Download prescription drug use and consequences

PRESCRIPTION MEDICATION
MISUSE AND THE
CONSEQUENCES
Steven Kipnis MD, FACP, FASAM
Medical 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 and Reward
•Dopamine is one of the primary neurotransmitters in the experience of pleasure
and the maintenance of addiction.
Image Credit: NIDA : “The Neurobiology of Drug Addiction”
NAc
VTA
GLU
FCX
Amphetamine
Cocaine
Opioids
Cannabinoids
Phencyclidine
HIPP
AMYG
CRF
GLU
5HT
GABA
OPIOID
OPIOID
GABA
GABA
DYN
5HT
ENK
VP
OFT
BNST
DA
GABA
NE LC
ABN
HYPOTHAL
Opioids
Ethanol
Barbiturates
Benzodiazepines
Nicotine
NE
LAT-TEG
PAG
END
To
5HT
dorsal
Raphé horn
RETIC
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
o
A DRUG IS ANY SUBSTANCE THAT MODIFIES BODY FUNCTIONS
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
o
o
o
RACE
GENDER
SOCIOECONOMIC STATUS
SEXUAL PREFERENCE
Percentage of U.S. Residents (Age 12 or Older)
Reporting Past Year Substance Use, 2010
Marijuana
11.5%
Nonmedical Use of Prescription Pain Relievers
4.8%
Nonmedical Use of Prescription Tranquilizers
2.2%
Cocaine
1.8%
1.1%
Nonmedical Use of Prescription Stimulants
Ecstasy
1.0%
Inhalants
0.8%
Nonmedical Use of Prescription Sedatives
0.4%
LSD
0.3%
Heroin
0.2%
0%
5%
10%
15%
20%
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.
25%
First Specific Drug Associated with Initiation of Illicit Drug Use among Past Year
Illicit Drug Initiates Aged 12 or Older: 2010
Pain Relievers (17.3%)
Inhalants (9.0%)
Tranquilizers (4.6%)
Hallucinogens (3.0%)
Marijuana (61.8%)
Stimulants (2.5%)
Sedatives (1.9%)
Cocaine (0.1%)
Heroin (0.1%)
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 firsttime use of any illicit
drug.
3.0 Million Initiates of Illicit Drugs
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 - Uses
 Psychiatric disorders
- Mainly anxiety, panic and agitation
- Anticonvulsant
- Muscle relaxant properties
- Alcohol withdrawal
Benzodiazepine Receptor
GABA is the major inhibitory neurotransmitter
and it operates in more than a third of CNS
synapses
Benzodiazepines enhance synaptic actions of
GABA
Benzodiazepine Use

11% of population use a benzodiazepine annually
o 80% for < 4 months
o 5 % for 4 - 12 months
o 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
Pharmacokinetics
 Oxidatively transformed drugs have longer half-life and longer duration of action
 Diazepam - T1/2 increases from 20 hours at 20 years to 90 hours at 90
years
 Desmethyl diazepam - T1/2 of 51 hours in young to 151 hours in old
 Lorazepam and oxazepam -little change in T1/2 with age
Benzodiazepines and
Memory
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
Performance 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
CNS
Headache
Pain
Parasethesia
Stiffness
Weakness
Tremor
Muscle twitches and
fasciculation
Convulsions
Ataxia
Dizziness,
lightheadedness
Blurred or double
vision
Tinnitus
Speech difficulty
Hypersensitivity to
light, sound, taste,
smell
Insomnia, nightmares
GI
Nausea, vomiting
Abdominal pain
Diarrhea or constipation
Appetite, weight change
Dry mouth
Metallic taste
Dysphagia
CVS and Respiratory
Flushing, sweating
Palpitations
Hyperventilation
Thirst
Loss of libido
impotence
Urogenital and
endocrine
Polyuria
Incontinence
Menorrhagia
Mammary pain or
swelling
Miscellaneous
• 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
Benzodiazepines
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
Chronic Benzodiazepine Users
Significant anxiety and depressive
