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MEDTOX® Journal
Public Safety Substance Abuse
Newsletter
In This Issue
Trends in Adolescent Drug
Abuse: "Starter Heroin and the
Smell of Cheese
Non-medical Use of Opiates and
Benzodiazepines Continue to
Climb
Junior High and High School
Campus-Based Drug Testing
Programs
From the Hotline: Phenibut
Update
Buprenorphine and HIV
Treatment
August 2010
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Version of Newsletter.
Name That Drug
Trends in
Adolescent
Drug Abuse:
"Starter Heroin"
and the Smell of
Cheese
Calls to the DAR Hotline
have increased in recent
weeks in response to
unusual changes in
adolescent drug abuse.
In particular, callers
from Texas and Arizona
have inquired about a
drug called "cheese" or
"mickey juice." This drug
is a substance that we
first reported on two
years ago when it was
alleged to be the cause
of scores of overdoses
and deaths in the DallasFt. Worth area. Scroll
forward to the present
and we find that this
form of "starter heroin"
continues to plague
communities in the
southwest. It appears
that Texas still bears the
brunt of "cheese."
Reports of its use in
Non-medical Use of Opiates and
Benzodiazepines Continue to Climb
Prescription opiates (hydrocodone, oxycodone, codeine) and
benzodiazepines (diazepam, alprazolam and lorazepam) have
become some of the most popularly abused prescription drugs
in America. A spate of celebrity overdoses and deaths has
spotlighted this problem. Non-medical utilization of these
drugs and the subsequent overdoses exceeds the carnage of
fatal automobile accidents in some states, especially in adult
populations ages 35-54. Prescription opiate abuse is
dominated by
hydrocodone and oxycodone; the
most common forms of these drugs
are Vicodin and Oxycontin.
Diazepam (valium) is a member of
a separate classification of drugs
called benzodiazepines. Included in
this family of substances are Ativan
(lorazepam) and Xanax
(alprazolam). The benzodiazepines
are frontline medications used to
induce sleep and reduce anxiety.
Frequently both classes of
prescription drugs are combined to
form "loads." The composition of
"loads" varies from city to city and
region to region. More often than
not, alcohol is mixed with these
prescription drugs. When this occurs, a pharmacological
synergy ensues resulting in exaggeration of sedative
symptoms and physiological loss of control. A trip to the
emergency room often follows.
The Drug Abuse Warning Network (DAWN) researchers
evaluated a sampling of emergency room records from 231
hospitals. From 2004 to 2008, emergency room visits for
nonmedical use of opiates increased from 140,000 to 300,000,
a 111% increase over that period. The reason most cited for
the emergency room visits was concern for patient overintoxication and/or overdose from use of oxycodone,
hydrocodone, and/or methadone prescription drugs. The
benzodiazepines experienced an 89% caused increase in ER
visits as well over the same period of time. ER visitation rates
peaked among people ages 21 to 24; nearly one quarter of
those who visited the hospital were ultimately admitted. Not
other states have been
sporadic. The impact of
this problem is borne by
young, oftentimes
inexperienced drug using
teenagers. The drug is
priced squarely for use
by young drug users; its
purity is relatively low
and led to the drug's
designation as "starter
heroin."
"Cheese" is a compound
made up of black tar
heroin and Tylenol PM.
Black tar is a potent, less
refined form of heroin.
It's typically found as a
sticky and very black
goo. The drug can be
smoked or it can be
injected intravenously.
"Cheese" purveyors mix
water, crushed Tylenol
PM, and black tar heroin
together. The mixture is
then heated mildly to
evaporate off the water
and to create a crispy
powdery appearance.
