Post on 26-Dec-2015
OxyContin, Vicodin, and Heroin Abuse: What's a Clinician to Do?
Peter A. DeMaria, Jr., M.D., FASAMTuttleman Counseling Services
Temple UniversityClinical Associate Professor of Psychiatry
Temple University School of Medicine
Disclosures
• Dr. DeMaria serves as a treatment advocate for Reckitt-Benckiser Pharmaceutical
• Generic versus Trade drug names• Off-label use of medication
College Student Developmental Stage
• Invincible• Subject to peer pressure• Risk-taking• Want to be independent
ADOLESCENCE
Some Factors Affecting Drug Experimentation/Continued Use/Addiction
GeneticsPeer Pressure
Stress
Availability
Trauma/abuse Curiosity
Boredom
Psychiatricproblems
The Life History of A Substance UserAbstinence
Experimentation
Abuse
Dependence
Sobriety
Recovery
Abstinence
Relapse toUse
Core Alcohol & Drug Survey-2005(A sample of 33,379 undergraduate students from about 53 colleges in the United States)
30 Day Prevalence Rate by Drug Type
College Student Opioid Use–CORE StudyYear No. of
StudentsNo. of Colleges
Annual Prevalence
30-day Prevalence
2006 71,189 134 1.3% 0.6%2005 33,379 53 1.4% 0.7%2004 68,000 133 1.5% 0.7%2003 38,857 89 1.7% 0.8%2002 54,367 125 1.8% 0.8%2001 54,444 131 2.1% 1.0%
If Temple has 33,000 students, then 429 used in the last year & 198 used in last 30 days
Monitoring the FutureAnnual Prevalence for College Students
Papaver somniferum (Opium poppy)
Patterns of Use• Heroin: $10 bags
– Snorted, injected, smoked– Average habit = $80-100/day
• Prescription Narcotics (Opioids)– Oxycodone [C-II]
• Percocet (~$5/pill)• OxyContin (~$0.50/mg.)
– Tylenol w/Codeine #3,4 (~$1-5/pill) [C-III]– Lortab/Vicodin (hydrocodone), [C-III]
Prescription Opioid Drugs
Percocet OxyContinVicodin
Tylenol #4 w/codeineDilaudid
Lortab
Opioids - Intoxication/Withdrawal/Overdose• Intoxication
– Rush, nod, miosis, constipation
• Withdrawal-Craving -Anxiety -Mydriasis-Insomnia -Weakness -Diaphoresis-Yawning -Lacrimation -Myalgias/arthalgias-Diarrhea -Piloerection -Rhinorrhea-Muscle twitches
• Overdose– Classic triad (Miosis, Respiratory depression, Coma)
Cycle of AddictionDrug Use
Physical dependence
Withdrawal symptoms
Need for drugs
Obtain money for drugs
Obtain drugs
Consequences of Addiction
• Inability to attend classes/do schoolwork • Breakdown of relationships• Decrease in self-care• Inability to work• Financial problems (cash flow)• Illegal behavior• Medical risks• Psychiatric illness
Progression of Opioid Use
Prescription Opioid Medication
Snort Heroin
Inject Heroin
Precontemplation
Contemplation
Preparation
Action
Maintenance
How People Change
Prochaska J, DiClemente C, Norcross J. In search of how people change: applications to addictive behaviors. Amer Psychol 47:1102-1114, 1992.
General Principles of Treatment
• Comprehensive evaluation• Engagement in treatment• Treatment setting• Detoxification vs. maintenance• Counseling (Individual, Group)• Self-Help (12 step)
Methadone Suboxone®Component(s) Methadone Buprenorphine +
naloxoneClassification Pure opioid agonist Partial opioid agonist
+ pure antagonistPrevent WD Yes YesCause euphoria No NoBlock euphoria Yes YesSafe in OD Lethal SaferDEA Regulation C-II C-IIIAdministration Oral SublingualAvailability Specialized clinics Outpatient physicians’
officesDosing visit Daily Up to monthly
Using Buprenorphine to Treat Opioid Dependent University Students:
Opportunities, Successes, and Challenges.• Peter A. DeMaria, Jr., M.D., FASAM
Robert C. Sterling, Ph.D.Robin Risler, Psy.D.Jeremy Frank, Ph.D., CAC
• Journal of Addiction Medicine• Available on-line: Published Ahead of Print• http://journals.lww.com/journaladdictionmedicine/
toc/publishahead
The Temple Experience• Retrospective chart review of treated students.• Time period = 1/04 through 4/08• 27 students inducted and treated at least 3
months• Average age = 22.37 ± 2.89 years old• 63% Male• 85% Caucasian• 97% Academic juniors or higher• 41% Not involved in a relationship
Year in School at Presentation
Opioid Use at Admission – Self Report
Initial Urine Drug Screen
Population Characteristics• Average length of use = 33.4 ± 28.79 months (range = 4-132 months)• 56% Use drugs IV• 67% Smoke tobacco• 56% Dink alcohol• No HIV or HCV infections• Family History
– Psychiatric = 52%– Drug & alcohol = 70%
• 59% Report a history of past addiction treatment• 30% Report a legal history
Psychiatric Diagnosis15/27 (55.6%) had a history of a psychiatric diagnosis
Treatment Characteristics
• Average Suboxone dose = 13.8 ± 5.69 mg (range = 4-24 mg).
• Well tolerated; no serious adverse events• Most common side effect = constipation• One student became pregnant and delivered
Urine Drug Screen ResultsN = 237 UDS, M = 8.8/student, Range = 0 - 33
Disposition of Admitted PatientsLength of Treatment = M = 12.00 ± 11.49 months
Range = 1 to 36 months
Treatment Received
Service N (%) Avg. No. + SD RangePsychiatric Evaluation
27 (100%) N/A N/A
Medication Management
27 (100%) 10.48 ± 9.75 1 - 30
Individual counseling
18 (67%) 7.56 ± 5.73 1 - 21
Group counseling
15 (56%) 8.60 ± 5.69 2 - 20
Self-Help 9 (33%) ? ?
Predicting Treatment Outcome
• Opioid positive UDS at follow-up– Use of heroin → (+)– Use of other substances → (+)– Time in treatment (p = 0.06) → (-)
• Time in treatment– No significant indicators
Challenges
• Accept the disease of addiction• Commit to sobriety• Acknowledge that marijuana is a drug• Engage in treatment• Finances• Managing free time/boredom
Study Limitations
• Uncontrolled• Retrospective• No comparison group• Small sample size• Limited to one university
Conclusions
Opioid dependent university students:• Are a unique group of substance
users• Can be safely and effectively treated
with buprenorphine in a university counseling center