actions against DEA registrants [four]

1999 2000 2001 2002 2003
Registrants 879,011 897,953 923,829 939,763 963,385
Deportment 765 783 698 568 441
Percent 0.09 0.09 0.08 0.06 0.05
1999 2000 2001 2002 2003
Registrants 879,011 897,953 923,829 939,763 963,385
Deportment 765 783 698 568 441
Percent 0.09 0.09 0.08 0.06 0.05

Table 9

Adverse actions against DEA registrants [4]

1999 2000 2001 2002 2003
Registrants 879,011 897,953 923,829 939,763 963,385
Actions 765 783 698 568 441
Pct 0.09 0.09 0.08 0.06 0.05
1999 2000 2001 2002 2003
Registrants 879,011 897,953 923,829 939,763 963,385
Actions 765 783 698 568 441
Percentage 0.09 0.09 0.08 0.06 0.05

One approach to assessing the contribution of diversion from medical exercise to illicit use is to compare the change in the retail distribution of medications to emergency department visits related to drug use through the DAWN. A study applying this approach over the interval 1990 through 1996 concluded that "The trend of increasing medical utilize of opioid analgesics to treat pain does non announced to contribute to increases in the wellness consequences of opioid analgesic abuse"[five].

Equally Table 10 illustrates, over the following 6 years (1997–2002), as retail sales increased, so did DAWN mentions. Changes in Hydrocodone mentions correlate almost exactly with changes in retail distribution, each rising 117%, while the dramatic increases in Oxycodone and Methadone retail distribution were accompanied by significant, although somewhat smaller increases in DAWN mentions. A recently published study covering the interval from 1997 to 2001 reports data consequent with Tabular array 10[half-dozen].

10

DAWN mentions and retail sales of opioid medications (grams of medication) 1997–2002

DAWN 1997 DAWN 2002 DAWN % change RETAIL 1997 RETAIL 2002 RETAIL % alter
Hydrocodone 11,570 25,197 117.8 8,669,311 18,822,618 117.1
Oxycodone   5,012 22,397 346.nine 4,449,562 22,376,891 402.9
Methadone   three,832 11,709 205.vi    518,737   2,649,559 410.8
Morphine   1,300   ii,775 113.5 5,922,872 10,264,264   73.3
DAWN 1997 DAWN 2002 DAWN % modify RETAIL 1997 RETAIL 2002 RETAIL % change
Hydrocodone xi,570 25,197 117.8 viii,669,311 18,822,618 117.i
Oxycodone   5,012 22,397 346.ix 4,449,562 22,376,891 402.ix
Methadone   3,832 11,709 205.vi    518,737   ii,649,559 410.8
Morphine   ane,300   2,775 113.5 5,922,872 10,264,264   73.3

ten

DAWN mentions and retail sales of opioid medications (grams of medication) 1997–2002

DAWN 1997 DAWN 2002 DAWN % change RETAIL 1997 RETAIL 2002 RETAIL % change
Hydrocodone xi,570 25,197 117.viii 8,669,311 18,822,618 117.i
Oxycodone   five,012 22,397 346.9 iv,449,562 22,376,891 402.9
Methadone   three,832 11,709 205.6    518,737   2,649,559 410.8
Morphine   one,300   ii,775 113.5 v,922,872 10,264,264   73.iii
DAWN 1997 DAWN 2002 DAWN % change RETAIL 1997 RETAIL 2002 RETAIL % change
Hydrocodone 11,570 25,197 117.viii 8,669,311 18,822,618 117.1
Oxycodone   five,012 22,397 346.ix four,449,562 22,376,891 402.9
Methadone   three,832 11,709 205.6    518,737   2,649,559 410.viii
Morphine   1,300   2,775 113.5 5,922,872 ten,264,264   73.three

The correlation of modify in DAWN mentions and the corporeality distributed to retail outlets does not prove that prescribed medications are the source of the medications that led to emergency room visits. Medications diverted to the illicit market could take been diverted past theft or fraud from a higher level in the distribution chain, or obtained through foreign buy.

There are no studies on the pattern of diversion of prescription medications from medical practice in the United states. Nevertheless, a recent British report of the illicit market place for prescription methadone in London may shed low-cal on the pattern of diversion from medical practice.

