Prescription Abuse: Cause,Consequence and Control

Glen R. Hanson, Ph.D., D.D.S.Professor in Pharmacology, University of Utah

Director of the Utah Addiction Center, University of UtahSenior Advisor, National Institute on Drug Abuse, NIH

What Do We Mean When We Say Prescription Drug Abuse?

Use: Prescribed and clinically appropriate

Misuse: Either not prescribed or

clinically inappropriate

Drug Abuse- use of a drug in a

manner not medically or “socially”

approved (recreationally??).

“Pharm Party”

Prescription

abuse

Drug addiction:

Dependence:

Persistent use resulting in adaptations typically

accompanied by accommodation or tolerance (causing

compensatory escalation) and withdrawal (e.g., aches,

diarrhea, depression and cravings)

Compulsive drug use that consists of repetition

to satisfy intense urges, despite severely negative

consequences

Categories of Rx drug users

• Legitimate (do not break laws and

drugs properly managed and used)

• Legitimate (laws not broken, but

either not being managed properly

or used improperly)

• Illegal (laws broken to obtain and/or

use)

• Combinations

• What is the attitude about the drug?

Necessary for a medical condition

(e.g., pain, stress, anxiety)

If the drug can be obtained

legally, everything will be OK

Obsessed: tremendous energy is

spent on assuring drug access

How many people are abusing

(misusing?) prescription drugs?

Approximately 9 million Americans use

prescription drugs at least once for

“nonmedical” reasons a year.

Approximately 4 million Americans report

using prescription drugs “nonmedically”

monthly.

Survey Says:

In 2010 nonmedical use &

consequences

• >12 yrs lifetime= 20%

• HS Seniors annual use

Vicodin= 10%

OxyContin= 5%

Adderall= 5%

• ~ 15,000 overdose deaths in U.S.A.,

2011

• What is the pharmacological status

of the patient/user?

Physically dependent, but not

addicted

Deriving medical benefit from

the medication

Physically dependent and addicted

• What is the role of the Rx provider &

dispenser?(DRUG DEALERS?)

AWOL (“take a number” attitude;

does not know patient nor history)

Enabler (excessively accommodating)

Candy man

Where do abused Rx drugs

come from (demographics)?

• Dealer = 8%

• Buy the drugs = 21%

• Took/stole the drugs = 12%

• Given the drugs = 33%

• Doctor’s Rx = 19%

• Friend or relative = 66%

• Internet purchases = minor

What should we do about it??

Utah Legislature/Governor

2010 Resolution:

• Objectives: more effective education

and assessment of risk before

prescribing and more effective

monitoring and disposal after

prescription issued

Why Does Someone

Abuse a

Prescription Drug?

Addiction Cycle for Prescription Drugs

• relieve medical condition (e.g., pain, anxiety,

stress, weight gain)

• reinforcing effects (stimulates reward pathways)

• induces physical dependence• often there is a tolerance and withdrawal

issue (usually occurs due to lengthy drug use)

• patients often have substance abuse risk

before treatment (mental risk/prexisting problem• patient uses various strategies to maintain

drug supply (often illegal)

Prevention

• Doctors/pharmacists need to

do their jobs-educate and

warn!

• Obtain accurate history (any drug

abuse problems in family or

personally?)

HOW?

DEFINING SBIRT PROGRAM

• SCREENING, BRIEF INTERVENTION, AND

REFERRAL TO TREATMENT (SBIRT) IS A

COMPREHENSIVE AND INTEGRATED

APPROACH TO THE DELIVERY OF EARLY

INTERVENTION AND TREAMTMENT

SERVICES THROUGH UNIVERSAL SCREENING

TO PERSONS WITH SUBSTANCE USE

DISORDERS AND THOSE AT RISK

Babor et al., 2007

DEFINING SBIRT

• SBIRT is designed to fill the gap between

primary prevention efforts and more

intensive treatment for persons with serious

substance use disorders

SBIRT PHYSICIANS and programs can

reach a significant proportion of the

population using alcohol and other drugs

before high-end interventions are needed

SBIRT PYRAMID

SAMHSA SBIRT PROGRAM, 2009

BRIEF INTERVENTION

BRIEF TREATMENT

REFERRAL TO TREATMENT

Division of Substance Abuse and Mental Health, 2010

AGE-RELATED NEED FOR SBIRT IN UTAH

Screen • Identification of substance related and emotion problems

Brief Intervention

• Uses motivational interviewing to raise awareness of risks and motivate client toward treatment engagement

Brief Treatment

• Evidence based cognitive behavioral treatment with clients who elect further treatment or need follow-up care (including co-occurring disorders)

Referral to Treatment

• Referral of those with more serious or emergent treatment needs

SBIRT CORE COMPONENTS

SBIRT CORE COMPONENTS

• SCREENING – accurate identification of “at risk”,

“high risk”, and “addicted” individuals

• ISSUES TO CONSIDER – important to consider

1) perceived threat, 2) cognitive capacity, 3) self

image, 4) denial – patient and medical staff, and

5) level of trust

SBIRT SCREENING TOOLS

• AUDIT (ALCOHOL USE DISORDERS IDENTIFICATION

TEST) – 10 questions, focuses on hazardous drinking

as well as alcohol use disorders, adult population, 5

min/3 min

• DAST (Drug Abuse Screening Test) – 10 or 28

questions, focuses on drugs, adult and adolescent

populations, 5 min/2 min

• TWEAK (Tolerance, Worry, Eye-Opener, Amnesia,

Cut-Down) – 5 questions, originally developed to

screen for alcohol use in pregnant women; adult

population, 3 min/2min

How can the health care provider

contribute?

• Only use the Rx to treat the

condition for which it was prescribed

• Recognize the symptoms of

dependence and addiction

(& difference)

• Rx addiction is a relapsing disorder

and often requires professional help

Patient Education

• How to safely store

• Legal prohibitions on sharing or

selling/protect family members

and others from unintentional or

intentional misuse

• Promptly dispose of the leftovers !!!

Tools to assist assessments:

• Division of Occupational and

Professional Licensing (DOPL)

Monitoring- regulator of Rx

drug prescribers

Licensing and certification

management-establish

qualifications and require

training (CE requirements)

Monitoring through databases-

approach real-time information

• High-risk patients:

Medication management

agreements

Tight control on Rx numbers and

routine accountability

Drug screens-- with consequences

• Be able to recognize if treatment

is required and get patient

help (be able to explain why

important and how it is done)