Outpatient Treatment and Outcome of Prescription Drug Abuse

2015

Forty-six consecutive patients who voluntarily sought outpatient treatment for abuse of one or more prescription drugs were studied. Barbiturates, amphetamines, and diazepam were the most common drugs abused. Desired treatments by patients included counseling, medical withdrawal, or medical maintenance with the drug of abuse or a chemically related drug. Twenty-two (47.8 percent) patients left treatment and relapsed within one month; another eight (17.4 percent) patients relapsed between one and three months after entering treatment. Only 13 (28.3 percent) reported abstinence 90 days after entering treatment. This experience suggests that a wide range of medical, social, and psychologic resources are required to treat prescription drug abuse, and that long-term drug abstinence is difficult to achieve with all patients.

Treatment of prescription drug abuse has dealt primarily with drug complications such as overdose, toxic reactions, and techniques for medical withdrawal. Other reports describe behavior patterns of prescription drug abuse and often refer to it as poly-drug abuse, since many persons frequently abuse more than one drug. Some reports emphasize the clinical complexity of poly-drug abuse and particularly note the severity of multiple medical and psychiatric complications. Few attempts have been made to describe treatment and outcome of prescription drug abuse.Reported here is a series of 46 consecutive patients who voluntarily sought outpatient treatment for prescription drug abuse. Type of treatment desired, concomitant medical and psychiatric conditions, treatment given, and outcome are described.

Methods

Forty-six consecutive patients voluntarily sought outpatient treatment for prescription drug abuse between January 1 and June 30, 1977. All patients stated that they used their prescribed drug(s) compulsively one or more times a day for at least 60 days. When admitted, a patient’s complete history was taken and a physical examination was done, including necessary laboratory and urine drug-screening Procedures. Part of the history taking included a written checklist of the following psychiatric symptoms and conditions: anxiety, depression, hallucinations, insomnia, and nervousness. Patients also completed, in writing, the following questions that were answered yes or no to help screen for psychosis and suicidal thoughts:

  • I am depressed at this time.
  • Have you ever tried to commit suicide?
  • Right now I feel as though I want to injure myself or someone else.
  • Right now I feel I do not particularly want to live.
  • I sometimes hear noises or see things that aren’t really there.
  • I sometimes think that part of my body disconnects and leaves for a short time.
  • I sometimes think I do not have total control over my mind.

I think that most of the people I know are against me. Depression and suicidal tendency were further assessed and documented by an elevated score (above 16 on a scale of 0 to 39) on the Beck Depression Inventory. No patients were admitted to the study who exhibited evidence of delirium, intoxication, or dementia. Patients were specifically asked the reason the drugs were prescribed, which drug(s) they used, and whether they perceived an adverse drug effect on health, mind, work, social function, and marriage, or whether they were physically addicted to their drug(s). The patients were also asked the type of treatment(s) desired, including medical withdrawal, counseling, or medical maintenance with the same drug or one chemically related to it. Following intake procedures, the patient was assigned to an experienced drug treatment team that consisted of a physician, registered nurse, psychiatric technician, and licensed marriage and family counselor.

If the patient desired medical withdrawal, a medical detoxification regimen was prescribed, which usually required that the patient attend clinic on a daily basis. Although amphetamines and methylphenidate hydrochloride do not apparently cause physical dependence, some patients requested medical withdrawal for dependence on these drugs; this was provided. The following drugs were used for detoxification and withdrawal purposes: hydroxyzine pamoate for barbiturate or other sedative-hypnotic dependence; hydroxyzine for amphetamine or methylphenidate dependence; and propoxyphene napsylate or diphenoxylate hydrochloride for codeine, pentazocine hydrochloride, oxycodone hydrochloride, and propoxyphene hydrochloride dependence. Hydroxyzine was chosen as a withdrawal agent since it is a sedative with antihistamine properties that has low abuse and overdose potential, and it has been found effective in alcohol withdrawal. Propoxyphene napsylate and diphenoxylate were chosen because they are compounds with relatively low abuse potential that can effectively suppress narcotic withdrawal. Withdrawal agents were administered in a declining dose fashion over a two- to three-week period. Following detoxification, each patient entered an ongoing counseling program in which the patient attended the clinic at least once a week. Counseling sessions lasted 15 to 45 minutes and were primarily supportive in nature, with attention particularly directed at the patient’s marital, employment, health, or financial problems. Special focus was directed on guiding the patient to find alternatives to taking a prescribed drug(s) when he/she experienced a symptom such as nervousness, lethargy, or depression, although no specific relaxation technique such as biofeedback, hypnosis, or meditation was used. Sessions often included family members, and they were continued weekly until. The patient dropped out of treatment. Medical maintenance was done by substituting a drug chemically related to the one of abuse. It was done when the patient desired it and when no treatment alternative was deemed viable. Each patient was interviewed by telephone or by face-to-face contact approximately 90 days after admission to solicit a self-report and determine outcome. Longer follow-up was obtained for patients who remained in treatment more than 90 days,

