Are Healthcare Professionals Prepared for the Current Drug Epidemic?

Trends and impact of Prescription drug abuse and Illegal drugs use in Society

Uncontrolled prescribing of opioids has made prescription drug misuse as the national epidemic of the USA leading to increased mortality, addiction and worst health conditions. Prescriptions are drugs are easier to obtain than illegal drugs and prescription drugs are preferred in areas where it is difficult to find cheap illicit drugs. Many studies have shown the correlation of prescription drug abuse with a higher incidence of smoking, drinking, marijuana, cocaine and illicit drug usage.

A survey in different areas of US showed that prescription drug abuse is common in rural, middle to moderate urban and suburb areas. This also revealed that opioid analgesics are the most commonly abused drugs in US among recreational drug users. National survey on Drug Use and Health in 2013 showed that drug misuse among persons of 12 years or more has increased with passing years with marijuana being the most common illicit drug and CNS depressants and stimulants being most used as non-medial prescription drug.

Prescription drug crisis has not only affected the physicians, pharmacists but also law enforcement agencies, domestic life and workplaces. It needs to be seriously addressed.

Role of Health care professionals

Health care professionals as physicians, pharmacists, dentists, and nurses all are the frontline workers that can play their part in controlling the drug abuse. It is a leading public health issue. Reports from various analyses have revealed the prescription drugs that are abused in high ratio and the consequences of their abuse. This information must be considered by health professionals to identify and treat the potential drug abusers. They should be capable enough to report and early diagnose the prescription drugs being misused in their community. Their role in overcoming the prescription drug abuse or illicit drug use consists of but not limited to;

• Screening and assessment of patients during routine medical check up
• Patients using prescription medications that carries the risk of being misused, must be counselled and given advice to reduce the drug misuse and abuse.
• Refer the patients with drug use disorder or risk of disorder to assessment and care
• Provide an ongoing support in follow up to prevent the relapse.
• Before prescribing any medication, health professionals must assess the family history, patients’ mental condition, alternate medication, appropriate use and potential risk associated with misuse.

Types of Prescription drug abuse

Most commonly abused prescription drugs are opioids, central nervous system depressants and stimulants. Prescription drug abuse is now qualified as an epidemic. It can be in any form. The emergence of clinically effective prescription drug has also led to its non-medical use and misuse by using drugs for reasons and motives other than the prescribed ones.

• Non-medical use or misuse;

This includes the use of high doses, prolonged duration of treatment, alternate route of administration, use with other medications, using for other reason irrespective of prescriber’s instructions. It can be abuse, diversion and non-prescribed use.

• Drug Abuse: refers to the non-medical use with specific motive to alter the physical performance and mental state like euphoria by using opioids.
• Drug diversion; refers to the distribution of drug to the person to whom it is not prescribed without knowing the person’s motive.
• Non-Prescribed use; refers to the use of drugs originally prescribed for some other reason to treat a different condition for example, an analgesic drug which was prescribed for treating pain from injury may be used to treat anxiety disorder.

Lack of Awareness and knowledge of health care professionals

Healthcare Professionals mainly physicians are the key people in prescribing of medications. Lack of knowledge of health professionals regarding prescription drug use is adding fuel to this epidemic. In the US, a postal survey was conducted with 1000 general practitioners, internists and family physicians to assess their knowledge and attitude towards the abuse of prescription opioids. All of them were aware that prescription drug misuse is a problem in society but only 66% were able to correctly identify the main route of abuse was swallowing a pill, and 25% were not concerned about the potential for drug abuse. Although most of the physicians supported the regulatory and clinical interventions including checking of centralized database before prescribing (88%) and restriction in advertising of opioids (77%) but (33%) considered that these interventions would prevent the appropriate access to clinical treatment.

A study was conducted in Nigeria to evaluate the knowledge, perception, awareness and attitude of medical professionals regarding the prescription medicines misuse. 375 Doctors and pharmacists were the part of the research and 78.5% of the participants perceive that prescription medication misuse is common in society, 60% of them had a good knowledge of health issues related to drug abuse. However, there were discouraging results about the attitude of health professionals in diagnosing the prescription drug abuse among their patients or customers.

Health care professionals specifically in emergency departments are in ideal place to early detect and treat the substance misuse. A study was conducted in Ireland to assess their knowledge and attitude in early diagnosis of substance misuse and it showed that only 25-50 % gets detected and all others are either misdiagnosed or remain untreated. Health professional attitude towards substance users has a negative influence on patient’s care. This is a need of time to improve emergency doctors’ and nurse’s knowledge and attitude towards drug abuse and drug abusers.

Lack of Education of health care professionals

Pharmacists have a leading role in detecting and preventing the prescription drug abuse. A research was conducted in Florida at different levels of continuing education program. The aim was to assess the knowledge and professional practices regarding controlled drug misuse and addiction. 67.5% of pharmacists revealed that they have 2 hours or less of drug abuse education in their pharmacy school and 29% showed the discouraging results as they got no education regarding drug abuse. Pharmacists who had education of abuse and addiction performed better in in answering queries regarding abuse. Pharmacists with more education have better patient counselling skills. 53.7% of the participants had never referred any patient for drug treatment.

