Nonmedical use of prescription drugs

Abstract

The current COVID-19 pandemic has dominated the global headlines in the past year. In this setting, it is perhaps easy to push other, equally challenging, global health priorities into the background. The long-term impact of diverting limited health resources to the battle against COVID-19, and neglecting other important priorities related to public health such as climate change, the immergence of drugresistant tuberculosis, the persistence of malaria, and the burden of non-communicable disease, may not be obvious for several years. An important health crisis that risks being neglected during the COVID-19 pandemic is the growing rate of prescription medicine misuse, also referred to as the nonmedical use (NMU) of prescription medicines. The misuse of prescription medicines generally refers to the intentional repurposing of prescribed medicines so that they are no longer used for the intended indication, often for recreational purposes or performance enhancement. The drugs of primary concern are prescription opioids, gabapentinoids, central nervous system depressants (e.g., sedatives and hypnotics), and stimulants (e.g., methylphenidate). While this problem is well recognised as a public healthcare issue in the United States and in other developed counties, there is increasing concern about growing morbidity and mortality from NMU globally. In this themed issue, Paul Dargan and David Wood from Guy s and St Thomas NHS and King s College, London have collected a series of papers that explore the broad impact of NMU globally. The papers stem from a symposium held during the 2019 annual meeting of the British Pharmacological Society in Edinburgh, Scotland. The Themed Issue explores the harm caused by the NMU of prescription opioids, but also of other prescription drugs of concern such as benzodiazepines, Z-drugs, and antiepileptic drugs. There are global insights into the NMU of prescription medicines in the United Kingdom, Europe, the United States, and several Asian countries. A welcome contribution to the literature is a summary of tools that can be used to characterise the NMU of prescription medicines. The extent of prescribed opioids abuse can be difficult to detect using the usual data sources such as prescription databases and insurance claims. This is because trafficking and sale occurs to a large part outside of legitimate channels. Hockenhull et al. describe the use of web-monitoring to get a better understanding of the abuse of buprenorphine, hydrocodone, oxycodone, and tramadol in the United Kingdom. Internet monitoring though is but one of the methods to measure prescription opioid misuse. Richard Dart et al. describe a strategy of mosaic surveillance which provides a comprehensive description of prescription and illicit opioid misuse. Interestingly, this real-world data analysis has revealed a declining abuse of prescription opioids in the United States since 2011, which is unfortunately offset by an increase in heroin and illicit fentanyl abuse. While opioid abuse will always continue to exist, it is anticipated that less prescriptions will ultimately translate into less overall abuse. Wood and Dargan describe additional sources of information on prescription-medicine misuse such as ambulance attendances, emergency department presentations, and hospital datasets, as well as Poison Centers and Poison Information Services. Bringing these sources of information together, in a process called ‘data triangulation’, is a powerful tool to further describe prescription medicine misuse. NMU of prescription drugs is a well-known public health problem in the United States, in Australia and New Zealand as well as in Europe. However, much less is known about the problem in other regions. Chan et al. fill in some of the missing information by reviewing several papers from various regions in the Asia-Pacific Region, including Iran, Iraq, China, Thailand, and Singapore. The available data suggest that there is substantial misuse but that much more effort is needed to fully characterise the problems this enormously wide and diverse region is facing. An overlooked drug in terms of NMU is tramadol. While tramadol addiction potential is regarded as low, its abuse potential is not. Review of the emergency department presentations by Layne et al, on behalf of the Euro-Den Plus project data project, found that tramadol misuse is relatively uncommon in Europe compared to other opioids and often involves the co-use of other drugs. This finding is in sharp contrast with the situation in Arabic countries and Iran where tramadol is a much more serious problem, possibly related to a higher incidence of ultra-rapid CYP2D6 metabolizers in the Middle East and North/West Africa. NMU of prescription drugs is not restricted to opioids. It also includes the benzodiazepines and the so-called Z-drugs such as zolpidem and zopiclone. Less is known about the misuse of these drugs, while data could again provide valuable insights that could be used for future policies to decrease the misuse. Hockenhull report data gathered from the UK survey of NMU of prescription drugs programme (NMURx), which is part of the Research Abuse, Diversion and Addiction Related Surveillance (RADARS®) System. The authors report interesting findings with respect to the misuse of these drugs, both alone and in combination with other drugs of abuse such as opioids and how the average user actually acquires these drugs. Finally, these authors also report data on the abuse of benzodiazepines and GABA analogues in various European countries using the NMURx survey from France, Germany, Italy, Spain, and the United Kingdom. There are interesting differences between countries, with highest abuse of GABA-analogues in Germany and highest abuse of benzodiazepines in Spain. This themed issue ably highlights the global importance of NMU of prescription medicines. In a future post-COVID-19 world, DOI: 10.1111/bcp.14797