Results

Most patients were under age 27 years (mean, 26.1 years). There were a few more men (25 of 46 or 53.3 percent) than women. The majority were neither married nor employed (Table Drugs of Complaint Among 46 Prescription Drug Abusers). Most patients (34 or 73.9 percent) desired counseling (6 or 13.0 percent) for treatment, although others requested medical withdrawal (11 or 23.9 percent) or medical maintenance (6 or 13.0 percent) with the same or related drug. Some patients wanted more than one type of treatment. The most common drugs of complaint were barbiturates, amphetamines, and diazepam (Table Drugs of Complaint Among 46 Prescription Drug Abusers).

TABLE Drugs of Complaint Among 46 Prescription Drug Abusers

Drugs

No. of Patients*

Barbiturates

19

Amphetamines

18

Diazepam

10

Codeine

3

Methaqualone

3

Propoxyphene hydrochloride

3

Pentazocine

2

Methylphenidate

1

Chlordiazepoxide

1

Meprobamate

1

Oxycodone

1

*Total is more than 46 since some patients complained about more than one drug.

Patients stated they had used their drugs from one to 14 years, with a mean of 4.5 years. Some patients used more than one drug obtained by prescription. Every patient stated that he used his drugs in excess to what was prescribed by his physician. Patients had usually obtained their drugs for depression, insomnia, anxiety, “nervousness,” weight control, or minor pain problems such as headache. All patients except one perceived that their drug use had developed into a “problem” and had an adverse effect on their mind, health, social and work functions, marriage, or that they were addicted (). These patients had numerous medical and psychiatric complaints. Anxiety or nervousness, depression, insomnia, chronic pain, suicidal thoughts, and obesity were the most common ().

Twenty-two (47.8 percent) patients left treatment within one month and reported relapse at 90-day followup (). Eight (17.4 percent) patients left treatment between one and three months and relapsed. Thirteen (28.3 percent) patients remained in treatment and reported abstinence at 90-day followup. Urine that did not contain a detectable, abusable drug was obtained from these patients and supported their claim of abstinence. Two of the 13 patients relapsed, however, shortly after the 90-day followup. Six (13.0 percent) patients requested medical maintenance with their chosen drug of abuse or a chemically-related drug, and this was provided in four of these patients. Three of the four were still in maintenance treatment at the 90-day followup. One patient relapsed shortly after three months, one continued maintenance after one year, and one achieved abstinence after almost one year of maintenance.

Comment

The patients studied here excessively abused one or more prescribed drug and volunteered for treatment. None was referred by the judicial system for mandatory treatment, which is frequently done with casual drug users. Patients perceived that prescribed drugs had a variety of adverse effects when used to excess. The three predominant treatments requested were counseling, medical withdrawal, and medical maintenance with their drugs of abuse or chemically-related drugs. Patients had many medical and psychiatric complaints and conditions, as has been previously reported with groups of polydrug abusers. The numerous medical and psychiatric conditons, variety of drugs abused, and different forms of treatment desired by these patients made treatment a complex endeavor that required a well-trained, multidisciplinary clinical team with considerable clinical resources. All patients were similar in that they knowingly exceeded the prescribed dosages intended by the initial prescribing physician.

Anderson et al. attempted to treat a group of patients with amphetamine, barbiturate, and hallucinogen problems on an outpatient basis and encountered dismal treatment outcomes. Only eight of their 83 patients even returned for a second clinic visit. Outcome in the patients studied here appeared better in that patients almost always returned to the clinic for followup treatment visits, but only 13 of 46 (28.3%) reported abstinence 90 days after entering treatment. A different treatment program that uses more frequent counseling, medical maintenance, or other techniques may have improved outcome. If patients had been mandated by the judicial system to accept treatment in lieu of incarceration, treatment outcome may have been better. Although medical maintenance with methadone is an accepted treatment for heroin addiction, the concept of medical maintenance for prescription drug abuse has not been well explored. Six of 46 (13%) patients specifically requested this form of treatment, which suggests that this approach to prescription drug abuse deserves further study. Despite difficulty in achieving long-term abstinence with most outpatients studied here, there is no reason to conclude that inpatient treatment would have produced better outcome.

Tennant, F. S., Jr.

Selections from the book: “Problems of Drug Dependence, 1979: Proceedings of the 41st Annual Scientific Meeting, The Committee on Problems of Drug Dependence, Inc.” A comprehensive assemblage of reports of ongoing research on all aspects of drug abuse and drug dependence, including studies of new compounds. National Institute on Drug Abuse Research Monograph 27, 1979.