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by Sonya Felix
Canadian Healthcare Manager
Prescription drug abuse is a chronic and sometimes fatal disease. It can be costly too, leading to lost productivity, absenteeism and even long-term disability. The key for employers is recognizing the signs and making help available.
"These drugs have a huge socio-economic impact. It is not only actual dollars paid for unnecessary drugs, but also the cost of visits to doctors and emergency rooms, insurance claims for disability and lost productivity."
"Stimulants can cause behaviour issues and narcotics can cause problems with attention span and co-ordination which can result in accidents."
Like anyone who loses a loved one to an untimely death, Joan Gadsby was devastated when her four-year-old son died in 1966. And, like many people, Gadsby turned to her family doctor to help her cope with the profound grief that left her unable to sleep.
She had no idea the prescriptions she received for tranquillizers and sleeping pills would lead to a 20-year drug addiction. Nor did she realize that the pills she was prescribed would create a nightmare of uncontrollable rages, violence, irrational behaviour, public humiliations and near-fatal overdoses. Her doctor never informed her of these possible side effects.
Today, Gadsby is well aware of the dangers of prescription drugs. She spent two and a half years suffering alone through the hell of protracted withdrawal as she slowly rebuilt her life. Finally, Gadsby had to face the loss of her son so many years before. "I couldn't deal with the grief until I was off the drugs," she says from her North Vancouver home, adding that the drugs acted as an "emotional anesthesia."
What happened to Gadsby is tragic and scary - even more scary when you realize this isn't an isolated case. Although there is no good Canadian data showing how many people are addicted to prescription drugs, treatment centres across the country have waiting lists of people seeking to kick addictions to drugs meant to treat anxiety, pain and depression. "It's difficult to say how widespread the problem is," says Dr. David Marsh, clinical director for addiction medicine at Toronto's Centre for Addiction and Mental Health (CAMH). "But, in general, non-medical substance abuse has increased over the last 10 years and has become a significant issue in society."
Gadsby can personally attest to the human toll. Drug-free for over 11 years, she's written a book, Addiction by Prescription, about her experience and is a well-known advocate against the overprescription of benzodiazepines and other potentially addictive prescription medications. "These drugs have a huge socioeconomic impact," she says. "It's not only actual dollars paid for unnecessary drugs, but also the cost of visits to doctors and emergency rooms, insurance claims for disability and lost productivity."The dangers of abuse
Coming up with a definition of prescription drug abuse isn't as straightforward as it first appears. Abuse means different things to different people and can be viewed as anything from taking the wrong medication to taking too much medication, taking it for too long or not long enough. But the type of prescription drug abuse that leads to physical dependency and addiction has serious health implications and can even be fatal.
Although any substance can be misused, the three classes of prescription drugs most commonly abused are opioids (prescribed to treat pain), CNS depressants (used to treat anxiety and sleep disorders) and stimulants (used to treat narcolepsy and attention deficit disorder). As many as 30% of Canadians receive drugs that are potentially addictive at some time in their lives, says Dr. Marsh. Medications such as benzodiazepine and opioid analgesics are commonly used pre-surgery and to treat musculoskeletal injuries, painful diseases such as cancer and for short-term emotional crisis management.
In certain cases, doctors may prescribe in excess of guidelines, such as for palliative care, says Brian Barr, director of health benefits management for Liberty Health in Markham, Ont. "For a chronic pain condition, the physician may have to weigh managing quality of life against the risk of someone developing an addiction."
When used for a medical purpose as prescribed by a physician, these drugs are normally considered safe. It's the non-medical use, however, that's worrisome. The National Institute on Drug Abuse (NIDA) estimates that four million Americans (2% of the population age 12 and older) used prescription drugs non-medically in 1999. Dr. Marsh agrees that the U.S. figures reasonably reflect the trends in Canada. And, according to studies done by CAMH, the biggest users are adolescents, women and the elderly - just as they are in the U.S.
Why do so many people use these drugs when they aren't medically warranted? The simple answer is that when used in higher amounts than they should be used, the drugs have a mood-altering effect that some people want, says Dr. Gerry Cooney, medical director of Bellwood Health Services, a private hospital and wellness centre in Toronto specializing in addictions and addiction-related disorders. "Some people perceive themselves as lacking the skills to deal with daily stress. Some, unfortunately, develop the quick fix habit of self-medicating to manage routine discomfort. 'I'm upset' translates into 'I need a tranquillizer.' 'I'm tired' means 'I need to swallow a mind stimulant.' Others use opiates to drift away from emotional pain."
Some people want a magic pill to help them get through a psychological reaction to a crisis, such as a death in the family, a job loss or a marital break-up. Some like the idea of taking a pill to help them cope with a demanding boss or a stressful workload. About six in 10 respondents to the 2001 Aventis Healthcare Survey reported they are experiencing "a great deal of stress" on the job.
