Nonmedical Use Of Pharmaceuticals Research Articles

Commentary on McCoy et al.: More pieces of the mosaic describing outcomes of the Australian up-scheduling of over-the-counter codeine to prescription only.

Data from the Australian Institute of Health and Welfare (AIHW) about trends in treatment and non-medical use of codeine and other opioids supports other recent studies indicating there has been no unintended harm from the February 2018 upscheduling of over-the-counter codeine to prescription only. Understanding the trends in non-medical use of pharmaceutical drugs and its consequences relies upon triangulating signals from different data sources to provide a mosaic overview [1]. McCoy et al.’s recent work forms an integral part of the picture in understanding outcomes from a major Australian opioid policy decision: the removal of codeine sales without a prescription [2]. The study examined those who regularly used codeine prior to the re-scheduling change and found reductions in codeine use, no increase in use of other opioids and reduced levels of opioid dependence following codeine re-scheduling. Small increases in general practitioner visits but a reduction in emergency department visits for opioids was also observed, alongside no change in mental health symptoms and an overall reduction in pain. These findings are consistent with work demonstrating a reduction in intentional poisonings with codeine [3], an analysis of population-level opioid supply showing no evidence of substitution to other opioids [4] and a study that found decreased codeine deaths, emergency department presentations and poisonings [5]. Collectively, these data sources provide a coherent picture indicating this policy change did not appear to have unintended harms. This may be linked to the substantial investment and implementation efforts that occurred at the time to raise awareness and support referral for pain management and alcohol and other drug treatment [6]. We write to describe the effects of up-scheduling using several sources provided by the AIHW, which represent a final piece of the puzzle. The National Drug Strategy Household Survey is conducted every 3 years. In 2016, past 12-month non-medical use of pharmaceuticals was the second leading category of drug misuse (4.8% of adults aged 14 or more years) after cannabis [7]. Non-medical use of painkillers/opioids was reported by 3.6% of the population: 29% misused painkillers/opioids at least weekly and 10.7% reported not being able to stop or cut back. Of those reporting misuse of painkillers/opioids, 74.8 and 40.6% reported non-medical use of OTC or prescription codeine, respectively. The prevalence of OTC codeine product misuse was highest in youths aged 14–19 years; 89% of those misusing painkillers/opioids reported this in the previous 12 months. In the 2019 survey, with codeine no longer available without a prescription, the proportion of people using codeine for non-medical purposes halved from 3.0% in 2016 to 1.5% [8]. The proportion of people who had recently misused pharmaceuticals decreased from 4.8% in 2016 to 4.2% in 2019. This included a decrease in the proportion of those recently misusing pain-killers/opioids from 3.6 to 2.7% during this period: of these, there was a statistically significant decrease in the proportion who had misused codeine, from 87.95% in 2016 to 60.7% in 2019. AIHW reports on episodes of care for clients seeking treatment from publicly funded Australian drug treatment services [9, 10] including reporting on trends where codeine was a drug of concern (Fig. 1). The number of codeine-related combined principal and additional drugs of concern closed episodes more than halved (51.1%), from 2711 in the last full financial year when codeine was available OTC (2016–17) to 1326 in the most recent year (2019–20). AIHW also reports standardized data concerning opioid agonist treatment with methadone or buprenorphine for the treatment of opioid use disorder [11]. From 2014 to 2020 heroin and pharmaceutical opioids accounted for 60–65% and 35–40% of the opioid of dependence, respectively (where reported). In the last calendar year (2017), when codeine was available OTC without a prescription, it accounted for 2095 cases (17.5% of all pharmaceutical opioids of dependence reported). This increased to 2332 (19%) in 2018, the first year following up-scheduling on 1 February 2018, and decreased each subsequent year to 2014 (15.7%) in 2020—the lowest proportion since 2015. The treatment and non-medical use data presented here support recent studies that indicate no evidence of unintended harms with codeine re-scheduling. This differs from that seen with re-scheduling of hydrocodone in the United States with a shift to other opioids [12]. This also contrasts with perceptions of pharmacists and consumers, and with concerns raised in submissions to the Therapeutic Goods Administration [13]. These findings may give the small number of countries who continue to supply codeine without a prescription confidence that, with appropriate implementation efforts, such a change can be made without adverse consequences for individuals and the community. Suzanne Nielsen was a co-author in the Addiction paper McCoy et al. to which we refer for this commentary.

