and to increased risk for diversion and nonmedical use. When taken to improve properly diagnosed conditions, these medica- tions can greatly enhance a patient’s quality of life. However, because many perceive them to be generally safe and effective, prescription stimulants such as Adderall® and Modafinil® are being misused more frequently. Stimulants increase wakefulness, motivation, and aspects of cognition, learning, and memory. Some people take these drugs in the absence of medical need in an effort to enhance mental performance. Militaries have long used stimulants to increase performance in the face of fatigue, and the United States Armed Forces allow for their use in limited operational settings. The practice is now reported by some professionals to increase their productivity, by older people to offset declining cognition, and by both high school and college students to improve their aca- demic performance.
Nonmedical use of stimulants for cognitive enhancement poses potential health risks, including addiction, cardiovascular events, and psychosis. The use of pharmaceuticals for cognitive enhancement has also sparked debate over the ethical implica- tions of the practice. Issues of fairness arise if those with access and willingness to take these drugs have a performance edge over others, and implicit coercion takes place if a culture of cognitive enhancement gives the impression that a person must take drugs in order to be competitive.
HOWCAN PRESCRIPTION DRUG MISUSE BE PREVENTED?
Physicians, their patients, and pharmacists all can play a role in identifying and preventing nonmedical use of prescription drugs.
Clinicians. More than 80 percent of Americans had contact with a health care professional in the past year, placing doctors in a unique position to identify nonmedical use of prescription drugs and take measures to prevent the escalation of a patient’s misuse to a substance use disorder. By asking about all drugs, physicians can help their patients recognize that a problem exists, provide or refer them to appropriate treatment, and set recovery
goals. Evidence-based screening tools for nonmedical use of prescription drugs can be incorporated into routine medical visits. Doctors should also take note of rapid increases in the amount of medication needed or frequent, unscheduled refill requests. Doctors should be alert to the fact that those misusing prescription drugs may engage in "doctor shopping"—moving from provider to provider—in an effort to obtain multiple pre- scriptions for their drug(s) of choice. Prescription drug monitoring programs (PDMPs), state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients, are also important tools for preventing and identifying prescription drug misuse. While research regarding the impact of these programs is cur- rently mixed, the use of PDMPs in some states has been associ- ated with lower rates of opioid prescribing and overdose, though issues of best practices, ease of use, and interoperability remain to be resolved. In 2015, the federal government launched an initiative di-
rected toward reducing opioid misuse and overdose, in part by promoting more cautious and responsible prescribing of opioid medications. In line with these efforts, in 2016 the Centers for Disease Control and Prevention (CDC) published its CDC Guide- line for Prescribing Opioids for Chronic Pain to establish clinical standards for balancing the benefits and risks of chronic opioid treatment. Preventing or stopping nonmedical use of prescription drugs is an important part of patient care. However, certain patients can benefit from prescription stimulants, sedatives, or opioid pain relievers. Therefore, physicians should balance the legitimate medical needs of patients with the potential risk for misuse and related harms.
Patients. Patients can take steps to ensure that they use pre- scription medications appropriately by: • following the directions as explained on the label or by the pharmacist • being aware of potential interactions with other drugs as well as alcohol • never stopping or changing a dosing regimen without first
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