PRESCRIPTION MEDICATION MISUSE AND THE CONSEQUENCES

Steven Kipnis MD, FACP, FASAMMedical Director, NYS OASAS

NYS Advanced Judicial Diversion Training Program

December 6, 2011

WHAT IS THE MOST COMMONLY USED PSYCHOACTIVE SUBSTANCE IN THE WORLD?

WHAT IS THE MOST COMMONLY USED PSYCHOACTIVE SUBSTANCE IN THE WORLD?

WHAT IS THE FIRST SPORT TO TEST FOR DRUGS?

WHAT IS THE FIRST SPORT TO TEST FOR DRUGS?

•Dopamine is one of the primary neurotransmitters in the experience of pleasure and the maintenance of addiction.

Dopamine and Reward

Image Credit: NIDA : “The Neurobiology of Drug Addiction”

NAc VTA

FCXAMYG

VP

ABN

Raphé

LC

GLU

GABA

ENK OPIOID

GABAGABA

GABA

DYN

5HT

5HT

5HT

NE

HIPP

PAG

RETIC

To dorsal horn

END

DA

GLU

AmphetamineCocaineOpioidsCannabinoidsPhencyclidine

Opioids

Ethanol

Barbiturates

Benzodiazepines

Nicotine

OPIOID

HYPOTHALLAT-TEG

BNST

NE

CRF

OFT

IT IS NOT ABOUT THE BRAIN BEING ADDICTED TO A SUBSTANCE, IT’S ABOUT THE BRAIN BEING

ADDICTED TO ITS OWN CHEMISTRY

Neurotransmitters, Medications and the Receptor Site

AGONIST

PARTIAL AGONIST

ANTAGONIST

SUBSTANCE USE THE INDIVIDUAL AND SOCIETY

• EVERY SOCIETY HAS ITS OWN DRUGS

SUBSTANCE USE THE INDIVIDUAL AND SOCIETY

• WHAT CONSTITUTES A DRUG?o A DRUG IS ANY SUBSTANCE THAT MODIFIES BODY FUNCTIONSo A PSYCHOACTIVE DRUG IS ANY SUBSTANCE THAT AFFECTS THE CENTRAL NERVOUS SYSTEM AND ALTERS CONSCIOUSNESS

AND/OR PERCEPTIONS

SUBSTANCE USE THE INDIVIDUAL AND SOCIETY

• THERE IS NO SUCH THING AS THE “TYPICAL” DRUG USER

• DRUG USE TRANSCENDS DIVISIONS OF

o RACEo GENDERo SOCIOECONOMIC STATUSo SEXUAL PREFERENCE

Percentage of U.S. Residents (Age 12 or Older) Reporting Past Year Substance Use, 2010

0% 5% 10% 15% 20% 25%

Marijuana

Cocaine

Ecstasy

Inhalants

LSD

Heroin

11.5%

4.8%

2.2%

1.8%

1.1%

1.0%

0.8%

0.4%

0.3%

0.2%

Nonmedical Use of Prescription Pain Relievers

Nonmedical Use of Prescription Tranquilizers

Nonmedical Use of Prescription Stimulants

Nonmedical Use of Prescription Sedatives

SOURCE: Adapted by CESAR from Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2010 National Household Survey on Drug Use and Health: Detailed Tables, 2011. Available online at http://oas.samhsa.gov/NSDUH/2k10NSDUH/tabs/Cover.pdf.

First Specific Drug Associated with Initiation of Illicit Drug Use among Past Year Illicit Drug Initiates Aged 12 or Older: 2010

Note: The percentages do not add to 100 percent due to rounding or because a small number of respondents initiated multiple drugs on the same day. The first specific drug refers to the one that was used on the occasion of first-time use of any illicit drug.

3.0 Million Initiates of Illicit Drugs

Marijuana (61.8%)

Pain Relievers (17.3%)

Inhalants (9.0%)

Hallucinogens (3.0%)

Stimulants (2.5%)

Tranquilizers (4.6%)

Cocaine (0.1%)Sedatives (1.9%)

Heroin (0.1%)

GENERAL RULES

• WITHDRAWAL IS USUALLY THE OPPOSITE OF THE SIGNS AND SYMPTOMS OF INTOXICATION

• ADDITIVE EFFECTS CAN BE GREATER THAN 1 + 1 IN INTOXICATION, WITHDRAWAL AND ADVERSE EFFECTS

Benzodiazepines - Benzodiazepines - UsesUses

Psychiatric disorders

- Mainly anxiety, panic and agitation- Anticonvulsant- Muscle relaxant properties- Alcohol withdrawal

Benzodiazepine Benzodiazepine ReceptorReceptor

GABAGABA is the major inhibitory is the major inhibitory neurotransmitter and it operates in more neurotransmitter and it operates in more than a third of CNS synapsesthan a third of CNS synapses

Benzodiazepines enhance synaptic actions Benzodiazepines enhance synaptic actions of GABAof GABA

Benzodiazepine UseBenzodiazepine Use

11% of population use a benzodiazepine annually

o 80% for < 4 monthso 5 % for 4 - 12 monthso 15% > 12 months ( about 1.6% of

population)

