DE: Substance Abuse, Chemical Depence, and Drug DiversionPage 3 of 12

1. Abuse of Controlled Substances

The misuse and abuse of drugs is a crisis, in our country and around the world. By 2020 mental health and substance abuse disorders will surpass all physical diseases as a major cause of disability worldwide. Abuse of prescription drugs is the largest drug problem in the United States, and one that is growing. According to the Centers for Disease Control and Prevention (CDC), people from all age groups, ethnic backgrounds, and genders are affected by this disease.

Accidental overdose and misuse of prescription drugs leads to the severe consequence of death and addiction. The 2013 National Survey on Drug Use and Health (NSDUH) indicates that 15.2 million people aged 12 or older used prescription drugs nonmedically in the past year, and 6.5 million did so in the past month. Prescription drugs are abused and misused more often than any other drug except marijuana and alcohol (SAMHSA/NSDUH, 2014a).

Defining the Problem

Medical professionals face a dilemma because they need prescription drugs for patients in pain but they also need to prevent the diversion and misuse of the drugs. Among the prescription drugs diverted and misused are opioid analgesics, powerful painkillers that are medically indicated in the treatment of chronic pain; however, when the patient takes the wrong dose, or the wrong person takes the opioid pain medication, consequences can be deadly.

While the sales of opioid analgesics increased four-fold between 1999 and 2010, the United States concurrently experienced an almost four-fold increase in opioid overdose deaths (SAMHSA, 2014). Other consequences of the abundance of opioids include emergency department visits and admissions, falls and fractures in older adults, and initiating injection drug use, which increases risk for infections such as hepatitis C and HIV.

In 2010 Delaware’s drug-induced overdose death rate (16.4 per 100,000 ) exceeded the national average (12.9 per 100,000) (ONDCP, 2013). In 2012 Delaware Governor Jack Markell established the Delaware Prescription Drug Action Committee to improve access to treatment, best practices, data tracking, provider education and public education (DPDAC, 2013). In October 2014 the state launched a new information website that emphasizes prevention, treatment, and recovery ( (DHSS, 2014).

The Delaware Board of Nursing Rules and Regulations now require Registered and Licensed Practical Nurses to complete continuing education (CE) on substance abuse. Starting with the next renewal, at least three of the required contact hours must be in the area of substance abuse (Section

This policy is a response to the state’s need for additional education about drug diversion and abuse mitigation. The following are some statistics for the State of Delaware.

Delaware has the tenth highest drug overdose mortality rate in the United States, with 16.6 per 100,000 people suffering from drug overdose fatalities, according to a new report, Prescription Drug Abuse: Strategies to Stop the Epidemic 2013 (TAH, 2013).

Between 1999 and 2010, annual age-adjusted drug overdose mortality rates in Delaware rose 156 percent, from 6.5 in 1999 to 16.5 in 2010. The increasing trend in drug overdose mortality appeared in both male and female rates, with the female rate more than tripling and the male rate doubling in the ten-year span. Despite the larger proportional increase in the female rate, males had a 2010 mortality rate 45 percent higher than the female rate (19.6 vs. 13.5 deaths per 100,000) (DHSC, 2013).

According to the National Survey on Drug Use and Health, 8.99 percent of Delaware residents reported using illicit drugs in the past month, compared to the national average of 8.82 percent (ONDCP, 2013).

In 2010–2011 Delaware was one of the top ten states in several drug-use categories: past-year nonmedical pain reliever use among persons 12 or older; past-month use of illicit drugs other than marijuana among persons 12 or older; and illicit drug dependence among persons 12 or older and young adults 18-15 (ONDCP, 2013).

The rate of drug-induced deaths in Delaware is higher than the national average (ONDCP, 2013). As a direct consequence of drug use, 147 persons died in Delaware in 2010. This is compared to the number of persons in Delaware who died from motor vehicle accidents (111) and firearms (88) in the same year. Delaware drug-induced deaths (16.4 per 100,000 population) exceeded the national rate (12.9 per 100,000) (ONDCP, 2013).

What is the role of nurses in the problem of prescription drug diversion, misuse, and abuse? Because nurses are the health professionals who treat the most patients, they are in a unique position to educate, identify, and intervene with patients and colleagues who are at risk for prescription drug misuse and abuse. Recognizing the signs of misuse and risk factors of drug abuse and diversion by patients and fellow healthcare professionals is an important responsibility of nurses. Educated nurses can be instrumental in changing patterns of misuse and abuse of prescription drugs for individuals, colleagues, and communities, and thereby reducing the public health epidemic.