The final dried product
has the appearance of
parmesan cheese, hence
its name. The drug is
packaged in ¼ to ½
gram bindles in wax or
notebook paper. A bindle
of "cheese" can cost
anywhere from $5 to
$10. Purity of "cheese"
can range from 5%20%, substantially less
than that of tar heroin
alone. The drug is
typically snorted, but
there have been seizures
of "cheese" crammed
into gelatin capsules.
captured in this data is the role that adjunct non-medical drug
use plays in ER visits. Carisoprodol (Soma) and Zolpidem
(Ambien) are popularly abused drugs that possess powerful
sedative features. Soma in particular is a widely abused drug,
one whose popularity goes well beyond its putative value as a
muscle relaxant. This barbiturate-like drug is mixed with
prescription opiates (Vicodin or Percocet) to create one of the
most popular "loads" for America drug abusers. This
dangerous and addictive phenomenon is poorly appreciated
and infrequently monitored by judicial and medical
professionals.
Non-medical use of prescription drugs continues to climb. In
2008, the number of ER visits involving non-medical use of
prescription drugs equaled the number of visits for illicit drugs
(methamphetamine, cocaine, ecstasy, and GHB). Physicians
assigned to emergency rooms, occupational medicine centers
and other clinical settings should be sensitive to this
development. Family physicians should also be vigilant for
signs of non-medical prescription drug use in their practices.
Urine drug testing is an effective means of monitoring this
problem. In a recent publication of the American Family
Physician [1], family doctors were encouraged to undertake
regular, broad-spectrum urine drug screening for the purpose
of detecting of both licit and illicit drugs. In the journal,
urinalysis was touted as a valuable office procedure for
physicians and other healthcare providers.
[1] Standridge JB, Adams SM, Zotos AP. Am Fam Physician. 2010 Mar 1;81
(5):635-640.
Junior High and High School
Campus-Based Drug Testing
Programs Fire Up for the Fall
Semester
Almost half of all people in grade 12 have used illicit drugs at
one point or another[1]. Many parents and school
administrators are concerned with the effect that drugs and
alcohol are having on students in terms of academic
performance, dropout rates and disruptive behavior. One
As is the case with use of
any opiate, chronic or
frequent use of this drug
will provoke addiction
and dependency. Even
though the purity of
"cheese" is significantly
less than other forms of
heroin, it can quickly and
easily overcome an
adolescent user. The
depressant effects of
heroin in "cheese" are
exacerbated by the
additive effects of
diphenhydramine; the
antihistamine
constituent of Tylenol
PM. Diphenhydramine is
the principle ingredient
of Benadryl, a
medication that is widely
utilized as a sleep aid.
When combined with the
heroin in "cheese," users
experience a profound
sense of relaxation and
calm. Non-tolerant users
of "cheese" will display
classic symptoms of
opiate abuse: lethargy,
somnolence, droopy
eyelids, constricted
pupils, dry mouth and
slow speech. Because of
the depressant effects of
diphenydramine,
"cheese" users will also
display evidence of
nystagmus and nonconvergence.
Concentrated doses
of diphenhydramine can
cause frank
hallucinations and a
catatonic like affect. The
more direct effects of
this form of heroin will
last for 3-6 hours. Signs
of withdrawal from
increasingly popular solution to these problems is voluntary
school-based drug testing. What exactly is voluntary schoolbased drug testing? In collaboration with a number of large
and small school districts, MEDTOX has created a highly
affordable drug-testing program that has excited parents,
school officials, and yes, the students themselves. This system
is an all-encompassing program that is comprised of three
interlocking sections: parent and student education, randomly
sampled drug testing, and professional counseling and
rehabilitation (if required). The program provides participating
schools with educational seminars that are taught by some of
America's most respected substance abuse experts. These free
and frequent seminars empower parents and students by
providing them with real life, no nonsense factual discussions
about the dangers of alcohol and drugs. Program lecturers
provide insight for parents into the Internet world where drugs
sales are arranged and cabinet parties are scheduled. This
experience is shocking for many of the parents who attend.
You can hear a pin drop in the lecture halls when parents hear
about how Facebook and social networking sites are exploited
by students to organize and coordinate parties and other
meetings where drugs and alcohol are used. In the end,
students and parents find themselves on the same page in
understanding the nature and the extent of their local drug
scene. Seminar leaders provide tudents and parents with
strategies for dealing with the various forces that tug at
students to use drugs and alcohol.