Mellenger et al, JAMA 1984;251:375-379

Frequency of Polydrug Use in Benzodiazepine – Involved ED Visits 2002

SEDATIVE/HYPNOTICS

INTOXICATION• DECREASE IN ANXIETY• SEDATION• OCCASIONAL ELATION SECONDARY TO DEPRESSION OF

INHIBITIONS AND JUDGMENT• PUPILS ARE MIDPOINT AND SLOWLY REACTIVE EXCEPT FOR

GLUTETHIMIDE WHERE PUPILS ARE ENLARGED

Benzodiazepine Benzodiazepine PharmacokineticsPharmacokinetics

Oxidatively transformed drugs have longer half-life and longer duration of Oxidatively transformed drugs have longer half-life and longer duration of actionaction

Diazepam - Diazepam - T1/2 increases from 20 hours at 20 years to 90 hours at T1/2 increases from 20 hours at 20 years to 90 hours at 90 years90 years

Desmethyl diazepam - Desmethyl diazepam - T1/2 of 51 hours in young to 151 hours in oldT1/2 of 51 hours in young to 151 hours in old

Lorazepam and oxazepam -little change in T1/2 with ageLorazepam and oxazepam -little change in T1/2 with age

Benzodiazepines and Benzodiazepines and MemoryMemory

Impair consolidation of memory and episodic memory

Anterograde amnesia (memory loss after drug has been taken) with IV administration and short half - life, high potency BZPs

Do not affect recall of information learned before drug taken

Elderly most sensitive with discontinuation, middle-aged and elderly report improved memory and testing improves

Psychomotor Psychomotor Performance and BZPsPerformance and BZPs

Impaired cognitive and neuromotor functioning

Decreased psychomotor speed

Impaired coordination - ataxia

Decreased sustained attention

Increased effects with:• Increased age • Increased dose• Alcohol

SEDATIVE/HYPNOTICS

BENZODIAZEPINE OVERDOSE• SEDATION WITH DECREASE IN LEVEL OF CONSCIOUSNESS• DECREASE IN RESPIRATORY RATE• HYPOTENSION• DECREASE IN TEMPERATURE• GASTRIC PARALYSIS• RESPIRATORY COMPROMISE• PULMONARY EDEMA

Withdrawal Symptoms

• Psychological• Central nervous system• Gastrointestinal• Cardiovascular and respiratory system• Miscellaneous

CNSCNSHeadachePainParasethesiaStiffnessWeaknessTremorMuscle twitches

and fasciculationConvulsions

AtaxiaDizziness,

lightheadednessBlurred or double

visionTinnitusSpeech difficultyHypersensitivity to

light, sound, taste, smell

Insomnia, nightmares

GIGINausea, vomitingAbdominal painDiarrhea or constipationAppetite, weight changeDry mouthMetallic tasteDysphagia

CVS and RespiratoryCVS and RespiratoryFlushing, sweatingPalpitationsHyperventilationThirstLoss of libidoimpotence

Urogenital and endocrine

PolyuriaIncontinenceMenorrhagiaMammary pain or

swelling

MiscellaneousMiscellaneous• Skin rash/itching

• Stuffy nose, sinusitis

• Influenza-like symptoms

SEDATIVE/HYPNOTICS

BENZODIAZEPINE WITHDRAWAL

• PERCEPTION CHANGES• ILLUSIONS• HALLUCINATIONS• DEPERSONALIZATION• SENSORY HYPERACTIVITY ( LIGHTS BRIGHTER, NOISE LOUDER,

ETC.)

Falls and Falls and BenzodiazepinesBenzodiazepines

High relative risk among patients:• prescribed benzodiazepines for the first

time• dose was increased• using several benzodiazepines Short half-life BZPs have significant

psychomotor effects in first few hours after administration in older patients

Increased falls if getting out of bed for any reason

(Herings et al, Arch Int Med, 1995)

Depression and Anxiety in Depression and Anxiety in Chronic Benzodiazepine UsersChronic Benzodiazepine Users

Significant anxiety and depressive psychopathology remains in many long-term benzodiazepine users