psychopathology remains in many long-term
benzodiazepine users
NOVEL NON – BENZODIAZEPINE HYPNOTICS
• ZOLPIDEM ( AMBIEN®) AND ZALEPLON (SONATA ®)
o
o
o
RAPID ONSET
SHORT DURATION
SHORT HALF – LIFE
• AMBIEN 2.5 HR, SONATA 1 HR
o
o
o
NO ACTIVE METABOLITES
AMBIEN HAS MINIMAL NEXT DAY EFFECT BUT ONLY SLIGHT
MEMORY IMPAIRMENT AND RECALL. THIS IS NOT SEEN IN
SONATA
FLUMAZENIL IS EFFECTIVE IN OVERDOSE
DEFINITIONS
Opiate = Rx derived from opium
Opioid = All Rx with morphine-like
actions
Papaver Somniferum
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
•
FENTANYL
o
SUBLIMAZE ®
• IV ANESTHETIC
o
DURAGESIC ®
• TRANSDERMAL PATCH
o
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
o
o
o
o
LICENSED
BOARD CERTIFIED IN ADDICTION PSYCHIATRY
CERTIFIED IN ADDICTION MEDICINE BY ASAM OR AOA
INVESTIGATOR IN BUPRENORPHINE CLINICAL TRIALS
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 DERIVATIVE
o
•
•
MAKES THIS LEGALLY CLASSIFIED AS AN OPIATE
PARTIAL OPIOID AGONIST
INITIALLY USED AS AN ANALGESIC
BUPRENORPHINE
• PARTIAL OPIOID AGONIST
o
VERY HIGH AFFINITY FOR MU RECEPTOR
• WILL DISPLACE MORPHINE, METHADONE
BUPRENORPHINE
• PARTIAL OPIOID AGONIST
o
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 AGONIST
o
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 USES
o
TREATMENT OF ADDICTIONS*
•
IN THE U.S.
o
o
2 & 8 MG SUBLINGUAL TABLETS MADE BY RECKITT & COLMAN CALLED
SUBUTEX®
2 & 8 MG SUBLINGUAL TABLETS WITH NALOXONE IN A 4:1 RATIO CALLED
SUBOXONE®
BUPRENORPHINE
• PHARMACOLOGIC USES
o
o
DOSES USED FOR OPIOID ADDICTION TREATMENT IS 1 -2
MG UP TO 16 - 32 MG
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
o
IF TAKEN S.L. BUP>>>>>>NALONXONE
IF TAKEN I.V. NALOXONE>>>>>BUP
BUPRENORPHINE
• SAFETY
o
o
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
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 EFFECTS
o
SIMILAR TO OTHER MU AGONISTS THOUGH LESS SO
• NAUSEA
• VOMITING
• CONSTIPATION
*NO DISRUPTION IN COGNITIVE AND PSYCHOMOTOR
PERFORMANCE
On the Horizon
• Implantable buprenorphine – Probuphine
o
o
6 month duration
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 patch
o
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 ADDICTION
IMPLICATIONS 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 ligandopioid receptor system allow interacting physiological
and behavior systems to become normal.
The patient is functionally normal.
Dole,Vincent P.
JAMA,
Nov 25,1988
Vol.260,No. 20
How Methadone Works Metabolically? Taming the Roller Coaster
Adequate methadone dosing
smoothes peaks & valleys –
shifting from opioid intoxication
to withdrawal and eventual
stability.
Patients can live more
comfortably normal lives
throughout each day.
Patients Receiving Methadone 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 TREATMENT
o
o
MOST EFFECTIVE TREATMENT FOR OPIOID DEPENDENCE
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
Source Where Respondent Obtained
More than One Doctor
(2.1%)
One Doctor
(17.3%)
Other1 (4.6%)
Bought on
Internet
(0.4%)
Drug Dealer/
Stranger (4.4%)
Bought/Took from
Friend/Relative
(16.2%)
Source Where Friend/Relative Obtained
Free from
Friend/
Relative
(55.0%)
More than
One Doctor
(3.6%)
One Doctor
(79.4%)
Free from
Friend/Relative
(6.3%)
Bought/Took from
Friend/Relative
(6.5%)
Drug Dealer/
Stranger (2.3%)
Bought on Internet
(0.2%)
Other1 (1.7%)
1The
Other category includes the sources "Wrote Fake Prescription," "Stole from Doctor’s Office/Clinic/Hospital/Pharmacy," and "Some
Other Way."