A survey with primary care physicians to evaluate their perception and concerns about opioid addiction and chronic pain was conducted. About 72% of physicians believed that their knowledge regarding management and treatment of opioid dependence is unsatisfactory. Many believed that medical training in not up to the mark and training programs must be started to address the chronic pain and addiction related problems with opioids.  It is evident from various surveys of Center on Addiction and
Substance Abuse that among the physicians only 40% have proper medical training regarding prescription drug abuse and addiction identification during their medical school. 43% do not even ask about the drug abuse with prescription drugs while taking history.

Lack of Communication among health care professionals:

A comparative study was conducted to evaluate the perception of pharmacist and physician concerning prescription drug abuse. Pharmacists perceive that 41% of patients are abusing the opioids as compared to physicians who perceive it to be 17%. This research showed the lack of communication among the prescriber and pharmacist. Another study also revealed similar observations that direct pharmacist to prescriber or prescriber to pharmacist communication regarding prescription drug abuse is rare. Although, indirect communication via patients, voice mail and staff is used the most.

Attitude towards Prescribing:

A survey in Canada revealed that patients misusing prescription drugs have a better access to physicians rather than those using illicit drugs. A National Survey on Drug Use and Health in 2012–2013 revealed that among patients of age 12 or more who were admitted to hospital for prescription drug misuse, annual average of 21% had pain relieving medications with one prescriber’s prescription and 2.6 % was prescribed from more than one doctor.

A survey was conducted to evaluate the prescribing pattern of opioid medications for pain by Primary care physicians. 91% of the respondent physicians were reported to prescribe opioids for pain relief. 81% mentioned that severe pain was the reason that opioid dependent patients are using opioids.

Illegal prescribing by physicians is rare but it exists. Malprescribing may be due to insufficient knowledge rather a deliberate effort. Arresting physicians by the DEA has decreased in practice from 81 in 1991 to 63 in 2005.

Prescription Drug Monitoring Programs was developed in the US to identify and report the drug diversions. The main aim was to provide information about illicit drugs and prescription drug misuse to the physicians and pharmacists.  The designs varied from state to state and it has the limitation of timely access by physicians so they can prevent or reduce the misuse of prescription drugs. 

Medical professionals’ knowledge, education, awareness and attitude towards drug abuse and abusers are negatively affecting the health care system.

• Lack of confidence in treating such patients, doubt about effectiveness of treatment and attitude towards addicted patients all lead to lower rates of implementation of evidence-based practices of early screening, assessment, treatment and follow up.
• Lack of education leads to poor patientcare as health professionals sometimes are unable to see the actual problem and only treats the addiction but not the reason behind it and this leads to relapse.
• Negative attitudes of health professionals towards substance abusers make the abusers lose confidence and motivation to get treated.

Interventions to create awareness and knowledge in health care professional

Health authorities must formulate the interventions to promote health and control the abuse of prescription drugs. Capacity building, public health interventions, education and early measures will help in reducing drug abuse.

Safe Med LA; a Coalition for coordinated effort to overcome the prescription drug abuse in Los Angeles County; has introduced clinical and policy interventions to reduce the mortality and improve the health outcomes relating to this endemic. These include;

• Safe Prescribing in Medical and Pharmacy practice; implementing guidelines for pain prescription in emergency departments. Pharmacists in retail pharmacies must have training to support safe prescribing.
• CURES is the California’s Prescription Drug Monitoring Program and prescribers must be encouraged to use this to identify the prescription drug abuse and improvise the prescribing pattern to control the misuse.

Higher Education

Education is required at all levels to prevent the drug abuse.

• Controlled substance education should be made mandatory in medical schools, pharmacy schools, and residency and training programs along with continuing education requirements.
• Residency programs must be started focusing on safety training and guidelines which will not only train the physicians about narcotics but other potentially abused drugs and illegal substances.
• Pharmacists along with pharmaceutical companies must educate health professionals about the potential abuse of prescription drugs and their abuse consequences.

In conclusion, Medical Professionals are in a challenging position to control the epidemic of prescription drug misuse and illegal drug use. Their lack of awareness regarding prescription and illicit drug safety, insufficient knowledge and training has led to an increase in drug abuse. Thus, coordinated efforts must be made to early detect, prevent and treat the patients of drug abuse. This can be achieved by launching training and residency programs to overcome the shortcomings of practicing professionals and improve their attitude towards drug abusers.  Physicians must screen and assess their patients and follow up to ensure they are practicing safe drug usage. Pharmacists must educate not only the physician but also the public about safe drug use and adverse consequences of illicit drug use alone and in combination with other drugs (prescription and illegal). This will lead to improved health outcomes with lower prescription drug abuse rates.

Harper Madison  

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