NOVEL NON – BENZODIAZEPINE HYPNOTICS

• ZOLPIDEM ( AMBIEN®) AND ZALEPLON (SONATA ®)o RAPID ONSETo SHORT DURATIONo SHORT HALF – LIFE

• AMBIEN 2.5 HR, SONATA 1 HRo NO ACTIVE METABOLITESo AMBIEN HAS MINIMAL NEXT DAY EFFECT BUT ONLY SLIGHT

MEMORY IMPAIRMENT AND RECALL. THIS IS NOT SEEN IN SONATA

o FLUMAZENIL IS EFFECTIVE IN OVERDOSE

DEFINITIONS

Papaver Somniferum

Opiate = Rx derived from opium

Opioid = All Rx with morphine-like actions

42

OPIATE INTOXICATION

• MOST COMMON• MIOSIS • NODDING• HYPOTENSION• DEPRESSED RESPIRATION• BRADYCARDIA• EUPHORIA• FLOATING FEELING

OPIATE OVERDOSE

• CLASSIC TRIAD SEEN IN OVERDOSE• MIOSIS• COMA• RESPIRATORY DEPRESSION

• PULMONARY EDEMA• SEIZURES

• DEMEROL, DARVON, TALWIN

WE CAN PREVENT THESE DEATHS

OPIATE WITHDRAWAL - EARLY

• LACRIMATION• YAWNING• RHINORRHEA• SWEATING

SENSE OF ANXIETY AND DOOM, THOUGH NOT LIFE THREATENING

OPIATE WITHDRAWAL - MIDDLE PHASE

• RESTLESS SLEEP• DILATED PUPILS• ANOREXIA• GOOSEFLESH• IRRITABILITY• TREMOR

OPIATE WITHDRAWAL - LATE PHASE

• INCREASE IN ALL PREVIOUS SIGNS AND SYMPTOMS• INCREASE IN HEART RATE• INCREASE IN BLOOD PRESSURE• NAUSEA AND VOMITING• DIARRHEA• ABDOMINAL CRAMPS• LABILE MOOD• DEPRESSION• MUSCLE SPASM• WEAKNESS• BONE PAIN

OPIATES

• MANY OF THE COMPLICATIONS OF OPIATES ARE DUE TO THE ROUTE OF USE AND NOT THE DRUG

ENDOCARDITIS – VALVE REPLACEMENT

ARTERIAL INJECTION

OPIATE MEDICATIONS

• FENTANYLo SUBLIMAZE ®

• IV ANESTHETICo DURAGESIC ®

• TRANSDERMAL PATCHo ACTIQ ®

• “LOLLIPOP”o ALL OF THE ABOVE HAVE ABOUT

80 TIMES THE ANALGESIC POTENCY OF MORPHINE

o ROUTES OF USE INCLUDE IV, SMOKED, SNORTED, ORAL OR TRANSDERMAL

BUPRENORPHINE

• OVERVIEW OF THE DRUG ADDICTION TREATMENT ACT OF 2000 - AN AMENDMENT TO THE CONTROLLED SUBSTANCES ACT (10/17/01)

o PRACTITIONER REQUIREMENTS• “QUALIFYING PHYSICIAN”

o LICENSEDo BOARD CERTIFIED IN ADDICTION PSYCHIATRYo CERTIFIED IN ADDICTION MEDICINE BY ASAM OR AOAo INVESTIGATOR IN BUPRENORPHINE CLINICAL TRIALSo 8 HOURS OF DESIGNATED TRAINING

• HAS CAPACITY TO REFER PATIENTS FOR APPROPRIATE COUNSELING AND ANCILLARY SERVICES

• NO MORE THAN 30 PATIENTS (INDIVIDUAL OR GROUP) INITIALLY, CAN GO TO 100 AFTER ONE YEAR (MUST APPLY)

• METHADONE CLINICS CAN HAVE UNLIMITED NUMBERS

BUPRENORPHINE

• THEBAINE DERIVATIVEo MAKES THIS LEGALLY CLASSIFIED AS AN OPIATE

• PARTIAL OPIOID AGONIST

• INITIALLY USED AS AN ANALGESIC

BUPRENORPHINE

• PARTIAL OPIOID AGONISTo VERY HIGH AFFINITY FOR MU RECEPTOR

• WILL DISPLACE MORPHINE, METHADONE

BUPRENORPHINE

• PARTIAL OPIOID AGONISTo DESIRABLE PROPERTIES

• LOW ABUSE POTENTIAL• LOWER LEVEL OF PHYSICAL DEPENDENCE• SAFETY IF INGESTED IN OVERDOSE QUANTITIES• WEAK OPIOID EFFECT AS COMPARED TO METHADONE

BUPRENORPHINE

• PARTIAL OPIOID AGONISTo IF GIVEN TO A PATIENT MAINTAINED ON A FULL AGONIST, IT CAN

PRECIPITATE AN ABSTINENCE SYNDROME DUE TO LOW EFFICACY AND DUE TO HIGH AFFINITY TO THE MU RECEPTOR

• CANNOT EASILY OVERCOME THE BUPRENORPHINE EFFECT NOR CAN AN ANTAGONIST OVERCOME ITS EFFECT.

BUPRENORPHINE

• PHARMACOLOGIC USESo TREATMENT OF ADDICTIONS*

• IN THE U.S.o 2 & 8 MG SUBLINGUAL TABLETS MADE BY RECKITT & COLMAN CALLED

SUBUTEX®o 2 & 8 MG SUBLINGUAL TABLETS WITH NALOXONE IN A 4:1 RATIO CALLED

SUBOXONE®

BUPRENORPHINE

• PHARMACOLOGIC USESo DOSES USED FOR OPIOID ADDICTION TREATMENT IS 1 -2

MG UP TO 16 - 32 MGo DURATION IS A FEW WEEKS TO YEARS?