This school-based drug-testing program that is available for
students in grades 7 through 12 is completely confidential and
private. It is firewalled so that testing results are kept
discreet; they're not shared with school officials. Positive test
results are communicated to parents through the auspices of a
medical review officer (MRO). Test results are treated as a
private health care matter. These programs are completely
voluntary with opt in forms necessary for each parent and
student to sign and acknowledge. Either student or parent can
verbally opt out of the program at any time. Once a student is
enrolled in the program, he/she is then assigned to a pool that
is subjected to random selection and collection. Professionally
trained collectors operate at participating schools at discrete,
out-of-the-way locations on the school grounds; collectors
have access to a variety of onsite urine and oral fluid
screening devices. Presumptive positive samples are sent to a
lab overnight. Once a sample has been produced by a
participating student, he/she is free to return to class. It takes
a student less than 15 minutes. Positive screening results are
confirmed at the SAMHSA certified laboratory utilizing gas
chromatography/mass spectrometry (GC/MS) technology.
"cheese" are likely to be
noticeable within 8-12
hours of the cessation of
direct effects. Peak
withdrawal symptoms
will occur between 24-48
hours following last
dose.
At present, "cheese" is
mostly a regional
phenomenon of Texas.
Isolated seizures of
"cheese" in other border
states have not been
significant. Mexico is the
source of nearly all tar
heroin consumed in the
United States. Texas's
proximity to Mexico puts
it in the crosshairs of
smugglers and cartel
operations. With Nuevo
Laredo (MX) becoming a
focus point of cartel
controlled tar heroin
smuggling, communities
proximate to the border
are likely to see
continued abuse of
"cheese." Parents,
teachers and friends
should be sensitive to
sudden and inexplicable
behavioral changes in
adolescents. Poor
performance in school,
withdrawal from friends
and from hobbies and an
affect of exhaustion are
all suggestive of a
"cheese" abuse problem.
Treatment of "cheese"
addiction and
dependency may require
in-patient detoxification
and enrollment in an
intensive outpatient
program afterwards.
Early intervention in a student's inclination to use drugs and/
or alcohol has proven critical in deterring substance abuse
problems later in life. Random drug testing programs also
provide students with motivations and social "cover" in
handling peer pressure directed at them to use drugs at
parties and at other gatherings. Reducing the rates of student
drug testing can save lives as well. With prescription drugs
topping the list of junior high school and high school drug
abuse tendencies these days, a random testing program is a
means of slowing or even reversing the pace of abuse for
substances such as Vicodin, Oxycontin and Percocet.
Depending on the nature of a local drug problem, a schoolbased program may also screen for abuse of over-the-counter
drugs and botanical hallucinogens, substances that are
exceedingly popular with high school students. The programs
are easy to customize and fit to the on-the-ground realities
affecting a participating school or school district.
These programs are endorsed by the California Narcotic
Officer's Association (CNOA), the Coalition for a Drug Free
California and the Partnership for Responsible Parenting. If
you want more information about this new program, please
contact a MEDTOX sales representative or a Drug Abuse
Recognition (DAR) Program representative at
[email protected].
[1]
www.drugabuse.gov
From the Hotline: Phenibut Update
We've previously reported on widespread use of a noncontrolled sedative called Phenibut. The drug has been sold
and traded on the Internet below the radar of law enforcement
and regulatory authorities. Up to now, most U.S. phenibut has
been sourced from the U.K. and Europe. But recently, an
"over-the-counter" Internet marketed product containing
phenibut has surfaced in America.
Called "Tranquila PM," this compound contains
350 mg of 4-amino, 3-phenylbutyric acid
(Phenibut) and an array of vitamins and herbs.
