Central nervous system depressants, such as sedatives and tranquilizers, are used for treating anxiety and sleep disorders. Due to their high abuse potential, stimulants are currently employed for only a few conditions, including for narcolepsy The potential for misuse and abuse of prescription drugs The prescription drug abuse problem has become an epidemic in the United States (McHugh, Nielsen, & Weiss, 2015), and in 2017 the United States Department of Health and Human Services declared it a public health emergency (HHS, 2019b). A number of possible reasons for the rise in prescription drug abuse in this country have been postulated. The volume of prescriptions written for the drugs in the most-abused categories increased substantially since the 1990s; between 1992 and 2002, as the U.S. population rose by 13%, prescriptions for controlled drugs rose 154% (Coalition Against Insurance Fraud, 2007). The overall opioid prescribing rate in the United States peaked and leveled off from 2010 to 2012 and has been declining since 2012, but the amount of opioids in morphine milligram equivalents (MME) prescribed per person is still around three times higher than it was in 1999 (CDC, 2018d). In spite of awareness of the problem, Medicare paid for more such prescriptions in 2012 than it had in 2011 (Ornstein & Jones, 2014). Pain relievers, the most abused category of drugs, have become both stronger and more effective, increasing their medical utility, but also their allure and street value. Adding to the problem of prescription drug abuse is our nation’s culture of believing that a “pill” will cure all and that these pills’ legal prescription status makes them somehow more acceptable or less harmful. Insufficient training of healthcare professionals and inadequate initiatives in educating the public are also factors that may contribute to the growing abuse problem. The perception that prescription drugs are safe is also promoted when drugs are advertised or labeled misleadingly. For example, the manufacturer originally labeled OxyContin as “less addictive, less subject to abuse, and less likely to cause withdrawal symptoms” than other pain medications – claims that were unsupported by the findings of the U.S. Food and Drug Administration (FDA), but resulted in the drug becoming popular with narcotic users. In 2007, the drug’s manufacturer pleaded guilty to felony misbranding (Chasan, 2007). About the time that OxyContin was first marketed, pain was gaining wider History of prescription drug abuse The use and abuse of drugs is not new. Narcotics and related drugs are known to have been used from as early as 3400 BC for relaxation, stimulation, or euphoria (History.com, 2019a). Addiction problems in the United States were recognized as early as 1875, when San Francisco outlawed opium dens (History. com, 2019a). It was not until the twentieth century, however, that national drug laws were enacted, with the Pure Food and Drug Act of 1906 (U.S. House of Representatives, n.d.) and the Harrison Narcotics Tax Act of 1914 (History.com, 2019a). These laws required labeling of medications containing opium and certain other drugs and forbade the sale of such drugs except by designated professionals; in 1920, a Supreme Court decision also made it illegal for physicians to knowingly prescribe narcotics to “cater to the appetite or satisfy the craving of one addicted to the use of the drug” (Schaffer Library of Drug Policy, n.d.). Drug abuse was recognized as a problem that often started at an early age and therefore required early intervention for prevention. Efforts by public school systems to introduce and require drug abuse education occurred as early as the 1930s, but were thwarted by fears that education would encourage experimentation; as a result, these efforts soon died out. At the same time that efforts by public schools began, other attempts to control drug abuse were being made by the federal government; however, by the 1950s, the use of marijuana, as well as amphetamines and tranquilizers, was increasing. In 1970, Congress enacted the Uniform Controlled Substances Act (CSA), which attempted to rank addictive drugs according
and attention-deficit/hyperactivity disorder (ADHD; Mayo Clinic, 2018b; NIDA, 2018h). Because the abuse and addiction potential for these drugs is high, the benefits from prescribing them must outweigh the associated risks for the patient. acceptance as a genuine medical condition, and the medical community increasingly recognized that patients, and chronic pain sufferers in particular, should not suffer needlessly when effective narcotic pain medications were available. Reflective of this thinking was the phrase coined by the American Pain Society and adopted in 2000 by the Veterans Health Administration: “Pain is the fifth vital sign.” The unintended result of this shift in thinking regarding pain management was a surge in the number of prescriptions for opioid pain relievers and the proliferation of “pill mills” – clinics, pharmacies, and doctors’ offices where narcotics are prescribed in large quantities or for nonmedical use under the pretense of legitimate pain relief (Coalition Against Insurance Fraud, 2007; Ling, Mooney, & Hillhouse, 2011). Researchers following this campaign to assist chronic pain sufferers found that their pain management was no more effective than before (Mularski et al., 2006). All of the three most abused categories of drugs – opioids, stimulants, and CNS depressants – have a high potential for abuse and addiction, but their pharmacological effects vary. Opioids, for example, reduce the intensity of pain, but can also produce a euphoric effect in some individuals who might then seek to increase the intensity of the experience through repeated or enhanced use of the drug. Stimulants, which increase attention, alertness, and energy, are more widely prescribed than ever despite the limited conditions they are used to treat. These effects, their broad availability, and the perception that they are safe because they are legal, have resulted in an upsurge in their use by diverse populations, including high school and college students, athletes, performers, and older adults (NIDA, 2018h). Around 6 million Americans (approximately 2% of the U.S. population aged 12 and older) misused prescription stimulants in 2016 (CDC, 2018d). Central nervous system depressants can be abused for their relaxing effects or to counter or enhance the use of other drugs (NIDA for Teens, 2019a). to their abuse potential (Cornell University Law School, Legal Information Institute, n.d.). The result was the classification of drugs into the five schedules that we use today, with Schedule I being drugs with no accepted medical use, such as heroin and LSD, and Schedule V being controlled substances with a low potential for abuse, such as the antitussives, antidiarrheal, and analgesic preparations. In between, and ranked by abuse potential, Schedule II drugs include pain relievers such as oxycodone and stimulants such as amphetamines, Schedule III drugs include anabolic steroids and the anesthetic ketamine, and Schedule IV consists of some of the CNS depressants such as diazepam and alprazolam (U.S. Drug Enforcement Agency [DEA], n.d.a). (See Table 1.) The Uniform Controlled Substances Act will be further discussed in a later section. In 1973, the Drug Enforcement Administration (DEA) was created to oversee enforcement of all controlled substance laws in the country. One year later, the National Institute on Drug Abuse (NIDA) was established as a federal agency for “research, treatment, prevention, training, services, and data collection on the nature and extent of drug abuse” (National Institutes of Health [NIH], 2018b). Fear that education would result in increased experimentation was finally countered by President Nixon’s “War on Drugs” in 1971, which included a call to increase awareness through education (History.com, 2019b). In 1988, the Anti-Drug Abuse Act was enacted to send a clear message of zero tolerance to the public, now including the user as well as the seller in the criminal and civil penalties that could
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