• SHORT-TERM TREATMENT IN ADOLESCENTS?o JAMA article by G. Woody et al, (2008) adolescents aged 15 to 21

did better with long term Suboxone than a short (2 week) detox protocol using Suboxone

o TO REDUCE POTENTIAL FOR ABUSE THE COMBINATION TABLET WAS MADE

• WORKS ON PRINCIPLE THAT NALOXONE IS 100 TIMES MORE POTENT BY INJECTION THAN BY THE SUBLINGUAL ROUTE

o IF TAKEN S.L. BUP>>>>>>NALONXONEo IF TAKEN I.V. NALOXONE>>>>>BUP

BUPRENORPHINE

• SAFETYo IF SWALLOWED ACCIDENTIALLY BY A NON- PHYSICALLY

DEPENDENT PERSON DUE TO POOR ORAL BIOAVAILABILITY THERE IS VIRTUALLY NO OPIOID EFFECT IN ADULT – PEDIATRIC CASES OF OVERDOSE

o REPORT OF 53 CASES OF HEPATITIS IN FRANCE SINCE 1996. ALL INVOLVED IV BUPRENORPHINE WHICH LEAD TO HEPATITIS

• PERHAPS DUE TO INCREASE BIOAVAILABILITY IF TAKEN IV

BUPRENORPHINE

• SIDE EFFECTSo SIMILAR TO OTHER MU AGONISTS THOUGH LESS SO

• NAUSEA• VOMITING• CONSTIPATION

*NO DISRUPTION IN COGNITIVE AND PSYCHOMOTOR PERFORMANCE

On the Horizon

• Implantable buprenorphine – Probuphineo 6 month durationo Being studied by Dr. Walter Ling at UCLA

• 108 patients and 55 placebo patients

• 40% in bup group and 28% in placebo group tested negative for illegal drugs at 16 weeks.

• At 24 weeks 66% of treatment group compared to 31% in placebo group were still in treatment

• Buprenorphine patcho For pain and not addiction – much different dosing

METHADONE

• SYNTHETIC NARCOTIC DEVELOPED IN GERMANY IN WW II

• 1963 USED FOR OPIATE DEPENDENT PATIENTS

• 1972 APPROVED BY THE FDA FOR TREATMENT OF OPIATE DEPENDENT PATIENTS

THEORIES OF NARCOTIC ADDICTIONIMPLICATIONS OF METHADONE

MAINTENANCE

THEORIES OF NARCOTIC ADDICTIONIMPLICATIONS OF METHADONE

MAINTENANCE

Prevents the “off and on” switch of fluctuating opioid blood levels that lead to euphoria alternating with cravings... Continuous occupation of the endogenous ligand- opioid receptor system allow interacting physiological and behavior systems to become normal. The patient is functionally normal.

Dole,Vincent P. JAMA,

Nov 25,1988Vol.260,No. 20

How Methadone Works How Methadone Works Metabolically? - Taming the Metabolically? - Taming the

Roller CoasterRoller CoasterAdequateAdequate methadone dosing methadone dosing

smoothes peaks & valleys – smoothes peaks & valleys – shifting from opioid intoxication shifting from opioid intoxication to withdrawal and eventual to withdrawal and eventual

stability.stability.

Patients can live more Patients can live more comfortably normal lives comfortably normal lives throughout each day.throughout each day.

Patients Receiving Methadone Patients Receiving Methadone Get “High”?Get “High”?

• At appropriate doses, normal function – no lasting euphoria or sedation.

• Adequate methadone dose avoids extremes of intoxication or withdrawal.

• After dosing, some patients may “sense” onset of methadone effects or have vague feelings of “well-being”(soon wears off after blood level peaks).

RATIONALE FOR OPIOID AGONIST MEDICATIONS

• OPIOID AGONIST TREATMENTo MOST EFFECTIVE TREATMENT FOR OPIOID DEPENDENCEo CONTROLLED STUDIES HAVE SHOWN SIGNIFICANT

• DECREASES IN ILLICIT OPIOID USE• DECREASES IN OTHER DRUG USE• DECREASES IN CRIMINAL ACTIVITY• DECREASES IN NEEDLE SHARING• IMPROVEMENTS IN PROSOCIAL ACTIVITIES• IMPROVEMENTS IN MENTAL HEALTH

Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users

Aged 12 or Older: 2009-2010

1The Other category includes the sources "Wrote Fake Prescription," "Stole from Doctor’s Office/Clinic/Hospital/Pharmacy," and "Some Other Way."

Free from Friend/Relative

(6.3%)Bought/Took from

Friend/Relative (6.5%)

Drug Dealer/Stranger (2.3%)

One Doctor (79.4%)

More than One Doctor

(3.6%)

Bought on Internet (0.2%)

Other1 (1.7%)

Free from Friend/

Relative (55.0%)

Bought/Took from Friend/Relative

(16.2%)

Drug Dealer/Stranger (4.4%)

Bought on Internet (0.4%)

Other1 (4.6%)

One Doctor (17.3%)

More than One Doctor (2.1%)

Source Where Respondent Obtained

Source Where Friend/Relative Obtained

STIMULANTS

• Adderall XR and Ritalino In the past students used caffeine

and cocaine to stay awake and cram for exams

o Dopamine effect whereby alertness and concentration increase

STIMULANTS

INTOXICATION• PUPILS DILATED• INCREASE IN HEART RATE (30-50%)• INCREASE IN BLOOD PRESSURE (15-20%)• NAUSEA / VOMITING• CONFUSION• TREMORS• WEIGHT LOSS• CHEST PAIN / ARRYTHMIA• QRS AND QT PROLONGATION

STIMULANTS

INTOXICATION• HEADACHE (MOST COMMON NEUROLOGIC COMPLAINT)• SEIZURES (CAN OCCUR AFTER ONLY ONE USE OF COCAINE, USUALLY

NEED MORE THAN ONE TIME USE FOR AMPHETAMINES TO CAUSE SEIZURES)

