Policy and practice briefingsAddressing the misuse of medicines

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Issues

Misuse of medicines refers to the use of a psychoactive medicine for self-medication, recreational or enhancement purposes, with or without a medical prescription and outside accepted medical guidelines. It may occur in the context of polydrug use.

Concerns have been growing in many European countries about increasing misuse of medicines, particularly in the light of large increases in deaths from prescription opioid analgesics in the United States. However, there are considerable differences between Europe and the United States with respect to prescribing practices.

The groups of medications that have been associated with misuse include:

  • Sedatives and hypnotics including barbiturates, benzodiazepines and benzodiazepine-like drugs such as the z-hypnotics.
  • Opioids, including pain relief medications and OST (opioid substitution treatment) medications.
  • Stimulants prescribed to treat attention deficit and hyperactivity disorder (ADHD).

These medicines may be obtained by regular prescribing, doctor shopping or visits to multiple pharmacies, diversion of supplies onto the illicit market and internet purchases. One important driver of misuse of medicines is poor prescription practice — this can be over-prescription or, particularly in the case of OST medication, under-prescription, which can result in people seeking to self-medicate. Clinical good practice in the prescription of OST medications reduces diversion and the harms associated with misuse of these medications.

Response options

  • Monitoring to establish the extent and nature of the problem is essential in developing appropriate responses. In addition to key epidemiological indicators and pharmacovigilance schemes, other potential data sources include hospital emergency cases of drug-related toxicity, sales statistics and prescription databases, and monitoring on-line forums where these drugs are discussed.
  • Prevention approaches include practitioner training and the establishment of quality standards and protocols to improve prescribing practice; controls on availability, such as limiting sales and packaging restrictions and disposal schemes for waste or surplus medicines; using special forms for certain drugs; and not allowing telephone or internet prescribing.
  • Drug treatment providers need to be ready to treat people with problems associated with misuse of medicines. This includes recognising the potential for clients presenting for treatment for illicit substances to also be misusing medicines and addressing this as necessary. In addition, since people with primary problems associated with misuse of medicines may be reluctant to seek help from traditional drug treatment services, alternative treatment in primary care may be necessary.

European picture

  • Information is limited on current treatment practices in Europe in managing misuse of medicines.
  • Work to better understand the extent and nature of the problem and monitor developments is underway and includes monitoring of acute events through sentinel sites (Euro-DEN Plus) and developing wastewater analysis.
  • There have been several EU-funded projects, such as CODEMISUSED looking at Codeine Use, Misuse and Dependence, and Access To Opioid Medication in Europe (ATOME) in this field, and there is ongoing collaboration between the EMCDDA and European Medicines Agency.

Summary of the available evidence

Treatment for misuse of medicines

Response option Quality of evidence

Cognitive behavioural therapy helps to reduce benzodiazepines use when added to tapering dosages in the short term.

lower quality evidence

Tailored letters sent by family doctors to patients, a standardised interview with GPs plus tapered doses, and relaxation techniques each showed promising results in individual small studies addressing benzodiazepine misuse. These approaches merit further investigation.

lower quality evidence

Key

  • speedometer at high High quality evidence — one or more up-to-date systematic reviews that include high-quality primary studies with consistent results. The evidence supports the use of the intervention within the context in which it was evaluated.
  • speedometer at medium Moderate quality evidence — one or more up-to-date reviews that include a number of primary studies of at least moderate quality with generally consistent results. The evidence suggests these interventions are likely to be useful in the context in which they have been evaluated but further evaluations are recommended.
  • speedometer at low Low quality evidence — where there are some high or moderate quality primary studies but no reviews available OR there are reviews giving inconsistent results. The evidence is currently limited, but what there is shows promise. This suggests these interventions may be worth considering, particularly in the context of extending services to address new or unmet needs, but should be evaluated.

Additional information

It is not clear if motivational interviewing can help to reduce benzodiazepine use.

Implications for policy and practice

Basics

Core objectives in this area include:

  • Ensuring that regulatory regimes for medicines with abuse potential provide sufficient availability for medical use, while limiting opportunities for misuse.
  • Ensuring that health care professionals are trained in correct prescribing guidelines and practice, identifying and treating problematic use, and how to address signs of misuse.

Opportunities

  • Develop and provide alternative treatment options to deal with misuse of medicines for patients who are reluctant to seek help in traditional drug dependence treatment settings.
  • Promote awareness among patients and the general population of the problem of misuse of medicines in order to destigmatise it and encourage help-seeking.

Gaps

  • Investigate and monitor the extent and nature of misuse of medicines locally and nationally, in order to facilitate the development of appropriate interventions, using a wide range of sources: surveys, treatment demand, sales statistics, police seizures, internet trends and wastewater analysis. This should include the relative importance of different sources of medicines on the illicit market as well as understanding how many and which people misuse medicines and for what reasons.

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