The size of the marketplace is substantial and appears to involve a large number of individuals, each diverting pocket-size amounts of their own prescribed drugs. Major motives for selling prescribed drugs are to enhance funds to buy other, preferred, drugs and/or to pay for a individual prescription. Buyers in treatment appear to exist motivated past a desire to supplement their own prescriptions considering they are dissatisfied with the particular drug prescribed, dosage and formulation. Drug users in handling tin can exploit the variations in prescribing practice—such equally how much "take-home" medication they are immune and whether tests are conducted to ascertain if they are using it themselves—and divert their prescribed drugs. [seven]

The office-based treatment of heroin addiction in the Uk has some elements in common with the part-based treatment of pain in the U.Southward.—patient command over medication and limitations in the power to detect diversion. If the American pattern follows the market construction outlined higher up, it is nigh likely that the largest proportion of prescription-based illicit supply comes from patients who receive prescriptions in the grade of routine medical care by well-intentioned doctors, and that these patients, in turn, sell or share some of their medications.

Patient Selection and the Risk of Diversion

The current policy accent on "appropriate" patient selection seems to suggest that patients may be divided into two discrete groups, the kickoff, with pain, honest, and reliable, the second, without pain and dishonest, who divert and/or abuse their medication. Police enforcement and medical lore propose that some individuals are able to feign medical conditions to obtain medications. If such individuals formed a substantial part of the illicit market, the prescription-monitoring programs to catch "doctor shoppers" and heightened care by physicians in selecting patients might hold some promise in reducing diversion. Sooner or later, such "patients" would be detected.

The clinical reality presents a more complex picture. Having a painful condition is no guarantee of honesty or reliability in the command of prescribed medications. Nor does a history of addiction or misdeed forbid the emergence of painful conditions or mandate noncompliance with medical instructions. The fact that there is a substantial subset of patients with painful atmospheric condition who may be unreliable raises both practical and ethical dilemmas for a strategy of diversion control predicated on accurate patient selection. Should such patient characteristics as prior drug abuse, prior criminal record, or uncertain financial resources to obtain medications, which might be assumed to be associated with a heightened take chances of criminal action, justify excluding patients from access to treatment of severe hurting? The awarding of these screening criteria probably entails a gamble of erroneously excluding a patient who would not divert medications. Should patients with these characteristics be forever denied effective pain handling? Are there practical measures to minimize the risk of diversion even in a loftier risk patient population?

The comorbidity of pain and addiction poses a pregnant challenge for a policy of diversion control based on exclusion of loftier-diversion-risk patients. Studies of heroin addicts in methadone handling study that the incidence of chronic hurting in this population is substantial. A study of patients in methadone maintenance in Massachusetts revealed that 61.3% suffered chronic pain [8]. A more than recent study of patients in methadone maintenance programs in New York revealed that 37% experienced chronic severe pain [nine]. Although there is an unofficial bias against treating addicts with opioid medications, professional person organizations support the concurrent handling of both conditions in a setting of heightened monitoring and control. 13 At that place are no reports on the success of these strategies, either with respect to clinical outcomes, such as pain control and functionality, or with respect to the risk of diversion.

There have been studies, however, of heroin addicts treated in an office-based settings in an endeavor to minimize the stigma and inconvenience of conventional methadone clinics. One study reviewed the experience of 158 addicts referred for office direction from 1983 to 1998 [10]. Of this grouping, 83.5% were compliant with the program, while 16.5% were non. A more recent study monitoring 73 "highly stable" patients selected for part-based methadone treatment over a 6-calendar month menses institute a 1%"muddy" urine charge per unit, very low rates of medication misuse, and no evidence of diversion [xi]. These patients were field of study to two random urine screens monthly and a "medication think procedure." Those who failed were referred for "intensified treatment."

Whether care of hurting patients could achieve the high level of patient performance reported in the afterward written report is uncertain. The study implemented a level of monitoring and command not typical of the approach taken in about medical practices, and the patients were advisedly screened for reliability prior to acceptance into the study protocol. The handling of pain typically requires more dosing flexibility than unremarkably afforded patients on methadone maintenance and therefore provides more opportunity for patient dishonesty and diversion.

Ane strategy that attempts to mitigate the adventure that hurting patients will misuse or divert their medication is the imposition of handling contracts authorizing physicians to monitor for abuse and diversion. Such contracts typically comprise provisions that patients plant to have violated the contract may be subjected to heightened scrutiny, referred for supplemental treatment of addiction, or discharged from care. xiv Withal, this assertion of professional person power transforms the physician from a benign healer into an intrusive policeman. Such procedures as monitored provision of urine specimens for drug testing are oft perceived as demeaning by patients.