• PRIAPISM• RENAL FAILURE SECONDARY TO RHABDOMYOLYSIS AND

MYOGLOBINURIA

STIMULANTS

OVERDOSE• ALL OF THE SIGNS AND SYMPTOMS OF INTOXICATION ONLY WORSE• MYOCARDIAL INFARCTION• STROKE• SEVERE PROGNOSIS IF HYPERTHERMIA PRESENT

STIMULANT ADVERSE EFFECTS

• STEREOTYPICAL MOVEMENT DISORDERSo REPEATED DISMANTLING OF AN OBJECTo REPEATED CLEANINGo REPEATED DOODLINGo AKATHISIA – “CRACK DANCERS”o BUCCOLINGUAL DYSKINESIA – “TWISTED MOUTH” “BOCA

TORCIDA”o INCREASES TOURETTES’S SYNDROME

PET SCAN

STIMULANT ADVERSE EFFECTS

• CARDIOVASCULARo MYOCARDITISo CARDIOMYOPATHYo HYPERTENSIONo INFARCTION

Normal pink small intestine

STIMULANT ADVERSE EFFECTS

• PULMONARYo EDEMAo PNEUMOTHORAXo PNEUMOMEDIASTINUMo THERMAL AIRWAY INJURY

STIMULANT ADVERSE EFFECTS

• MISCELLANEOUSo ARFo DECREASE GASTRIC MOTILITYo GI INFARCTIONo RHABDOMYOLYSISo RHINITISo SEPTAL DEFECT

Stimulant exemptions in baseball on the rise

 

• Baseball authorized nearly 8 percent of its players to use drugs for ADHD last season, which allowed them to take otherwise banned stimulants.

o A total of 106 exemptions for banned drugs were given to major leaguers claiming attention deficit hyperactivity disorder from the end of the 2007 season until the end of the 2008 season, according to a report released Friday by the sport's independent drug-testing administrator.

• There seems to be an epidemic of ADD in major league baseball," said Dr. Gary Wadler, chairman of the committee that determines the banned-substances list for the World Anti-Doping Agency.

• 01/10/09

Reported Sources of Prescription ADHD Medications Among Past-Year Nonmedical Users, 2005

(Among adults ages 18 to 49 without a prior diagnosis of or prescription for ADHD)

Given by Friend or Family Member

Taken/Stolen Obtained Fraudulently

From a Doctor

Bought from Friend or Family

Member

Internet Pharmacy

0%

20%

40%

60%

80%

100%

66%

35%

20%13%

5%

SOURCE: Adapted by CESAR from Novak, S.P., Kroutil, L.A., Williams, R.L., and Brunt, D.L.V. “The Nonmedical Use of Prescription ADHD Medications: Results from a National Internet Panel,” Substance Abuse Treatment, Prevention, and Policy 2(32), doi:10.1186/1747-597X-2-32, 2007.

STIMULANTS

• CAFFEINEo MOST WIDELY USED MOOD – ALTERING DRUG IN THE

WORLD

CAFFEINE INTOXICATION

1. RESTLESS2. NERVOUSNESS3. EXCITEMENT4. INSOMNIA5. FLUSHED FACE6. DIURESIS7. GI DISTURBANCE8. MUSCLE TWITCHING9. RAMBLING FLOW OF THOUGHT &

SPEECH10. TACHYCARDIA OR CARDIAC

ARRHYTHMIA11. PERIODS OF INEXHAUSTIBILITY12. PSYCHOMOTOR AGITATION

RESOLVES IN 4 – 6 HOURS

CAFFEINE WITHDRAWAL

• HEADACHE – DIFFUSE AND THROBBING (50%)

• FATIGUE• SLEEPINESS• DIFFICULTY CONCENTRATING• WORK DIFFICULTY• IRRITABILITY• DEPRESSION• INFLUENZA - LIKE

ANABOLIC STEROIDS

FDA CLASS III• APPROVED FOR

• METASTATIC BREAST CANCER• STIMULATE BONE MARROW IN ANEMIA• DECREASE SYMPTOMS OF HEREDITARY

ANGIOEDEMA• STIMULATE SEXUAL DEVELOPMENT IN

PRESENCE OF TESTICULAR DYSFUNCTION

OTC• DHEA (DEHYDROEPIANDROSTENONE)• ANDROSTENEDIONE (“ANDRO”)- BANNED

ANABOLIC STEROIDS

“BODY BUILDERS”• CYCLING

• PYRAMIDS - BUILD UP TO A TOP DOSE AND THEN TAPER DOWN

• STACKING - COMBINE IV AND ORAL PREPARATIONS (UP TO 8 DIFFERENT DRUGS AT ONE TIME)

o INJECTIBLES HAVE A LOW ASSOCIATION WITH HEPATITIC TOXICITY UNLIKE ORAL

ANABOLIC STEROIDS

EFFECTS• BEHAVIOR

• EUPHORIA• AGGRESION• INCREASED MOTIVATION• IMPAIRED JUDGMENT

ANABOLIC STEROIDS

EFFECTS• MALES AND FEMALES

• HAIR LOSS• MOOD SWINGS• ACNE• DIFFICULTY URINATING• SWELLING OF THE HANDS AND

FEET• WEIGHT GAIN• ADENOMAS IN THE LIVER (LIKE

BIRTH CONTROL PILLS)• PELIOSIS HEPATITIS ( BLOOD

FILLED CYSTS IN THE LIVER)