Enhancement motivations for using prescription drugs among young adults in Nigeria

BackgroundThe desire for enhancement is a common motive for non-medical use of prescription drugs in Western countries. Little is known about the factors that motivate use in non-Western contexts. MethodsThe study explores access to prescription drugs and the motivations for using them among educated young adults in a city located in Anambra State, South-Eastern Nigeria. Semi-structured interviews were conducted with 23 participants aged 23–29 years. Data were thematically analysed using NVivo 12 Software. ResultsThe data indicate that prescription drugs are widely available and easy to access without a prescription in the unregistered ‘pharmacies’ and medicine shops that form part of Nigeria's informal healthcare system. Social networks are also a source of drugs. Participants shared detailed perspectives on their use of prescription drugs, revealing that codeine, Rohypnol, and high doses of tramadol are used to enhance performance in several social life domains. These drugs were described as enhancing performance and productivity in the workplace, and were taken by participants working as labourers and sales representatives. Male participants also shared accounts of using high doses of tramadol to improve stamina and skill in sports. Some participants took Rohypnol to enhance their creative and academic performance. Participants stated that drug use enabled them to meet the pressures associated with work, academia, and parental expectations. ConclusionThe findings suggest that prescription drugs are being strategically and instrumentally deployed by users to enhance different domains of social life. This is driven by users’ experiences of the drugs’ bodily effects, and it is supported by a context in which self-medication and informal healthcare are common. Participants’ reasons for seeking drug-induced enhancement reflect sociocultural factors within Nigeria and some West African countries, such as employment scarcity and the championing of sporting prowess. The findings can be used to inform the design of tailored approaches to reduce the harms presented by the non-medical use of pharmaceuticals among young adults.

Students’ non-medical use of pharmaceuticals to manage time in everyday life crises

This article examines students’ narratives of lived experiences with non-medical uses of prescription pharmaceuticals (NMUP) and analyzes how their experiences of time in everyday life influence the meanings they ascribe to their NMUP. The analysis draws on sociological notions of time and 28 in-depth qualitative interviews with young adults (age 20-30), who have used pharmaceuticals non-medically while enrolled at a university or college in Denmark. The article focuses on how a majority of students associate their NMUP with situations in which they experience urgency and a crisis of temporal agency due to their inability to pursue perceived necessary rhythms of studying or resting. It examines how these students consider NMUP a normative exception yet employ pharmaceuticals to manage their embodied and everyday life rhythms in order to relief senses of urgency and re-gain temporal agency. The article suggests the notion ‘everyday life crises’ to account for how students reflect that the time pressure associated with the experience of urgency relate to their everyday lives’ temporal practices, structures and norms. In conclusion, the article suggests that the analysis of NMUP as a practice embedded in everyday living highlights the relevance of conceptualising NMUP as ‘time work’ and suggests that future prevention campaigns should focus on students’ experiences of temporal conflicts in everyday life.

U.S. Emergency Department Visits Resulting From Nonmedical Use of Pharmaceuticals, 2016

National data on morbidity from nonmedical use of pharmaceuticals are limited. This study used nationally representative, public health surveillance data to characterize U.S. emergency department visits for acute harms from nonmedical use of pharmaceuticals and to guide prevention efforts. Data collected in 2016 from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project were analyzed in 2018 to calculate national estimates of emergency department visits for harms from nonmedical use of pharmaceuticals. Based on 5,130 surveillance cases, there were an estimated 358,247 emergency department visits (95% CI=280,675, 435,819) in 2016 for harms from nonmedical use of pharmaceuticals and 41.1% resulted in hospitalization (95% CI=32.3%, 49.8%). One half (50.9%, 95% CI=46.6%, 55.3%) of estimated visits involved patients aged ≤34 years; more than one half of estimated visits also involved non-pharmaceutical substances (52.9%, 95% CI=49.7%, 56.1%), including illicit drugs in 34.1% (95% CI=30.9%, 37.2%) and alcohol in 21.8% (95% CI=19.8%, 23.9%). Overall, benzodiazepines were implicated in 46.9% (95% CI=42.5%, 51.2%) of estimated emergency department visits for nonmedical use of pharmaceuticals but were the only substance implicated in just 6.5% (95% CI=5.1%, 7.9%). Prescription opioids were implicated in 36.2% (95% CI=30.8%, 41.7%) of estimated emergency department visits and were the only substance implicated in 11.3% (95% CI=8.6%, 14.0%). Although prescription opioids or benzodiazepines are frequently implicated in emergency department visits for nonmedical use, because other substances and additional pharmaceuticals are most often involved, prescribing clinicians should consider implementing specific screening to address polysubstance use and, when warranted, treatment interventions.