The product is packed into a small 2 fl. oz., oneshot plastic bottle that's designed for fast, nohassle ingestion. Tranquila PM's marketing
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message states that the drug is a worthy
alternative to traditional prescriptions and overthe-counter sleep aids. One online purveyor of
Tranquila PM asserts that a single dose of the
drug brings about a "general relaxation effect
that leads to a sound and restful sleep." (http://
www.tranquila.com/)
Phenibut is a chemical relative of the inhibitory amino acid
transmitter, GABA. The drug possesses some of the sedative
powers of gabapentin (Neurontin), Baclofen and gamma
hydroxy butyrate (GHB). Its effects are mediated through its
agonist actions at GABAB receptors; the drug exerts less of an
effect at GABAA receptors. In some Internet drug cafes,
phenibut is advocated as a means of weaning off of powerful
drugs such as GHB and GBL. It's also advocated for those that
want to avoid the withdrawals from other depressant drugs,
such as alcohol and benzodiazepines. The drug is also alleged
to be an aphrodisiac. In its early development stages, the drug
was also thought to be nootropic (a memory enhancer). In
fact, modern phenibut aficionados tout it as a "smart drug,"
something akin to the prescription drug Provigil and several
other substances thought to be cognitive accelerants. The
Russian space program even packed phenibut into the
medicine chests of the Soyuz spacecraft.
Phenibut is not known to cross-react or otherwise interfere
with modern drug test systems. Someone who uses phenibut
products will not yield a positive drug test for a controlled
substance. But phenibut does pose challenges to readers who
work in the drug rehabilitation industry. For patients in
recovery, phenibut poses risks. In particular, patients with
alcohol and central nervous system depressant addictions may
get undesirable drug cravings from the sedating and euphoric
effects of phenibut. For others working in residential programs
and sober living homes, phenibut use by participants could
threaten the safety and security of the house. Chronic
phenibut use can lead to tolerance. There have been reports of
withdrawal following extended periods of use. Tranquila PM
contains a warning to users that following two weeks of
continuous use of the drug, a 5-7 day drug holiday should be
taken. That admonishment from a phenibut distributor sums
up the dangers that a drug like phenibut poses to people in
recovery and the people and programs that support them.
Buprenorphine and HIV Treatment
In communities where intravenous use of drugs is rampant, so
is HIV. When people with HIV are also addicted to opiates,
treating both simultaneously helps improve outcomes and
reduces the spread of HIV or other infections that are
transmitted through needle sharing and/or risky sexual
behaviors. Combining and coordinating care for the HIV-opiate
addicted patient has been spotty. Treatment systems typically
fail to integrate the care of one condition in coordination of the
other. Patients with HIV and opiate dependencies have
traditionally been unable to get coordinated treatment for their
conditions in one clinical setting.
With expansion of buprenorphine treatment into clinics staffed
by HIV clinicians, patients now have the option of receiving
treatment of both opioid addiction and HIV infection
contemporaneously. With this development, a growing body of
evidence suggests that patients and the state of public health
will benefit. Since 2002, buprenorphine has been available in
the U.S. as an office-based treatment for opioid dependency.
This development represented a substantial realignment of
drug treatment resources from the inpatient clinic
environment to smaller outpatient offices where individual or
small groups of physicians organize and manage drug
treatment. Physicians who want to prescribe buprenorphine
must undergo a training program and become certified by the
Substance Abuse and Mental Health Services Administration
(SAMHSA). Buprenorphine has been a game-changing drug
because of its ability to expand access to treatment for opiate
addicts. Nearly 19,000 physicians are currently certified to
prescribe buprenorphine; most are medical doctors and
osteopathic physicians working general practices and family
medicine.
Studies suggest that patients with HIV infection and untreated
opiate addictions often experience delayed treatment until the
later phases of the disease. Delays in treatment of HIV result
in extended period of risky behavior and I.V. drug use that
puts them and their partners at risk for new infections.
Treating affected patients for both HIV and opiate dependency
can improve their outcomes on both counts. New research
suggests that buprenorphine has several advantages over
traditional methadone maintenance programs. A recent
randomized trial found that office-based care can improve
addiction related outcomes for patients with HIV and opioid
dependency and may lead to more effective interventions. [1]
The results of the trial indicated that patients randomized to
clinic-based buprenorphine therapy entered addiction
treatment much more quickly than those who were assigned
to specialty addiction treatment centers elsewhere. Retention
in the clinic-based treatment programs was much better than
it was in the more distant treatment centers. Patients
receiving buprenorphine in the clinic environment also had
fewer urine test results that were positives for other opiates or
cocaine. These patients also visited their primary HIV
physicians more frequently. These are all positive outcomes
effecting treatment success rates.