The attitudes and procedures suitable for pain management are in tension with those suitable for the management of habit and the prevention of diversion. Those attitudes and procedures useful to monitor for addiction and diversion infuse the md–patient relationship with mutual suspicion and distrust. Those physician qualities that promote the trust and artlessness required for constructive pain treatment make the medico vulnerable to charade and exploitation.

In an age that gives upstanding approval and legal force to respect for patient autonomy, the exclamation of professional paternalism to command addiction and diversion in the context of pain medicine is difficult to reconcile with the contemporary ethical commitments of professional person practice. Information technology is an result that needs give-and-take and dialogue between and within both the medical and regulatory communities.

The Ethics of Medical Policing

Medical do is grounded in ethical principles designed to afford patients competent, empathetic intendance that respects their dignity. At its core, the treatment of pain is the expression of medical pity, a sentiment rooted in its virtually idealistic formulation, in the recognition of a mutual humanity between doctor and patient—a common humanity that transcends the differences and distinctions that usually give rise to prejudicial handling in the course of social interactions.

In the provision of routine medical intendance, doctors frequently come into contact with patients who deviate from order's or the particular doctor's conception of virtue. Sexual promiscuity, adultery, or homosexual orientation, excessive consumption of booze or food, and use of tobacco or illicit drugs are among the most unremarkably disapproved behaviors. Patients' candor regarding their behavior may well be critical to the provision of effective medical care and the protection of 3rd parties. A judgmental or punitive response to patient disclosure of disapproved behavior would inhibit candor and frustrate treatment.

Information technology is a generally accepted platonic that the quality of medical care and attention should not be determined by the social or moral status of the patient, merely by the clinical characteristics of his or her illness. The disposition to limit the bear upon of adverse moral judgment on medical intendance and to refrain from exploitation of professional status and power in the service of nonclinical objectives serves patient interests by providing a supportive social relation that encourages patient candor and confidence and that is complimentary of physician motive ulterior to the patient's clinical involvement. This principle applies, for case, to prisoners and to wounded enemy soldiers. To encourage clinically egalitarian medical care for prisoners, prison doctors are routinely kept in the dark regarding the crimes of which their inmate patients take been convicted. It is considered a violation of internationally recognized medical upstanding norms to breach the confidentiality of enemy combatants through the disclosure of medical data to their interrogators [12].

Physicians are not gratuitous to exploit their professional power to impose their conceptions of morality. The professional approach to the monitoring of pain treatment is in tension with the more customary nonjudgmental, nonmoralizing mode of medical care. As noted in a higher place, physicians are advised to ascertain boundaries of acceptable patient behavior, transgression of which will lead to heightened monitoring and command or discharge from care. Patients are monitored for the apply of illicit drugs, the misuse of prescribed drugs, and criminal activity. When such behavior is detected, steps are taken to control information technology which involve heightened monitoring and other possible sanctions. Such boundaries are frequently included in hurting treatment contracts and are designed to induce patients to comply with the laws governing controlled substances.

Whether such constraints nether the threat of possible discharge from pain care are constructive is unknown. Although bandage in therapeutic terms, the imposition of sanctions to subject area patient beliefs constitutes a dramatic departure from the advisory role respectful of patient autonomy that physicians typically undertake in routine medical care. When the approach used to monitor addicts is applied in the handling of pain, the md–patient relationship is transformed into one of professional command based on the power to inflict pain by terminating pain treatment.

Pain care may demand to be premised on the explicit requirement that patients discipline themselves to heightened monitoring and possible termination of handling for deviation from approved behavior to prevent diversion and abuse. However, such policing, enforced past subjecting patients to involuntary withdrawal, is in conflict with the contemporary ethical framework of an advisory physician part in a consensual dr.–patient relationship.

Decision and Implications

Definitive information on the structure of the market for illicit drugs are not bachelor. There is sufficient information, however, to suggest that criminal acts by doctors cannot business relationship for a substantial proportion of the medications diverted to the illicit marketplace. The lack of clear differentiation between patients with pain and those prone to addiction or diversion suggests that there is no simple technical solution to the trouble of patient option.