Safe drugs in drug facilitated crimes and acute intoxications in Northern Italy.

Toxicological analyses are often performed in drug-facilitated sexual assaults (DFSA), when the victim shows or reports impaired consciousness and reduced ability. However, in other crimes or fatalities, especially in cases of concurrent natural disease or when another likely cause of death has been established, the involvement of drugs can be overlooked. The aim of this study is to report a series of cases of (i) victims of drug-facilitated crimes (DFC) other than DFSA and (ii) victims of acute intoxications, in which "licit" psychoactive drugs were found in blood samples, with the aim of understanding in which circumstances and to what extent prescription drugs have been used for non-medical purposes in recent Italian casuistry. Circumstantial, autopsy, and toxicological data were collected through a retrospective analysis performed between 2013 and 2017 in the Forensic Toxicology Unit of the University of Bologna. Cases of "DFC other than DFSA" and "Acute Intoxication" in which "psychoactive drugs" or "prescription drugs" or "licit drugs" were found in the blood samples of the victims were included in the study. Nine cases of DFC other than DFSA, and 11 cases of acute intoxication, were identified. Different categories of "licit" psychoactive drugs (e.g. hypnotics, antipsychotics, antidepressants, anticonvulsants) had been used to facilitate diverse types of crime (homicide, robberies, elder abuse, fatal poisoning) or acute intoxication (suicide, attempted suicide, accidental death). The circumstances of these cases, as well as toxicological findings in blood samples and other relevant forensic elements, are reported, summarized and discussed in this paper. The non-medical use of pharmaceuticals has been identified by recent forensic literature and the present study as a significant and growing phenomenon, and its implication in fatalities should be taken into consideration and accurately investigated through appropriate toxicological analysis. Our study presents an overview of the circumstances of non-medical use of prescription drugs, usually considered "safe drugs", and their involvement in cases of DFC, suicides and accidental intoxication. In order to estimate the real incidence of these medications in DFC and acute intoxication, and thus collect more analytical and contextual data, further studies are needed, along with effective cooperation among police officers, clinicians, forensic pathologists, and toxicologists.

A "Middle Way": Introducing a Flexible Year-Long Program to Prepare for Certification in Addiction Medicine.

Substance use is endemic in the USA. In 2012, an estimated 22 million Americans, or 8.5 % of the population, met criteria for a substance use disorder in the past year [1]. In 2011, there were 2.5 million emergency department visits that involved drug misuse or abuse, a 52 % increase since 2004. Half of these visits involved the nonmedical use of pharmaceuticals, which is an increase of 132 % since 2004 [2]. Yet despite the tremendous need for treatment, only 11 % of addicted individuals received specialized substance abuse treatment in 2012 [1]. So, how can this enormous treatment deficit be addressed? Given the high prevalence of substance use disorders in a variety of clinical settings (ranging from 8 to 29% in inpatient settings and up to 20 % in primary care) [3, 4], it would make sense to identify individuals with substance use disorders in these settings and then connect them to treatment. Screening and brief intervention have been shown to be effective in primary care and an increasing number of settings, and models of integration into routine practice have been described [5]. Successful referral to substance abuse treatment from a primary care setting has even been shown to improve depression [6]. However, many surveys have found that physicians do not feel prepared to diagnose or treat addiction, and residents do not feel that they have received sufficient training in addictive disorders during residency [7]. In addition to proposals for curriculum design in residencies and medical schools, online-based programs have been implemented to teach skills to physicians, residents, and medical students, with varied success [8]. Psychiatry residents can subspecialize in addiction psychiatry by training in an Accreditation Council on Graduate Medical Education (ACGME)-certified addiction psychiatry fellowship program. In addition, physicians from psychiatry and other specialties can become certified by the American Board of Addiction Medicine (ABAM). There are two pathways: (1) a 1-year fellowship training similar to addiction psychiatry programs but administered by the American Board of Addiction Medicine Foundation or (2) to qualify to take the ABAM exam after completing 50 h of addiction-related continuing medical education (CME) courses and practicing in the field of addiction medicine for 1 year. The first pathway requires an additional year of training, which can be difficult for many physicians with large amounts of medical education debt. The second pathway does not provide much structure, making it difficult to physicians to stay motivated. To encourage physicians to complete the second pathway, we developed the Rutgers New Jersey Medical School Executive Fellowship in Addiction Medicine (Exec-FAM). In addition to providing structure for ABAM exam requirements, we hope this fellowship will increase a practitioner’s confidence and accuracy in assessing and diagnosing addictive disorders, and raise her or his comfort level in providing evidence-based treatment for addicted patients.

