Monday, July 29, 2013

Is all substance misuse really abuse?

- Jennifer Middleton, MD, MPH

I appreciated AFP's article last week about "A Primary Care Approach to Substance Misuse" and its practical review of screening and treatment options for patients struggling with this issue.  The article appropriately included discussion about prescription drug abuse.

Prescription painkiller deaths have been on the rise in the United States. Drug overdose (60% of which are pharmaceutical drug overdoses) is now the number 1 cause of injury-related death in the U.S.  The Centers for Disease Control and Prevention (CDC) states that every 3 minutes a middle-aged woman presents to the Emergency Department for prescription opioid "misuse or abuse."   Every single one of those prescription medications originated from a doctor's prescription pad (paper or virtual).

I continue to ruminate, though, about the word "misuse" in the AFP article. Usually, when I think about problems with inappropriate substance use, I think of the word "abuse," not "misuse."  Clearly these words share a similar meaning, but, for me at least, the connotation of "misuse" is a bit gentler than "abuse."  "Misuse" sounds more like a mistake than the intentional impropriety of "abuse."

I have previously thought of the substance "abusers" as those who are inappropriately requesting prescription painkillers.  My office, as I'm sure many others do, has a controlled substance policy that supports frequent urine drug screens, and we discontinue prescribing for patients with discordant results.

But what about the "misusers?"  What about the patients who have some legitimate pain source but don't always use their prescription opioids as prescribed?  Or the patients who never tell me that they're borrowing someone else's prescription medications?  After all, the CDC found that 55% of the people misusing or abusing prescription pain medications obtain them for free from a friend or relative. Only 11% buy their pills from friends or family, and only 4% purchase their meds from a dealer.  Learning that most of my patients using these medications inappropriately are getting them at no cost from friends and family changes how I think about who those patients might be.

What I appreciate about the term "misuse" is its reminder that, as a prescriber of these medications, I need to be on the alert for more than just the "abusers."  I should probably be asking all of my patients the single question screen for substance disorders outlined in last week's AFP article (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) on a regular basis.  I need to broaden who I think of as at risk from problems related to substance misuse and abuse.

How often do thoughts of prescription medication misuse and abuse occur during your practice day? Does the term "misuse" help you to think more widely about prescription medication problems, or is it an unnecessary term?