It may also be the case that buprenorphine has fewer
interactions with antiretroviral drugs than methadone.
Methadone is the more traditional opiate agonist used in
narcotic replacement therapy regimens. Studies suggest that
an antiretroviral can trigger withdrawals in some patients
taking methadone; this does not seem to happen when
buprenorphine is used. Trying to get HIV patients to abide by
their treatment plans and take antiretroviral drugs is difficult
when they're experiencing the gnawing pangs and pains of
opiate withdrawal. Buprenorphine may well enhance
compliance with HIV treatment regimens. As a mixed property
narcotic analgesic, buprenorphine is less sedating than
methadone and poses fewer side effects and interactions with
HIV treatment.
Buprenorphine is a drug that can be used in a variety of
different settings to treat stubborn opioid addiction. With
greater expansion of buprenorphine-trained physicians into
community clinical settings, HIV patients and others with
complicated medical histories may experience better
healthcare outcomes and a more satisfying quality of life.
[1] Lucas GM et al. Annals of Internal Medicine 2010, Clinic-Based Treatment
of Opioid-Dependent HIV-Infected Patients Versus Referral to an Opioid
Treatment Program. 2010; 152:704-711.
Name That Drug
The subject of this month's "name that drug" is a substance of
significant complexity and great potential. A relative
newcomer to the mean streets of drug abuse, this substance
has established itself as one of the most after prescription
drugs in the world for reasons that you
might not expect. This month's drug
came into the pharmaceutical world as
(2S)-2-[(-)-(5R,6R,7R,14S)-9αcyclopropylmethyl-4,5-epoxy-6,14-ethano3-hydroxy-6-methoxymorphinan-7-yl]-3,3dimethylbutan-2-ol. Embedded in the
International Union of Pure and Applied
Chemistry (IUPAC) nomenclature is a hard
clue as to this drug's biochemical makeup.
The drug is an opiate, a distillate of the
minor opium constituent called Thebaine.
This month's drug is one of a half-dozen
notable Thebaine derivatives that includes oxymorphone
(Opana), oxycodone (Oxycontin) and naloxone (Narcan). The
drug is a semi-synthetic opioid controlled in the United States
under terms of DEA Schedule III. This drug resembles the
chemical actions and mixed characteristics of pentazocine
(Talwin), the subject of July's newsletter "name that drug"
column.
The drug is available by prescription in several different forms
and iterations. In addition to a transdermal patch application,
the drug can be found in sublingual and tablet forms. There is
a formulation for intramuscular injection and an even newer
application that involves an implantable depot format designed
for slow, even absorption into the bloodstream. Like Talwin,
the drug has been compounded with naloxone to reduce the
potential of intravenous injection and parenteral addiction. As
a Schedule III medication, the potential for abuse of this drug
is rather modest, viewed similarly to drugs like hydrocodone
and the opiate cough syrups. In its early years as a
prescription medication, the drug was assigned to the much
less confining spaces of federal Schedule V. Recent reports
and studies of this drug suggest that abuse of it is becoming
widespread. This drug is a game changer however. Initially
conjured as an opiate analgesic, the drug has since morphed
into a powerful means for treating opiate dependency. It has
transformed the way opiate addicted patients are now treated
and managed. It is foreseeable that this drug may ultimately
dispatch more traditional methods of treatment (methadone
maintenance).
