Saturday, December 11, 2010

The Most Widely Abused & Dangerous Drug for Pain

Briefly NotedWith concerns about prescription analgesic misuse and abuse taking precedence, policy makers, regulatory agencies, healthcare professionals, and the public have ignored the most harmful and prevalently misused drug. Commonly, and erroneously, used by patients to self-treat pain, this drug surpasses heroin, crack cocaine, crystal meth, and 16 other abused substances when it comes to harming the individual and others, according to a recent report in The Lancet medical journal.

What is this drug? Alcohol.

An international group of researchers known as the Independent Scientific Committee on Drugs and led by professor David J. Nutt in the UK, examined 20 common substances of abuse from perspective of harms to the individual and to others or society [Nutt et al. 2010]. Using a multi-criteria decision analysis the harms were organized into 5 general subgroups covering physical, psychological, and social aspects. Within those groups, there were 9 criteria related to harm to an individual from a drug, while 6 looked at harm to others. Scoring was done on a 100-point scale, with 100 being the most damaging and zero no damage.

Alcohol, with a score of 73, topped the list of all drugs as most damaging to the individual and others overall; nearly a third greater than next highest heroin (score=55) or crack cocaine (score=54). Tobacco was ranked sixth highest with a score of 26, coming after methamphetamine (33) and cocaine (27). And, marijuana, at a score of 20, was ranked about a quarter as harmful as alcohol, despite all its media attention and public angst. For unexplained reasons, prescription opioids as substances of abuse were not considered in the analysis; however, the prevalence of such abuse and degree of harms relative to the other substances would likely place this very low on the list.

Clinical Implications: As we long ago noted [see blogpost 9/16/09], more than 15 million Americans abuse or are addicted to alcohol, plus 3 million have abuse or addiction involving both alcohol and illicit drugs, according to U.S. government survey data. These figures, combined with the 58 million persons who are binge drinkers and 17 million reporting heavy drinking, amounts to about 93 million persons with alcohol-use problems to some degree.

Among the individual criteria in the above study on substances of abuse, alcohol also ranked highest in incurring personal injury. So, many persons misusing or abusing alcohol end up in emergency departments or clinics with acute pain. Other research has shown that 1 in 4 patients with pain may abuse alcohol as an analgesic, which appears to be most problematic among young white males and is exacerbated by greater pain frequency and depression [discussed in blogpost here]. Furthermore, it is well known that serious adverse reactions may occur when alcohol is mixed with over-the-counter pain relievers for self-medication, and there is a high risk for toxicity including overdose when alcohol is combined with many prescription analgesics.

While alcohol is usually mentioned when considering analgesic safety, particularly in combination with opioids and other CNS depressants, the topic does not get the full attention it deserved and the public often hears mixed messages about alcohol’s harms versus health benefits. We, ourselves, reported [here] on research from Switzerland finding that light-to-moderate drinkers showed a slower progression of joint damage due to RA than nondrinkers. However, the emphasis was on light-to-moderate alcohol intake, which is a rather vague concept, easily misinterpreted by practitioners and patients alike.

As a further complication, professor Nutt and colleagues note that polydrug consumption is more the rule than the exception, and that combinations of substances of abuse can significantly alter their adverse events and harmful effects. For example, alcohol with cocaine produces cocaethylene, an extremely toxic compound, or alcohol with cannabis can seriously affect an individual's ability to drive (or even walk) safely. Add an opioid analgesic to the mix and the resulting cocktail can be lethal, whether from drug effects directly or accidental injuries. This is something worth considering when prescribing analgesics for patients who may also consume alcohol.

REFERENCE: Nutt DJ, King LA, Phillips LD, et al. Drug harms in the UK: a multicriteria decision analysis. The Lancet. 2010;376(9752):1558-1565 [abstract here].