Glossary of Terms

Aberrant drug-related behaviors: any medication-related behaviors that depart from strict adherence to the physician-prescribed plan of care, ranging from mildly problematic behavior (such as hoarding medications) to illegal acts (such as selling medications).

Addiction: a primary, chronic, neurobiologic disease whose development and manifestation is influenced by genetic, psychosocial, and environmental factors. Addiction behaviors often include impaired control over use, compulsive use, continued use despite resulting harm, and craving (Corsini & Zacharoff, 2014).

Abuse/nonmedical use: Abuse is the use of an illicit drug or the intentional self-administration of a prescription (or over-the counter) medication for any nonmedical purpose, such as altering one’s state of consciousness, eg, “getting high.” However, some critics dislike the term abuse being applied to substance use disorders and claim it is inaccurate and reflects morality-based language to depict what may actually be a medical condition (Corsini & Zacharoff, 2014).

Chronic pain: any pain that last more than 12 weeks, but may last for months or years. Whereas acute pain is a normal sensation that alerts the body to injury or damage, chronic pain persists. Chronic pain may result from an injury or an ongoing cause such as illness, or there may be no clear cause. Chronic pain often limits a person’s activities of daily living (ADLs) and movement, and is often accompanied by other health problems (NIH, 2011).

Diversion: the intentional removal of a medication from legitimate distribution and dispensing channels. Diversion also involves the sharing or purchasing of prescription medication between family members and friends or individual theft from family and friends (Corsini & Zacharoff, 2014). Diversion can also occur in healthcare settings if health professionals divert medication from the intended recipient.

Misuse: any therapeutic use of a medication other than as directed or indicated, whether intentional or unintentional, and regardless of whether it results in harm. Increasing a medication dose without clinician approval is misuse, whether the reason is dependence, tolerance, desire to achieve greater therapeutic effect, or forgetfulness (Corsini & Zacharoff, 2014).

Physical dependence: a state in which the body has adapted to a drug or class of drugs to the degree that withdrawal syndrome occurs upon abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist (Corsini & Zacharoff, 2014).

Pseudoaddiction: a state of inadequate analgesia that may lead to aberrant drug-related behavior, such as increasing dosage without a physician’s order or acquiring more than one prescription.

Tolerance: a state in which the body has adapted to a drug or class of drugs over a prolonged period of use to the degree that there is a decrease or loss of therapeutic effect over time, or the need to escalate the dose to maintain the same therapeutic effect (Corsini & Zacharoff, 2014).

Loss of tolerance: When a person stops taking a drug or class of drugs after taking it for a long time, loss of tolerance occurs. Serious adverse effects, including overdose, can occur if the person takes the previously tolerated dose of the drug (SAMHSA, 2014d).

Controlled Substances

Drug abuse is not a new problem. The United States Congress passed the first Controlled Substances Act in 1970, but addictive drugs were first outlawed in America in the early 1900s. The current, 2012, Controlled Substances Act has five schedules, known as schedules I, II, II, IV, and V.

Source: DEA, CSA, 2014.

Controlled Substances, 2012

DEA schedule

Medical use/abuse potential

Examples of abused drugs

Schedule 1

No accepted therapeutic use. Lack of safety even under medical supervision. High potential for abuse; abuse may lead to severe psychological or physical dependence

Heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“Ecstasy”)

Schedule II

Accepted therapeutic use. Highly restricted. High potential for abuse; abuse may lead to severe psychological or physical dependence

Amphetamine (Dexedrine, Adderall), methamphetamine (Desoxyn), methylphenidate (Ritalin), amobarbital, glutethimide, pentobarbital, and hydrocodone (Vicodin, Lortab), oxycodone (OxyContin, Percocet, Tylox)

Schedule III

Accepted therapeutic use. Highly restricted. Less high potential for abuse; abuse may lead to moderate or low physical dependence or high psychological dependence.

Products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine), and buprenorphine (Suboxone), benzphetamine (Didrex), phendimetrazine, ketamine, and anabolic steroids such as Depo-Testosterone

Schedule IV

Accepted therapeutic use. Low potential for abuse relative to Schedule I, II, and III drugs; abuse may lead to limited physical dependence or psychological dependence.

alprazolam (Xanax), carisoprodol (Soma), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion)

Schedule V

Accepted therapeutic use. Low potential for abuse relative to Schedule I, II, III, and IV drugs; abuse may lead to limited physical dependence or psychological dependence.

Cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC, Phenergan with Codeine), and ezogabine

On August 22, 2014, the U.S. Drug Enforcement Agency (DEA) formally rescheduled hydrocodone combination products (HCPs), moving them from Schedule III to Schedule II of the Controlled Substances Act.