Surprising Findings About the Evolution of the Drug Epidemic

Most primary care physicians, corresponding to about 62%, fear the opioid drug crisis will transition to a new prescription drug crisis and about 72%, worry that chronic pain patients will turn to illicit drugs if they do not have access to prescription opioids, according to a new Health Trends report from Quest Diagnostics.

The report, Drug Misuse in America 2019: Physician Perspectives and Diagnostics Insights on the Evolving Drug Crisis, provides insights into physicians' concerns about patient misuse of prescription and other drugs, as compared with results of objective lab data.

Within the lab data, half of test results of patients prescribed an opioid or other controlled medication, about 51% show signs of drug misuse and one in four, or 24% show signs of potentially dangerous drug mixing.

The first-of-its kind report includes findings from a new online survey of 500 U.S. primary care physicians, conducted by The Harris Poll, and commissioned by Quest Diagnostics in consultation with Center on Addiction, about the use of controlled prescribed medications, such as opioids, amphetamines, benzodiazepines and illicit drugs.

It comapres the survey responses with an analysis of more than 4.4 million de-identified drug monitoring test results ordered by physicians for patients prescribed controlled medications and performed by Quest Diagnostics between 2011 and 2018.

These two data sets reveal the contrast between physician expectations about patient drug use and the evolution of the drug epidemic and actual patient behavior, as revealed by objective lab data, amid a national drug crisis that claimed an estimated 68,500 lives last year. 

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"Quest Diagnostics undertook this research so that we could provide insights into the evolving drug crisis and the potential role of physicians' perspectives about their patients in drug misuse and use disorders," says report co-author Harvey W. Kaufman, MD, senior medical director and director, Health Trends Research Program, Quest Diagnostics. "We found that primary care physicians, who are on the front lines of the drug epidemic, are well-intentioned but under-prepared and may miss some of the drug misuse risks affecting their patients, as reflected by our nationally representative laboratory data."

Among the key findings:

Physicians may be overconfident in their ability to recognize prescription drug misuse:

• One in two patient test results, about 51%, showed misuse of a controlled medication or other drugs in 2018, a rate that is virtually unchanged from a misuse rate of 52% in 2017 and 2016. Yet, 72% of physicians trust their patients to take their controlled substances as prescribed.

• Nearly all physicians, about 95%, feel confident in their ability to discuss risks of prescription drug misuse with patients, but only 55% said they actually discussed potential misuse with most of their patients who were prescribed controlled substances in the past month.

Drug mixing, the most prevalent form of drug misuse, is underestimated by physicians:

• Most physicians, about 53%, believe that less than 20% of patients misuse their controlled substances through drug mixing. However, 24% of all patient test results in 2018 showed signs of combining prescription medications with other non-prescribed drugs or substances, including illicit drugs.

• Drug combining involving fentanyl is also prevalent. Among patient test results that were positive for heroin, 64% were positive for non-prescribed fentanyl. Among patient test results that were positive for cocaine, 24% were positive for non-prescribed fentanyl. The company's testing detects prescription forms of fentanyl, not illicitly manufactured fentanyl, so it is possible actual rates of fentanyl drug combining are even higher.

Gabapentin is emerging as an alternative pain therapy to opioids-just as misuse increases:

• Seventy-eight percent of physicians say in an effort to avoid prescribing opioids for the treatment of chronic pain, they often prescribe gabapentin to their patients.

• Laboratory data show a 40% increase in non-prescribed gabapentin misuse in just the past year, with 13.4% of patient results showing this type of misuse-making gabapentin the most commonly detected non-prescribed controlled medication in 2018.

Gabapentin, an anticonvulsant that can be used to relieve neuropathic pain, has recently been classified as a controlled substance in some states, the study says.

"A vast majority of physicians recognize the need for more tools to prevent opioid drug misuse and substance use disorders, and that is why many are tightening opioid prescribing and turning to gabapentin as an alternative," says report co-author and practicing pain specialist Jeffrey Gudin, MD, senior medical advisor of Prescription Drug Monitoring, Quest Diagnostics. "While gabapentin may not have opioids' addictive potential, it can exaggerate euphoric effects when combined with opioids or anxiety medications. This drug mixing is dangerous."