Not everyone who feels stress or anxiety uses a prescription drug to make themselves feel better, but a growing number of Canadians are receiving prescriptions for tranquillizers, antidepressants and sleeping pills, according to Canadian Profile 1999, put out by the Canadian Centre on Substance Abuse and the CAMH.
Inappropriate prescribing practices by physicians have been blamed for some abuse. Gadsby got 20 years' worth of tranquillizers and sleeping pills through prescriptions from the same family doctor. "I trusted him," she says. (She also sued him once she got off the drugs.) But not every person who becomes drug-dependent first receives them from a physician. Other sources include taking someone else's prescription or illegally buying drugs on the street.
Even when the first prescription does come from a physician, the prescribed dosage typically isn't enough to sustain an abuser's increased tolerance to the drug, and they need to find an alternative source. One common tactic is to double-doctor (get prescriptions from several doctors simultaneously) and fill them at multiple pharmacies. Or people may look for other substances to give them the same effect.
"I've known individuals who no longer need codeine for pain and have been refused prescription renewal by their physician and who, to get the 'codeine buzz' will ingest large amounts of Tylenol 1 purchased over the counter, unaware of or despite the liver toxicity of acetaminophen," says Dr. Cooney.
It's important to note that not everyone who develops a physical dependence to prescription drugs, such as codeine, actually becomes addicted. Dependence is largely a neurobiological phenomenon due to continued exposure to the drug. Actual addiction includes psychological and social dimensions. When a person is addicted they have lost control over how much of the drug they take. Getting and using the drug become the focus of their life at the expense of relationships and other things that were once important to them.
A person who is physically dependent on benzodiazepines or opioids may suffer excruciating symptoms when they stop taking the drugs: irritability, insomnia, anxiety and mood swings. Withdrawal from stimulants like diet pills can cause severe depression, confusion, irritability, excessive hunger and thirst, and altered perceptions. As bad as getting over a physical dependency sounds, it's even worse for a person who is addicted.
"Once a chemical abuse turns to addiction, it's a long process to get better," says Dr. Cooney. "People have to realize that addiction is a serious chronic disease which causes psychological, physiological, sociological and spiritual damage. And it can be fatal. Addicts can reach the point where they don't care about the health implications and in that case the ultimate prognosis is death."Drug abuse at work
During the years that Gadsby was addicted to benzodiazepines, she continued to work. She held numerous executive-level positions in marketing and management and was an elected city councillor for 13 years. As her addiction spun out of control and her behaviour became increasingly irrational and unpredictable at home, her co-workers didnít seem to notice she had a serious problem.
That's not surprising, say addiction experts. For one thing, it's often difficult for an employer to know if someone has a problem. Privacy issues prevent employers from knowing the kinds of drugs their employees take. And sometimes the last place a person deteriorates is at work, says Barbara Veder, EAP national clinical director for FGI.
Employers are often not aware of the early signs of substance abuse, which closely mirror the symptoms of other personal issues. For instance, people who misuse substances like alcohol and drugs are more often late for work, take more sick time, are more likely to be injured and less likely to be productive. "The problem of prescription drug abuse is much bigger than most people think it is," says Dr. Cooney.
Employers should be alert to behaviour indicative of substance abuse because even a modest level of abuse can compromise safety, says Barr at Liberty Health. "Stimulants can cause behaviour issues and narcotics can cause problems with attention span and co-ordination which can result in accidents."
Any alterations in behaviour, such as a change in productivity, being late for work, taking longer lunch hours, frequent bad moods and missing work on Mondays and Fridays are all tell-tale signs of substance abuse, says Dr. Cooney. If someone does exhibit these symptoms, sometimes it's enough to ask what's wrong and to let the employee know they will be keeping an eye an them and will review the situation in six months.
"If supervisors or co-workers notice behaviour changes at work, it's best to be open and encourage the person to seek support," says Veder. "If the company has an EAP, you could just say, 'You look like you are stressed and I'm worried about you. Maybe you should give the EAP a call.' An EAP is a gentle and confidential place for employees to seek counselling."
Pharmacy benefit managers have a role, too. "Drug utilization programs can pick up prescription drug abuse in some instances," says Barr. "Adjudication and setting certain limits around quantities of dispensing certain classes of drugs could help reduce the amount of drugs in a patientís hands at one time. "
Barbara Martinez, head of marketing and sales far Healthcare Management Services in Toronto, agrees that drug audits can pinpoint abuse. "If someone is going to 29 different doctors there should be systems in place to alert insurers," she says. "Insurance companies have the legal right to investigate claims and usually they go back to the prescribers to figure out what's going on."
As well, employers and healthcare professionals could be doing more to help people learn to cope with stress and anxiety in non-medicinal ways. "It's in their interest to try to do something about it," says Gadsby.
Sonya Felix is a Toronto-based freelance writer.
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