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OxyContin, Vicodin, and Heroin Abuse:
What's a Clinician to Do?
Peter A. DeMaria, Jr., M.D., FASAM
Tuttleman Counseling Services
Temple University
Clinical 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
ADOLESCENCE
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Invincible
Subject to peer pressure
Risk-taking
Want to be independent
Some Factors Affecting Drug
Experimentation/Continued Use/Addiction
Peer Pressure
Genetics
Psychiatric
problems
Stress
Availability
Boredom
Trauma/abuse
Curiosity
The Life History of A Substance User
Abstinence
Abstinence
Experimentation
Abuse
Dependence
Sobriety
Recovery
Relapse to
Use
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 Study
Year
2006
2005
2004
2003
2002
2001
No. of
Students
71,189
33,379
68,000
38,857
54,367
54,444
No. of
Colleges
134
53
133
89
125
131
Annual
Prevalence
1.3%
1.4%
1.5%
1.7%
1.8%
2.1%
30-day
Prevalence
0.6%
0.7%
0.7%
0.8%
0.8%
1.0%
If Temple has 33,000 students, then 429 used
in the last year & 198 used in last 30 days
Monitoring the Future
Annual 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
OxyContin
Tylenol #4 w/codeine
Dilaudid
Vicodin
Lortab
Opioids - Intoxication/Withdrawal/Overdose
• Intoxication
– Rush, nod, miosis, constipation
• Withdrawal
-Craving
-Anxiety
-Insomnia
-Weakness
-Yawning
-Lacrimation
-Diarrhea
-Piloerection
-Muscle twitches
-Mydriasis
-Diaphoresis
-Myalgias/arthalgias
-Rhinorrhea
• Overdose
– Classic triad (Miosis, Respiratory depression, Coma)
Cycle of Addiction
Drug Use
Obtain drugs
Physical dependence
Obtain money for drugs Withdrawal symptoms
Need for drugs
Consequences of Addiction
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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
How People Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
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
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Comprehensive evaluation
Engagement in treatment
Treatment setting
Detoxification vs. maintenance
Counseling (Individual, Group)
Self-Help (12 step)
Methadone
Suboxone®
Component(s)
Methadone
Buprenorphine +
naloxone
Classification
Pure opioid agonist
Partial opioid agonist
+ pure antagonist
Prevent WD
Yes
Cause euphoria No
Yes
No
Block euphoria
Safe in OD
DEA Regulation
Yes
Lethal
C-II
Yes
Safer
C-III
Administration
Availability
Oral
Specialized clinics
Dosing visit
Daily
Sublingual
Outpatient physicians’
offices
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 Diagnosis
15/27 (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 Results
N = 237 UDS, M = 8.8/student, Range = 0 - 33
Disposition of Admitted Patients
Length of Treatment = M = 12.00 ± 11.49 months
Range = 1 to 36 months
Treatment Received
Service
Psychiatric
Evaluation
Medication
Management
Individual
counseling
Group
counseling
Self-Help
N (%)
Avg. No. + SD Range
27 (100%) N/A
N/A
27 (100%) 10.48 ± 9.75
1 - 30
18 (67%)
7.56 ± 5.73
1 - 21
15 (56%)
8.60 ± 5.69
2 - 20
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
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Accept the disease of addiction
Commit to sobriety
Acknowledge that marijuana is a drug
Engage in treatment
Finances
Managing free time/boredom
Study Limitations
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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