ANABOLIC STEROIDS

EFFECTS• MALES

• TESTICULAR ATROPHY

• DECREASE IN SPERM COUNT

• INFERTILITY

• BALDNESS

• INCREASED BREASTS

• INCREASE RISK OF PROSTATE CANCER

ANABOLIC STEROIDS

EFFECTS• FEMALES

• FACIAL HAIR• CHANGES IN MENSTRUAL CYCLE• MALE PATTERN BALDNESS• DEEPER VOICE

*SIDE EFFECTS IN WOMEN ARE USUALLY IRREVERSIBLE

ANABOLIC STEROIDS

WITHDRAWAL• CRAVING • FATIGUE• DEPRESSION• RESTLESS• ANOREXIA• INSOMNIA• DECREASE IN LIBIDO• HEADACHES

MISCELLANEOUS

• Airsickness Drug Dramamine Used to Get High

• High doses of dimenhydrinate, the active ingredient in Dramamine, can have hallucinogenic effects

o 2005, a teenager in Oregon drowned after taking the drug mixed with alcohol

o 2004, five high-school freshmen from Virginia hospitalized after an overdose

o If abuse of Dramamine becomes widespread then authorities might have to look at restricting sales, just as sales of cold medicines have been limited to prevent people from making methamphetamine.

DXM - DEXTROMETHORPHAN

• ROBITUSSIN, CORICIDIN COUGH & COLD

• MEGA-DOSING – WHOLE BOTTLE, 10 – 40 PILLS

• ACCESSIBLE AND CHEAP• DRUNK, HIGH, AND TRIPPING AT

THE SAME TIME• RISK• RISK DUE TO ACETAMINOPHEN

(TYLENOL)TOXICITY

PLATEAUS

• The first plateau, 1.5 to 2.5 mg/kg, is like a slightly intoxicating stimulant; music and movement are often pleasurable.

• The second plateau, 2.5 to 7.5 mg/kg, is intoxicating, with a "stoning" a bit like that of nitrous oxide or marijuana; sounds and sights seem to be on strobe-effect ("flanging"), short-term memory is somewhat disrupted, and there are occasional mild hallucinations.

• The third plateau, at 7.5 to 15mg/kg, consists of strong intoxication, hallucinations, and overall disturbances in thinking, senses, and memory; third plateau trips can be unpleasant.

• The fourth plateau, above 15mg/kg, is similar to a sub-anesthetic dose of ketamine, with dissociation of the mind from the body, and may be dangerous physically and psychologically.

• Most recreational use of DXM happens at the first and second plateau. DXM starts to become toxic around 20 to 30mg/kg.

How am I Supposed to Drink Cough Syrup? • Materials:

o 2 glasses o A sink with COLD water o cough syrup o toothpaste

• Procedure: o Fill one glass with water, the other with Robo.

Keep the water running (it makes the sensation less gross for some reason). Do not allow Robo to be smelled under any circumstances!

o Pinch nose shut with one hand o Sip water o Take 5-6 deep hyperventilative breaths o Slam the entire 8oz bottle of Robo at one

time. o While still holding nose, drink remainder of

water o Refill glass with water and drink the entire

glass of water. o Repeat again, for a third glass of water. o Still holding your nose, spread toothpaste

in your mouth, thoroughly coating the inside of your mouth.

o Release your nose, and exhale through both nose and mouth.

• Minty fresh!

• Prescription drugs when taken as directed for legitimate medical purposes can be safe and effective.

• Prescription drug misuse occurs when a medication is not used by the person it was written for , or in the intended manner.

• Prescription drug misuse occurs in all social, economic, geographic and cultural groups.

• Children as young as 12 are using prescription drugs to get high.

• Diversion is the unauthorized,rerouting or appropriation of a medication

• DIVERSION – HOW ONE OBTAINS MEDICATION• MISUSE – HOW ONE USES MEDICATION

The White Paper, "You've Got Drugs!" IV: Prescription Drug Pushers on the Internet, released at the U.S. Senate Judiciary Committee hearing on "Rogue

Online Pharmacies: The Growing Problem of Internet Drug Trafficking,"

• 581 Web sites advertising or selling controlled prescription drugs in 2007 compared to 342 sites in 2006.

o The National Center on Addiction and Substance Abuse (CASA) at Columbia University.o 84 percent of sites selling these drugs did not require a prescription.

• Of the 16 percent that claimed to require a prescription, most (57 percent) simply ask that it be faxed, allowing a customer to forge it or use the same prescription many times to load up on these drugs.

• Benzodiazepines (Xanax and Valium) continue to be the most frequently offered controlled prescription drug, sold on 79 percent of the sites; followed by opioids (Vicodin and OxyContin) on 64 percent of the sites.

• There are no controls stopping sale of these drugs to children.

Internet Provides Prescription Drug Abusers Information on Tampering Methods

SOURCE: Adapted by CESAR from Cone, E.J. “Ephemeral Profiles of Prescription Drug and Formulation Tampering: Evolving Pseudoscience on the Internet,” Drug and Alcohol Dependence 83(S1):S31-S39, 2006. For more information, contact Edward Cone at edward.cone@comcast.net.