Whether the proposed strategies focusing on physician performance are likely to be effective in reducing prescription drug abuse is unknown. Given the apparent capacity of the illicit marketplace to respond to need for abusable drugs, it is at least conceivable that whatever curtailing of supply through medical channels is likely to be offset by increased nonmedical distribution of the restricted medications or an increase in the use of alternative illicit medications. Information technology is likely, however, that heightened scrutiny of physicians and harsh sanctions for inappropriate prescribing will take an adverse upshot on patient care, as normally cautious physicians employ measures to minimize their risks, such every bit accepting fewer patients for pain handling and imposing tighter restrictions on those who authorize.

There is lilliputian to guide physicians or policy makers in establishing rational criteria for patient selection or in the determination of the all-time trade-off between access to hurting treatment and command of diversion and corruption. In that location are no published epidemiological data on the hazard of diversion by patients, or how the run a risk might vary as a function of patient characteristics. At a more global level, while the NSDUH and DAWN surveys endeavor to provide routine systematic information on the prevalence and brunt of illicit drug utilize, there is no comparable routine systematic evaluation of the prevalence and burden of untreated or inadequately treated hurting. Without such data, there is no way to assess whether the application of current or proposed screening and monitoring approaches, or regulatory policy as a whole, impose disproportionate costs on deserving patients in relation to the benefits of diversion control. How can in that location be a balanced policy without a calibration to measure out all the relevant outcomes?

Imposition on doctors of the duty to treat pain and to avoid diversion imposes inconsistent requirements that cannot achieve both objectives with the resources and organizational characteristics of conventional medical practice. In this author'southward opinion, the accent on control of diversion from medical practice entails a transformation of the practice of medicine that is incompatible with the traditional ethical commitments to the primacy of the individual patient, the voluntary and consensual basis of the dr.–patient human relationship, and the sanctuary for privacy, confidentiality, and acceptance based on mutual humanity afforded by civilized societies in the structure of medical care.

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Footnotes

1

Office of National Drug Control Policy Press Release, U.S. Drug Prevention, Handling, Enforcement Agencies Accept on "Doctor Shoppers,""Pill Mills," March i, 2004.

iii

The National Survey of Drug Utilize and Health (NSDUH) is available online at http://world wide web.oas.samhsa.gov/nhsda/2k2nsduh/html/toc.htm. The drug use prevalence data in this commodity are extracted from Tables 1.1B, 1.2B, 1.3B, one.4B, i.19B, 1.26B, v.25B, 5.27B, and 8.2N accessible through the referenced website or from Tables H.1 through H.vi, H.xvi, H.22, and H.44 from SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 at http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/appH.htm.

four

Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-4), published by the American Psychiatric Association, Washington, DC, 1994.

6

Table H.16, Alcohol Use, Percentages, 2002, Tabular array H.22, Cigarette Use, Percentages, 2002, and Table H.6, Any illicit Drug Use, Percentages, 2002 referenced before.

10

Information Brief: Prescription Drug Abuse and Youth, National Drug Intelligence Centre, Document ID: 2002-L0424-004, Baronial 2002.

eleven

"On average, 2 drugs were mentioned in each ED visit involving narcotic analgesics, and more than one drug was involved in 72% of the visits … Cocaine taken with unspecified narcotic analgesics was the almost frequently reported combination in 2001."The Dawn Report, January 2003. Available at http://dawninfo.samhsa.gov/pubs_94_02/shortreports/files/DAWN%20Report%xx NA_10.pdf.

12

Table H.1, NSDUH, 2002.

xiii

PUBLIC Policy Statement on the Rights and Responsibilities of Healthcare Professionals in the Apply of Opioids for the Treatment of Pain, adopted past American Society of Habit Medicine, April 1997; revised April 2004, Adopted by American Academy of Pain Medicine, March 2004, adopted past American Pain Order, March 2004, available at http://asam.org/ppol/opioids.htm.

14

If the patient is adamant to be at loftier risk for medication abuse or have a history of substance abuse, the physician may employ the use of a written agreement between doctor and patient outlining patient responsibilities including: 1) urine/serum medication levels screening when requested; ii) number and frequency of all prescription refills; and three) reasons for which drug therapy may exist discontinued (i.e., violation of agreement). Model Guidelines for the Use of Controlled Substances for the Treatment of Pain, the Federation of State Medical Boards of the United States, Inc. (adopted May 2, 1998).