Abuse Potential of Noncontrolled Drugs Often Overlooked, Official Says
To get a real handle on drug abuse, clinicians need to look beyond opioids and consider the abuse potential of noncontrolled drugs, says Michael Cohen, operations officer for the investigations branch of the Department of Health and Human Services (HHS) Office of Inspector General (OIG) in Washington, D.C.
When he brings up the subject of noncontrolled drugs, Cohen said, "I pretty universally find among the pharmacists that this material that I talk about is not well known."
Cohen said drug abusers may take noncontrolled drugs in combination with other prescription, nonprescription, or street drugs.
"Muscle relaxants are extremely popular. And, believe it or not, HIV drugs" are used as potentiators in some recreational drug cocktails, he said.
Part of OIG's mission is to prevent fraud and abuse in the Medicare program.
The federal government, Cohen said, spends about $137 billion annually on Medicare Part D medications, including $127 billion on noncontrolled drugs.
"That's a big bucket of drugs that we have purview over," he said.
When asked about the abuse potential of noncontrolled medications, he said "We think it's a huge problem."
At the Greater Rochester Independent Practice Association in New York, prescribers have begun to pay attention to the issue, said Kathryn Dorward, ambulatory care clinical pharmacist for the practice. She's been compiling information from various sources and hopes to eventually develop fact sheets for her colleagues.
Dorward said prescribers are generally aware that gabapentin and quetiapine, drugs commonly used by the practice's elderly patients, have abuse potential.
That information isn't found in the drugs' labeling but appears in published case reports. Annual reports from the American Association of Poison Control Centers also describe exposures to gabapentin or quetiapine (usually in combination with other drugs) that may have contributed to fatal poisonings.
Dorward said her physician colleagues are interested in the abuse potential of noncontrolled drugs because they want to be better informed about what they're prescribing.
"The biggest question is, what is out there that can be abused that we don't even know about?" Dorward said. "What do we need to look for? How can we try to identify those patients? Just looking at pharmacy data, what do we need to look for?"
Cohen said OIG can analyze pharmacy data for unexpected spikes in the use of specific medications. Sometimes, he said, the data suggest that expensive drugs, like hepatitis C medications, are being diverted.
"And there are some drugs that aren't worth very much financially. So we have to start digging into some of those and [asking] why, exactly, these drugs are . . . so popular," he said.
One of the best ways to answer that question, he said, is to scan "drug blogs." Members of online communities post the results of their personal experiences using various drugs and, importantly, drug combinations with potentiator effects.
"We have several drug blogs that we cruise around in," Cohen said.
Sometimes, he said, a drug comes to OIG's attention that doesn't appear in blog entries.
In that case, Cohen said, "I'll make an inquiry: 'What can I do with this drug?' And I'll get 12 responses."
He said visiting these venues can be eye-opening for healthcare professionals.
"The dissemination of information and these recipes is not illegal," Cohen noted. "These are just regular dot-com sites you can get on and learn about the drugs. As long as you're not selling drugs on these sites, you can say whatever you want."
He said that when a "good recipe" appears on the blogs, many people try it, and word quickly spreads among recreational drug users.
"There's dozens of new postings every day," Cohen said. He said a user can post a positive experience with a drug combination on a Friday, and it will be in use nationwide by the following Monday.
He noted that since patients know about these sites, healthcare providers also need to become familiar with them.
Dorward said the drug blogs and other limited information she's found on the recreational use of drug cocktails has, indeed, been eye-opening.
"I had no idea," she said.Cohen said it's extraordinarily difficult to anticipate the next big thing in recreational drug use.
"I do this full-time, and I still can't keep up with it," he said. "Drug abusers are always looking to get a better high."
Pharmacists are an important audience for OIG's education efforts around noncontrolled drugs, and Cohen encouraged members of the profession to seek traditional and nontraditional sources of information about all the drugs used in their practice.
"If your radar is just up for a controlled substance, then you're not doing your job. You need to know what's going on with these noncontrolled drugs as well," he said.
[This news story appears in the March 15, 2017, issue of AJHP.]