• A recent review of tampering methods reported on the Internet for selected pharmaceutical products found four main methods of tampering:

o Altering dosage forms to allow alternate routes of administrationo Removing the active drug from high-dose formulations, such as

patcheso Separating narcotic drugs (codeine, hydrocodone, oxycodone)

from undesirable drugs (aspirin, acetaminophen, ibuprofen) or inactive ingredients

o Overcoming time-release formulations

MISUSE

ADDICTION

PAIN

DIVERSION

• Non-medical use of prescription drugs among young people has become an increasing problem in the United States.

o 2009 Youth Risk Behavior Surveillance System (YRBSS), 20.2% of high school students have taken prescription drugs without a doctor’s prescription.

• According to SAMHSA:o One in 3 teens has reported that there is "nothing wrong" with

using prescription drugs "every once and a while." o Prescription drugs are the drug of choice among 12- and 13-

year-olds. o Girls are more likely than boys to intentionally use prescription

drugs to get high.

AVAILABILITY

Oxycodone Pills Purchased by Medical Practitioners January to June 2010

Oxycodone Pills Purchased by Medical Practitioners January to June 2010

Sales of opioid analgesics, such as oxycodone and hydrocodone, have

increased more than 600% since 1997, according to data from the DEA

Controlled Substance Prescription Statistics

• Number of Prescriptions dispensed by pharmacies per year (new prescriptions and refills) in NYS

YEAR TOTAL

SCRIPTS

# OF PATIENTS

2010 22,575,704 4,878,188

2009 21,502,426 4,837,414

2008 19,207,181 4,703,805

Controlled Substance PrescriptionsNumber of Prescriptions per Calendar Year

2008 2009 2010

Hydrocodone

(Vicodin)

4, 221, 880 4, 501,956 4,441,224

Clonazepam

(Klonopin)

1,054,020 1,170,218 1,272,631

Alprazolam

(Xanax)

1,507,725 1,691,816 1,842,260

Zolpidem

(Ambien)

2,375,276 2,921,992 3,038,600

Oxycodone

(Oxycontin)

2,141,367 2,591,668 3,030,976

Buprenorphine Misuse in US

• 2005 – 2007 National Survey of >1000 persons seeking prescription opioid abuse treatment in ~100 sites

o Diverted prescription medications• Less than 3% use buprenorphine to get high

Street Value

Drug Value in $

Vicodin 6 – 8

Oxycontin 1 per mg

Methadone 10 – 40 per dose

Fentanyl 25 – 40 per patch or Actiq

Blank Rx 300

Data on Unintentional Drug Overdose Deaths

• Nationalo In 2007, there were 27,658 unintentional drug overdose deaths

in the United States.o From 1999 through 2006, the number of fatal poisonings

involving opioid analgesics more than tripled.o The rates of overdose deaths are now 4-5 times higher than they

were during the heroin epidemic of the mid 1970s.o In many states unintentional drug overdose deaths now exceed

deaths from motor vehicle accidents.

• New Yorko In New York State, unintentional drug overdose deaths have

exceeded deaths from motor vehicle accidents since 2006.o From 1999-2007 more than 8,000 New Yorkers died from an

unintentional drug overdose.

Prescription Drugs OverdoseType of Drugs and Reasons for Use

• 1970s – Black Tar Heroin Epidemic

• 1980s – Crack Cocaine Epidemic

• Over 27,000 OD deaths = one every 19 minutes

Nonmedical Users Among Opioid Overdose Deaths

Why Do Teens Misuse Prescription or OTC Drugs?

• The reasons that an increasing number of teens are misusing prescription and OTC drugs are not completely understood.

o Many teens think that these drugs are safe because they have legitimate uses and are often found at home in the medicine cabinet.

o Parents purchase OTC drugs for family use and may not realize that their kids are abusing these products.

o As a rule, teens do not see any negative consequences of using OTC preparations, nor do they think that they can get in trouble if caught using them.

o The proliferation of Internet pharmacies provides an opportunity for illegally obtaining medications.

Why Do Teens Misuse Prescription or OTC Drugs?

• Pharming• Fish – Bowl Parties

o Must bring 3 reds and a green pill or similar combination

The College Community

• Prescription drug abuse among college students is a growing trend on most campuses. Students are using these drugs inappropriately to not only “get high”, but to help with concentration when cramming for papers or tests, to self-medicate for anxiety or depression, and even to enhance their stamina when playing sports.

Seniors

• People over the age of 65 take an average of 2-7 prescription medications per day.

o The most commonly prescribed mood altering drugs include Benzodiazepenes (Ativan, Librium, Serax, Valium and Xanax) for anxiety, insomnia and alcohol withdrawal; sedative/hypnotics (Ambien, Dalmane, Halcion and Restoril) for insomnia; and Opioids (Codeine, Darvon, Demerol, Lortab, Percodan/Percocet) for pain control.

• Pain Management Patientso The swing of the pendulum from under-treatment of pain to over-prescribing

of pain medications has had a significant impact on the misuse of pharmaceuticals and the increase in overdose death due to prescribing errors in many patients.

o OASAS has worked closely with DOH and NYCDOHMH to give guidelines and educational resources.

o A new study by Geisinger Health System researchers has found a high prevalence of prescription pain medication addiction among patients with chronic pain.

