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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/