Primary Care Behavioral Interventions to Reduce Illicit Drug and Nonmedical Pharmaceutical Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for illicit drug use. The USPSTF reviewed the evidence on interventions to help adolescents who have never used drugs to remain abstinent and interventions to help adolescents who are using drugs but do not meet criteria for a substance use disorder to reduce or stop their use. This recommendation applies to children and adolescents younger than age 18 years who have not been diagnosed with a substance use disorder. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care-based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. (I statement).

Primary Care Behavioral Interventions to Prevent or Reduce Illicit Drug Use and Nonmedical Pharmaceutical Use in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force

Drug use among youths is associated with negative health and social consequences. Even infrequent use increases the risk for serious adverse events by increasing risk-taking behaviors in intoxicated or impaired persons. To systematically review the benefits and harms of primary care-relevant interventions designed to prevent or reduce illicit drug use or the nonmedical use of prescription drugs among youths. PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through 4 June 2013; MEDLINE through 31 August 2013; and manual searches of reference lists and gray literature. Two investigators independently reviewed 2253 abstracts and 144 full-text articles. English-language trials of primary care-relevant behavioral interventions that reported drug use, health outcomes, or harms were included. One investigator abstracted data from good- and fair-quality trials into prespecified evidence tables, and a second investigator checked these data. Six trials were included, 4 of which examined the effect of the intervention on a health or social outcome. One trial found no effect of the intervention on marijuana-related consequences or driving under the influence of marijuana; 3 trials generally found no reduction in depressed mood at 12 or 24 months. Four of the 5 trials assessing self-reported marijuana use found statistically significant differences favoring the intervention group participants (such as a between-group difference of 0.10 to 0.17 use occasions in the past month). Three trials also reported positive outcomes in nonmedical prescription drug use occasions. The body of evidence was small, and there were heterogeneous measures of outcomes of limited clinical applicability. Trials primarily included adolescents with little or no substance use. Evidence is inadequate on the benefits of primary care-relevant behavioral interventions in reducing self-reported illicit and pharmaceutical drug use among adolescents. Agency for Healthcare Research and Quality.

Kitchen chemistry: A scoping review of the diversionary use of pharmaceuticals for non‐medicinal use and home production of drug solutions

Misuse of pharmaceuticals is of increasing drug policy and public health concern. A scoping review was conducted on the diversionary use of pharmaceuticals for non-medicinal use and home production of drug solutions. The research question was broad: What is known from the existing literature about the diversion of pharmaceuticals for non-medicinal use and for home production of drug solutions? The scoping process centred on the systematic selection, collection, and summarization of extant knowledge within this broad thematic remit. One hundred and thirty-four records were grouped into discrete thematic categories namely: non medicinal use and tampering with pharmaceuticals, oral misuse of codeine cough syrups, homemade drug solutions, and home-produced drug-related harms in the narrative review design. Forms of abuse of codeine cough syrup include mixtures with alcohol or soft drinks ('Purple Drank'), with kratom leaves ('Kratom cocktails'), or chemically altered to extract dextromorphan ('Lemon Drop'). Production of homemade opiates ('Cheornaya', 'Kolyosa', Himiya', 'Braun', 'Krokodil'), methamphetamine ('Vint', 'Pervitin'), methcathinone ('Jeff'), and cathinone ('Boltushka') are described. Displacement patterns between the non-medical use of pharmaceuticals, commercial, and homemade drugs appear dependent on availability of opiates, prescribing practices, supervision of substitution drug dosing, availability of cheap ingredients, policing, and awareness of harms. Adverse health and social consequences relate to the use of unknown and contaminated (end) substances, injecting practices, redosing, medical complications, and death. The review highlights a public health imperative requiring a multidisciplinary approach to quantify potential impact and required integrated policy responses incorporating international regulation, enforcement, health surveillance and service delivery.