• In addition, the researchers found that the American Psychiatric Association's new definition of addiction, which was expected to reduce the number of people considered addicts who take these medicines, actually resulted in the same percentage of people meeting the criteria of addiction.

• Published in the Journal of Addictive Diseases, the study found that 35% of patients undergoing long-term pain therapy with opioids such as morphine, OxyContin, Percocet and Vicodin meet the criteria for addiction.

 

Far-reaching Public Health Impact of Widespread Opioid Analgesic Use

• WHAT CAN YOU/WE DO?

By taking a few simple steps, all of us can help decrease the abuse of pharmaceuticals:

• Prescription drugs that are no longer needed should be disposed of properly, such as through a community take-back program conducted with law enforcement officials.

The Role of Parents

• The Partnership for a Drug-Free America recommends a 3-step approach: (1) educate; (2) communicate; and (3) safeguard. Parents are encouraged to:

o Educate themselves about which medications can be misused or abused, and learn about the very real dangers and risks of this behavior;

o Communicate these risks to their kids, dispelling the notion that medicines can be safely abused; and

o Safeguard medications by limiting access to those that can be abused, keeping track of quantities, and safely disposing of medications that are no longer needed. Parents should also enlist the support of fellow parents to ensure that they do the same.

Schools

• Increase communication inside and outside of your school regarding the dangers of prescription drug misuse. Last year, the National Association of School Nurses (NASN) announced two major initiatives: o “Smart Moves, Smart Choices: A Prescription Drug Abuse

Education Program” features free videos to educate youth and parents. The program also includes a school assembly tool kit to help your school host student and/or parent assemblies.

o “The Current State of Teenage Drug Abuse: Trend Toward Prescription Drugs” is a 2.0 CNE program that is available online. A toolkit provides school nurses with educational resources and tools for preventing, identifying and managing young people’s misuse of prescription drugs.• Both of the above resources can be found on the NASN web site at:

http://www.nasn.org/Default.aspx?tabid=506

• OASAS released a Medicine Cabinet Inventory to help prevent prescription drug abuse in homes across New York and is available on the agency's Web site at www.oasas.state.ny.us/pio/documents/medicineCabBrochure.pdf

o The Medicine Cabinet Inventory provides a format to record the type of prescription, dosage amount, the date filled and quantity. A periodic check should be done to ensure that the medications are still safely stored.

o The Medicine Cabinet Inventory is a valuable tool in helping elderly family members track their medication use.

Role of Health Practitioners

• Communication, honesty, and vigilance are the keys to success for healthcare professionals who treat teens. Practitioners should talk with adolescents directly to ascertain whether they are misusing or abusing prescriptions or other drugs.

• It is important to address the health and safety risks that such practices present.

o "borrowing" prescriptions, such as antibiotics, exacerbates antibiotic resistance.

o "Sharing" acne medication is dangerous because these drugs contain teratogens.

o Research has demonstrated that education for teens must be reinforced over several encounters

GUIDELINES FOR PATIENTS

• Provide healthcare provider with an accurate history• Participate fully with treatment plan discussions• Do not use psychoactive drugs with pain medications• Do not use alcohol and over the counter medications without discussion with your

healthcare provider• Keep an open mind as to the success of the treatment plan and be open to trying

alternative strategies• Get all medication if possible from one provider, or at a minimum let the primary healthcare

provider know which medications are being used• Fill all prescriptions at a single pharmacy• No sharing of medications with others• Keep a watchful eye on all medications• Safe storage at home is extremely important (locked medicine cabinets should be

considered).• No hording of medications• Patients should use caution driving while stabilizing on benzodiazepine or opioid dosing

regimens 

Collaborative Efforts with the New York State Department of Health

• OASAS is working closely with the Department of Health (DOH) and the Bureau of Narcotic Enforcement (BNE)

o Some of these efforts include the Practitioner Notification Program, Prescription Opioid Addiction Treatment Education and Intervention, and a Health Advisory: Intervention to Prevent Opioid Overdose.

Official NYS Prescription Forms

• All forms contain a unique serial number

• Pharmacist “test area” – heat sensitive ink

• Heat sensitive ink on back of form

• The word “void” will appear if a prescription has been copied, scanned, physically or chemically erased

• Saves Medicaid 1.5 million dollars per month

New York State Law

• April 1, 2006: It is legal for a non-medical person to administer naloxone (Narcan) to someone else in order to treat a potentially fatal overdose: naloxone is first aid.

• However, by federal regulation naloxone requires a prescription• NYSDOH promulgated regulations for implementation

OD prevention project

http://www.nyhealth.gov/diseases/aids/harm_reduction/opioidprevention/

Effect of naloxone on overdose death: New York City, US Law passed

establishing naloxone programs

NYC Vital Signs 2/10

NYS LAW

• 911 Law passes and signed in July 2011

“Dinner with your Parents Project”

CASA 2005

SAMHSA program: http://www.talkaboutrx.org/

The Future

• Educationo General Publico Medical Practice

• Urine drug screens

• Monitoring• Proper medication disposal• Enforcement• Overdose Prevention• Treatment• Adolescent Use and Prevention• Outcomes

stevenkipnis@oasas.ny.gov

www.oasas.state.ny.us/admed/