The drug is one of the most powerful opiates in the modern
pharmaceutical armamentarium. It possesses affinity for
opiate receptors that bests all other modern narcotics, a broad
class of medications that includes other powerful drugs such
as morphine, fentanyl, methadone and heroin. But what sets
this drug apart from other drugs of the opiate class is the
binding strength that it demonstrates at opiate receptor sites
in the brain. The drug is classified as a mixed property
narcotic, and although it possesses unparalleled affinity for
opiate receptor sites, it performs as an agonist at some and an
antagonist at others. These characteristics make the drug
complicated to deal with. Physicians who prescribe the drug
must undergo specialized training and certification before they
can begin treating patients. This is the only drug of its type
where specialized medical instruction is required before
utilization. Because of the drug's mixed properties at opiate
receptors, someone under the influence of the drug will not
experience a traditional opiate euphoria. In fact, some users of
the drug describe the effects of this drug as more of an edgy
dysphoria. Because of its exclusive action at opiate receptors,
the drug can effectively reverse the effects of other opiates
that may be present in the bloodstream; this drug
competitively preempts other narcotics from opiate receptors
in the brain. This effect can be dramatic. For instance,
someone who is abusing and is physically dependent on heroin
would be put into instant opiate withdrawal if this month's
drug were taken. The drug would act similarly and interrupt
the action of any other opiate were it to be inadvertently
mixed in to a patient or addict's narcotic regimen.
Because of this drug's unique chemistry, it acts in blockade at
opiate receptor sites, making it important in the practice of
drug treatment and rehabilitation. For nearly two generations,
methadone has been the go-to therapy in the treatment and
management of opiate dependency. Addicted patients who
failed in therapy or those who experienced multiple relapses,
methadone (dolophine) represented a fairly safe and reliable
means of managing the problem. "Methadone maintenance"
has been the standard of care therapy in treatment of patients
with chronic opiate abuse histories. Methadone substitution
therapy crafted a pharmacological solution whereby opiate
addicts could pull back from their lives on the street, pull the
needles from their arms and transition to a medically
supervised therapy that provided them with the necessary
narcotics to stave off withdrawals. But in the end, methadone
is one of a slew of very potent narcotic analgesics itself, not all
that different than the abused opiates it replaces. Methadone
is frequently abused too, sometimes fatally. Heroin addicts
"chip" and add bits and pieces of other narcotics on top of
their methadone therapy to get high. Some methadone
patients take to the abuse of drugs like Xanax to create a
super methadone cocktail that is uniquely stupefying. This
month's mystery drug may dislodge methadone from its
primacy in narcotic replacement therapy and become the
standard of care for the treatment of narcotic addicts.
When utilized in the roll of narcotic replacement therapy, this
month's drug can be tricky to use. Physicians have to follow a
strict set of protocols to bridge heroin and methadone addicts
over to short acting narcotics, such as morphine, before the
substitution therapy with this drug can begin. In fact, an
addicted patient must actually descend into a mildly acute
withdrawal before therapy can begin. Once those withdrawals
are evident, the drug is administered. Withdrawals stop
shortly afterwards. The dose is adjusted over the course of
several days of trial and error. Once sufficient concentrations
of the drug are present to suppress withdrawals and a patient
has become stable, he/she can then be titrated down off the
drug. Becoming more vogue however is the utilization of the
drug in the roll of substitution therapy. As is the case with
methadone maintenance, affected patients are weaned down
to as small a dose as possible and then maintained on a low
dose of it over and extended period of time.
As an analgesic, this month's drug does not hold a great deal
of promise. Its mixed property status makes it a poor
candidate to treat most types of moderate and serious pain.
But there are some patients where the drug may be an
appropriate fit. To that end, physicians have options that
include the transdermal patch, a product not to be confused
with a fentanyl transdermal patch. As a drug of abuse, there
have been sporadic reports of "outbreaks" in communities
where the drug is commonly used in treating narcotic
dependency. In the club scene, the drug has been found in the
possession of those who tend to use ecstasy, GHB and
hallucinogens. Many people who use the drug to get high are
often disappointed with their purchase. The mixed agonistantagonist properties of this drug often cause it to be a dud on
the party scene. And although this drug may come off a little
flat for those looking to get high, its real value is in the
stabilization, detoxification and maintenance of the addicted
opiate patient. For the narcotic dependent and the addicted,
this month's drug may be nothing short of a miracle.
August 2010 Mystery Drug: Buprenorphine (Suboxone,
Subutex, Buprenex)
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