The value and pitfalls of speculation about science and technology in bioethics: the case of cognitive enhancement

In the debate on the ethics of the non-medical use of pharmaceuticals for cognitive performance enhancement in healthy individuals there is a clear division between those who view "cognitive enhancement" as ethically unproblematic and those who see such practices as fraught with ethical problems. Yet another, more subtle issue, relates to the relevance and quality of the contribution of scholarly bioethics to this debate. More specifically, how have various forms of speculation, anticipatory ethics, and methods to predict scientific trends and societal responses augmented or diminished this contribution? In this paper, we use the discussion of the ethics of cognitive enhancement to explore the positive and negative contribution of speculation in bioethics scholarship. First, we review and discuss how speculation has relied on different sets of assumptions regarding the non-medical use of stimulants, namely: (1) terminology and framing; (2) scientific aspects such as efficacy and safety; (3) estimates of prevalence and consequent normalization; and (4) the need for normative reflection and regulatory guidelines. Second, three methodological guideposts are proposed to alleviate some of the pitfalls of speculation: (1) acknowledge assumptions more explicitly and identify the value attributed to assumptions; (2) validate assumptions with interdisciplinary literature; and (3) adopt a broad perspective to promote more comprehensive reflection. We conclude that, through the examination of the controversy about cognitive enhancement, we can employ these methodological guideposts to enhance the value of contributions from bioethics and minimize potential epistemic and practical pitfalls in this case and perhaps in other areas of bioethical debate.

Problematizing “Drugs”: A Cultural Assessment of Recreational Pharmaceutical Use among Young Adults in the United States

Recent trends in the recreational use of pharmaceuticals among young adults in the United States highlight a number of issues regarding the problematization of drugs. Two constructions of recreational pharmaceutical use are analyzed. On the one hand, categorical frameworks based upon epidemiological data are created by institutions and media and depict recreational pharmaceutical use as illicit in unqualified, absolute terms. This is done through discourses that equate nonmedical pharmaceutical use with culturally established forms of illicit drug use. On the other hand, users' multi-dimensional constructions of recreational pharmaceutical use emphasise social context, personal experience, and individual risk perceptions. The problematization of recreational pharmaceutical use points to intergenerational conflicts, as well as to struggles over definitions of "drug abuse" and "hard drugs", and highlights the impact of pharmaceuticalization on recreational drug use among young people.

Pharmaceutical drugs: The delicate balance between reducing pain and reducing harm

Pharmaceutical drugs: The delicate balance between reducing pain and reducing harm

Pragmatic neuroethics: improving treatment and understanding of the mind-brain

Today the measurable health burden of neurological and mental health disorders matches or even surpasses any other cluster of health conditions. At the same time, the clinical applications of recent advances in neuroscience are hardly straightforward. In Pragmatic Neuroethics, Eric Racine argues that the emerging field of neuroethics offers a way to integrate such specialties as neurology, psychiatry, and neurosurgery with the humanities and social sciences, neuroscience research, and related healthcare professions, with the goal of tackling key ethical challenges and improving patient care. Racine provides a survey of the often diverging perspectives within neuroethics, offers a theoretical framework supported by empirical data, and discusses the neuroethical implications of such issues as media coverage of neuroscience innovation and the importance of public concerns and lay opinion; nonmedical use of pharmaceuticals for performance enhancement; and the discord between intuitive notions about consciousness and behavior and the scientific understanding of them. Racine proposes a pragmatic neuroethics that combines pluralistic approaches, bottom-up research perspectives, and a focus on practical issues (in contrast to other more theoretical and single-discipline approaches to the field). [He discusses ethical issues related to powerful neuroscience insights into the mechanisms underlying moral reasoning, cooperative behavior, and such emotional processes as empathy.] In addition, he outlines a pragmatic framework for neuroethics, based on the philosophy of emergentism, which identifies conditions for the meaningful contribution of neuroscience to ethics, and sketches new directions and strategies for meeting future challenges for neuroscience and society. Basic Bioethics series