The 20th century’s War on Drugs focused on curbing the supply and illegal use of dangerous drugs, such as cocaine, marijuana and heroin. While the crisis involving illicit substances continues, a new—and potentially more dangerous— health epidemic has recently emerged: the increasing misuse of legal, heavily regulated prescription medications.
The inappropriate use or diversion of prescription drugs, particularly prescription pain medications, is a national health epidemic. According to the CDC, over 20,000 Americans die each year of prescription drug abuse, 14,800, or 74%, due to misuse of opioid pain medications.1 Opioid pain relievers now account for more overdose deaths than cocaine and heroin combined. In addition, misuse of prescription pain narcotics was responsible for more than 475,000 emergency room visits in 2009 – nearly double the rate five years prior.1 Estimated annual costs related to health, crime and productivity associated with illicit drug use, including prescription drug misuse, total more than $193 billion.2
For those suffering from chronic pain, however, prescription pain medications are often therapeutic necessities. Approximately 116 million Americans suffer from chronic pain – more than the number of people affected by diabetes, heart disease, and cancer combined.3 For many people, pain relief can only be achieved through prescription drug therapies.
Potentially addictive medications are the most commonly abused prescription drugs. They include opioid pain killers, such as oxycodone (e.g. OxyContin®, Percocet®), hydrocodone (e.g. Vicodin®, Lortab®) and methadone (e.g. Dolophine®, Methadose®). They also include central nervous system depressants, mainly prescribed to treat anxiety, including benzodiazepines such as alprazolam (e.g. Xanax®) and stimulants, commonly prescribed to treat attention-deficit hyperactivity disorder (ADHD), primarily amphetamine (e.g. Adderall).
In recent years, physicians have unexpectedly found themselves at the center of the new front of the prescription drug epidemic. The U.S. Drug Enforcement Administration (DEA) and state licensing boards regulate prescription of controlled substances for legitimate medical use, and set forth requirements
for physicians to exercise oversight of controlled prescription medications. Physicians who do not comply may face malpractice liability and criminal prosecution.4 In addition, 48 states and one territory have operating prescription monitoring programs or have passed legislation to implement them.5
Physicians have several tools to help monitor patients for prescription drug adherence, including: clinical observation and evaluation; requiring patients to sign ‘pain contracts’ that specify rules patients must follow; self-reporting questionnaires; interviewing a patient’s prior doctors; and reviewing past medical records. Yet, research suggests some physicians do not commonly employ these tools in practice.6 In addition, some patients may mislead their physicians about their drug use and urine drug tests may therefore provide an objective basis for assessing appropriate medications.
Laboratory testing to identify the presence of prescribed or non-prescribed drugs and drug metabolites aids physician monitoring for drug misuse. Organizations such as the American Pain Society and American Academy of Pain Medicine in their 2009 Clinical Guidelines on “The Use of Chronic Opioid Therapy in Chronic Noncancer Pain”, and the American College of Occupational and Environmental Medicine in their 2011 “Guidelines For The Chronic Use of Opioids”, have included recommendations for urine drug testing.
About this study
This study provides insight into trends in the misuse of prescription drugs.
As the world’s leading diagnostic testing company, Quest Diagnostics is well positioned to identify trends in prescription drug monitoring and misuse. Our comprehensive prescription drug testing services build on our long-standing leadership in workplace drug testing for employers. For information about the use of drugs by American workers, refer to Quest Diagnostics Drug Testing IndexTM reports at QuestDiagnostics.com/DTI.
For the present study, Quest Diagnostics medical and health informatics experts analyzed a national sample of 75,997 de-identified urine specimen results performed in 2011. The study included results of patients of both genders, ranging in age from 10 years old and above, from 45 states and the District of Columbia. The objectives of our study were to assess the scope and demographic drivers of prescription drug misuse in America and the impact of laboratory testing on monitoring for prescription drug adherence.
All patients were tested using our proprietary prescription drug monitoring service and medMATCH reporting methodology for tests for up to 26 commonly prescribed and abused drugs, including pain medications, central nervous system medications and amphetamines, as well as illicit drugs such as marijuana and cocaine. Our medMATCH service reports if a prescribed drug(s) and drug metabolite(s) are in a specimen, as indicated by the ordering physician, as well as other drugs. A physician’s orders specify medications prescribed and which drugs, including illicit, the physician orders for testing. Consistent results are those which indicate only the prescribed drug(s) for the patient was detected. Inconsistent results suggest that the patient did not take the specified drug(s), took the drug with other drugs, or took drugs not indicated by the physician. For more information, refer to “Interpreting a Test Result” called out in the margin.
All specimens are screened by immunoassay-based methods and all positive results were confirmed by mass spectrometry, the most sensitive drug testing method.
Our findings include:
* The majority of patients tested misused their prescription medications, potentially putting their health at risk. Test results of the majority of patients (63%) were inconsistent with a physician’s orders. Comparable rates of inconsistency were found among all commonly prescribed drug classes tested.
* Many patients took or combined additional drugs without physician oversight. Of those patients whose results were inconsistent, more than half (60%) tested positive for drugs not specified by the ordering physician. This finding demonstrates that a large number of patients are using drugs, potentially in dangerous combinations, without the oversight
of a trained healthcare professional.
* A large number of patients showed no drug in their specimen. In 40% of inconsistent cases, no drug was detected. This finding suggests many patients are failing to take their prescription medication as directed, possibly due to financial constraints (medications too costly), poor compliance or diversion (illegal sale).
* Anyone is at risk of misuse. While some groups, such as the very young, were more likely to misuse, our data suggests that women and men of all ages are at risk, regardless of income level and health plan membership.
* Repeat testing was associated with lower prescription drug misuse. Among patients tested 30 days or more after an initial screen, the number of patients with inconsistent results declined by 10%. Our data supports medical recommendations that physicians perform routine urine testing to monitor prescription drug misuse.