STIMULANTS
•
Adderall XR and Ritalin
o
o
In the past students used caffeine
and cocaine to stay awake and
cram for exams
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 DISORDERS
o
o
o
o
o
o
REPEATED DISMANTLING OF AN OBJECT
REPEATED CLEANING
REPEATED DOODLING
AKATHISIA – “CRACK DANCERS”
BUCCOLINGUAL DYSKINESIA – “TWISTED MOUTH” “BOCA
TORCIDA”
INCREASES TOURETTES’S SYNDROME
PET SCAN
STIMULANT ADVERSE EFFECTS
•
CARDIOVASCULAR
o
o
o
o
MYOCARDITIS
CARDIOMYOPATHY
HYPERTENSION
INFARCTION
Normal pink small intestine
STIMULANT ADVERSE EFFECTS
• PULMONARY
o
o
o
o
EDEMA
PNEUMOTHORAX
PNEUMOMEDIASTINUM
THERMAL AIRWAY INJURY
STIMULANT ADVERSE EFFECTS
• MISCELLANEOUS
o
o
o
o
o
o
ARF
DECREASE GASTRIC MOTILITY
GI INFARCTION
RHABDOMYOLYSIS
RHINITIS
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)
100%
80%
66%
60%
35%
40%
20%
20%
13%
5%
0%
Given by Friend
or Family
Member
Taken/Stolen
Obtained
Bought from
Fraudulently Friend or Family
From a Doctor
Member
Internet
Pharmacy
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
• CAFFEINE
o
MOST WIDELY USED MOOD – ALTERING DRUG IN THE
WORLD
CAFFEINE INTOXICATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
RESTLESS
NERVOUSNESS
EXCITEMENT
INSOMNIA
FLUSHED FACE
DIURESIS
GI DISTURBANCE
MUSCLE TWITCHING
RAMBLING FLOW OF THOUGHT &
SPEECH
TACHYCARDIA OR CARDIAC
ARRHYTHMIA
PERIODS OF INEXHAUSTIBILITY
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
o
o
2005, a teenager in Oregon drowned after
taking the drug mixed with alcohol
2004, five high-school freshmen from Virginia
hospitalized after an overdose
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
o
The National Center on Addiction and Substance Abuse (CASA) at Columbia University.
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 [email protected].
• A recent review of tampering methods reported on the Internet for
selected pharmaceutical products found four main methods of
tampering:
o
o
o
o
Altering dosage forms to allow alternate routes of administration
Removing the active drug from high-dose formulations, such as
patches
Separating narcotic drugs (codeine, hydrocodone, oxycodone)
from undesirable drugs (aspirin, acetaminophen, ibuprofen) or
inactive ingredients
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
o
o
One in 3 teens has reported that there is "nothing wrong" with
using prescription drugs "every once and a while."
Prescription drugs are the drug of choice among 12- and 13year-olds.
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
# OF
SCRIPTS PATIENTS
2010
22,575,704
4,878,188
2009
21,502,426
4,837,414
2008
19,207,181
4,703,805
Controlled Substance Prescriptions
Number 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
• National
o
o
o
o
In 2007, there were 27,658 unintentional drug overdose deaths
in the United States.
From 1999 through 2006, the number of fatal poisonings
involving opioid analgesics more than tripled.
The rates of overdose deaths are now 4-5 times higher than they
were during the heroin epidemic of the mid 1970s.
In many states unintentional drug overdose deaths now exceed
deaths from motor vehicle accidents.
• New York
o
o
In New York State, unintentional drug overdose deaths have
exceeded deaths from motor vehicle accidents since 2006.
From 1999-2007 more than 8,000 New Yorkers died from an
unintentional drug overdose.
Prescription Drugs Overdose
Type 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
o
o
o
Many teens think that these drugs are safe because they have
legitimate uses and are often found at home in the medicine
cabinet.
Parents purchase OTC drugs for family use and may not realize
that their kids are abusing these products.
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.
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 Patients
o
o
o
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.
OASAS has worked closely with DOH and NYCDOHMH to give guidelines
and educational resources.
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
o
o
Educate themselves about which medications can be misused or
abused, and learn about the very real dangers and risks of this
behavior;
Communicate these risks to their kids, dispelling the notion that
medicines can be safely abused; and
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
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.
“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/docum
ents/medicineCabBrochure.pdf
o
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.
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
o
o
"borrowing" prescriptions, such as antibiotics, exacerbates
antibiotic resistance.
"Sharing" acne medication is dangerous because these drugs
contain teratogens.
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
Law passed
City, US
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
• Education
o
o
General Public
Medical Practice
• Urine drug screens
•
•
•
•
•
•
•
Monitoring
Proper medication disposal
Enforcement
Overdose Prevention
Treatment
Adolescent Use and Prevention
Outcomes
[email protected]
www.oasas.state.ny.us/admed/