Medical Director, Restacare Free Clinic, Concord, California, USA
The article by Irene Scholz and Associates , published in Swiss Medical Weekly, is another chapter in the ongoing, world-wide saga of the diversion of prescription and OTC medications to use as recreational drugs. It may be that some intoxications by benzodiazepines and opiates have been suicides, but most of the diversions were undoubtedly efforts to achieve some kind of altered psychological state.
The article highlights four main areas of concern: (1) the issue of the recreational diversion of prescription and OTC drugs is world-wide and not isolated to a particular country or continent; (2) the supply of prescription and OTC medications available for diversion appears to be broad and diverse; (3) The co-use of multiple substances magnifies the risks; and (4) the case of propofol poisoning is troublesome and requires a more in-depth study.
The authors document in their introduction that the issue of diversion is global. While many scientific articles on diversion originate in the United States, it is because physicians in that country have set up systems to look for it. Other countries are doing the same and the authors cite the European Drug Emergencies Network as an example. As more monitoring systems come on line, the problem of diversion will become more known to the scientific and lay communities.
The list of diverted medications discovered in this study include opioids, methadone, benzodiazepines, antipsychotics, and amphetamines. That is a lot of pills available on the market for people to take. Is there really that much anxiety and sleep deficit in the patient population to warrant the large number and variety of benzodiazepines on the market? Is it really necessary for the world-wide medical profession to treat every worry and anxiety with a chemical? Clearly, the fewer pills on the market, the less the likelihood for diversion. The same can be said for opioids and amphetamines. Is there that much ADHD and narcolepsy out there to warrant the massive production of these medications?
Intravenous fluid administration was provided in 277 cases in Scholz’s study and intubation in 11 cases. This indicates that a significant number of people would probably have died without an aggressive emergency medical response system. The study showed that co-use of cocaine, alcohol, and marijuana substantially potentiated the sedative effects of the diverted medications. Given that benzodiazepines were the most diverted medication and that alcohol was the most common legal co-toxicant, the risk of respiratory depression in this type of drug experimentation is high. A properly targeted public education campaign might decrease the number of such incidents by pointing to the huge risks of using alcohol and sedative-hypnotic medications together.
The motivators associated with the abuse of prescription drugs by teenagers in this study were self-medication to treat anxiety or insomnia, to enhance performance, to get high, or to experiment with the drug effects. Among older patients, the reasons were more restricted, including self-treatment of chronic pain and anxiety. Significantly, women were found to keep more unused medications on hand and used additional drugs to enhance the effect of analgesics.
It seems reasonable to suppose that efforts to decrease the need and use of respiratory depressants, analgesics, and other drugs might decrease the number of drugs that are diverted. Substitute treatments such as cognitive therapies are a viable alternative to medications in the treatment of anxiety and depression. They are more work for the physician and the patient, but they are certainly safer than a pill. Medication disposal containers at locations that patients frequent such as doctor’s offices and pharmacies can give people a convenient place to discard surplus medications to keep them out of teenage hands. Education targeted at the deadly combination of prescription medications and OTC’s may be beneficial if properly presented.
Finally, the diversion of propofol by a physician is especially troublesome. Before the death of Michael Jackson in Los Angeles, few – if any – healthcare professionals thought of this useful general anaesthetic as a drug of abuse. Of special note is the one case in the author’s study which reinforces the medical homily that any medication or OTC can become a drug of abuse in the right person under the right circumstances. Clearly, this case calls for a broad and intense collection of data in various global health care settings to further define how common the problem is and to answer the questions of why and how people divert this medication.
No financial support and no other potential conflict of interest relevant to this article was reported
James E. Lessenger, MD, 750 W. K St, Benicia, CA 94510, USA, Agbook[at]lessenger.net
1 Scholz I, Schmid Y, Exadaktylos AK, Haschke M, Liechti ME, Liakoni E. Emergency department presentations related to abuse of prescription and over-the-counter drugs in Switzerland: time trends, sex and age distribution. Swiss Med Wkly. 2019;149:w20056 . http://dx.doi.org/10.4414/smw.2019.20056 PubMed
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