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