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Complexitiesof
Prescription Drug Misuse
Seddon R. Savage MD
Director,Dartmouth Center on Addiction
Recovery and Education
Pain Medicine ConsultantManchester VAMC
Associate Professor of AnesthesiologyAdjunct Faculty, Dartmouth Medical School
• Concept of balance, medical and legal
• Common misused drugs
• Available data on Rx drug misuse
• Clinical perspective on Rx drug misuse
• Strategies to reduce Rx drug misuse
Prescription Medication
Relief of symptoms
Improved function
Restored quality of life
Side effects
Toxicity
Unintended consequences
Benefits Risks
Clinical Challenge with Controlled Substances
Relief of pain
Improved function
Restored quality of life Side effects
Toxicity
Unintended consequences
Misuse Addiction Diversion
Benefits
Risks
U.S. Controlled Substances Act
”Many of the drugs included within this subchapter have a useful and legitimate medical purpose and are necessary to maintain the health and general welfare of the American people.”
“The illegal importation, manufacture, distribution,
and possession and improper use of controlled
substances have a substantial and detrimental
effect on the health and general welfare of the
American people”
Medical TreatmentControlled Substances
Relief of symptoms
Improved function
Restored quality of life
Side effects
Toxicity
Unintended consequences
Misuse Addiction Diversion
BenefitsRisks
?
Controlled Substance Classes
Classified by– Relative potential for “abuse”– Identified current legitimate medical use– Risk of physical or “psychological”
dependence [sic] - (in appropriate medical terms: “risk of physical dependence or addiction”)
Controlled Substance ClassesExamples of Inclusions
i. Heroin, marijuana, lsd, psilocybin
ii. Pure mu opioids, topical cocaine
iii. Combination opioids with non-opioid, stimulants, anabolic steroids
iv. Sedative hypnotics including barbiturates, benzodiazepines, sleep meds
v. Dilute opioids, pregabalin
Unscheduled: Soma, tramadol
Commonly Misused Rx Drugs
• Medical or pharmacologic classes– Sedative hypnotics– Stimulants– Opioid analgesics
– Narcotics
6.2 Million Americans (~2%) Used Prescription Drugs Non-Medically Past Month
2008 NSDUH Data
Stimulants
• Clinical indications – Attention deficit hyperactivity disorder (ADHD) – Disease- or medication -related sedation– Narcolepsy – Depression (rare)– (Weight loss)
• Commonly prescribed stimulants– Ritalin (methylphenidate)– Concerta (long acting methylphenidate)– Adderall (amphetamine and dextro-amphetamine)
Stimulant Neurobiology
Stimulants
Increase dopamine by:•Stimulating synthesis•Releasing from presynaptic vesicles•Inhibiting reuptake
Increase noradrenaline by:•Releasing from presynaptic vesicles
Image from: Chronic amphetamine use and abuse. The American Academy of Neuropsychopharmacology. http://www.acnp.org/g4/GN401000166/CH162.htm.Accessed on 30 January 2003.
Stimulant Therapeutic Effects
• Increased attention
• Increase energy
• Reduce sleep
• Decreased appetite
• Euphoria
• In ADHD – decreased impulsivity, reduced hyperactivity
Stimulant Toxic Effects
• Sleep interference
• Anxiety, psychosis
• Seizures
• Hyperthermia
• Elevated blood pressure and heart rate
• Heart attack, cardiac arrest and stroke possible
Stimulant Withdrawal
• Low energy level
• Hypersomnia (or insomnia)
• Dysphoria
• Anhedonia
• Depression
• Irritability
Sedative Hypnotics
• Clinical uses: anxiety, sleep induction, PTSD, alcohol and drug withdrawal
• Action: enhance GABAa activity, calms CNS• Types
– Benzodiazepines: Valium, Librium,
Ativan, Klonopin, Xanax etc
– Barbiturates: phenobarbital, butalbitol
– Sleep medis: Ambien, Sonata, Lunesta
– Miscellaneous: Soma (carisoprodol)
Sedative Hypnotic Actions
Reprinted from: Medications for analgesia and sedation in the intensive care unit: an overview. Diederik Gommers and Jan Bakker, Critical Care 2008 Supplement 3-4 at www.ccforum.com
Sedative Hypnotics Effects
• Relaxation > sedation > stupor
• Dysequilibrium: impaired balance, coordination, and gait, slurred speech
• Impaired cognition and memory
• Increased risks with opioids and alcohol
• Tolerance, physical dependence
and addiction may occur
Sedative Hypnotic Withdrawal
• Cardiovascular arousal– Increased pulse or blood pressure
• Neurologic arousal– Sleeplessness, irritability, agitation, anxiety– Tremor– Seizures
• Autonomic arousal– Sweating– Nausea and vomiting
Opioid Medications
• Clinical indications– Analgesia – Anti-tussive– Anti-diarrheal– Teatment of opioid addiction
• Oral, transdermal , transmucosal and parenteral forms
• Quick onset, short acting vs slower onset longer acting vs sustained release meds
Opioid Types
• Pure mu opioid agonists: – Natural or semi-synthetic: morphine, codeine,
hydrocodone, oxycodone, hydromorphine– Synthetic: fentanyl, methadone,
propoxyphene
• Partial mu agonists:– Buprenorphine, tramadol
• Kappa opioid agonist/mu antagonists– Pentazocine, butorphanol, nalbuphine
Opioid Therapeutic Actions
• Analgesia through stimulation central and peripheral opioid receptors
• Inhibit intestinal motility
• Suppressive cough reflex
• Euphoria, sense of well being
• Mildly sedative, induce sleep
Opioid Side Effects
• Constipation
• Respiratory depression
• Sedation, cognitive blurring
• Sweating, meiosis, urinary retention
• Tolerance, physical dependence, hyperalgesia
• Reward and addiction in vulnerable
Opioid Withdrawal
• Flu-like syndrome: muscle aches, joint pains, sweating, stomach cramping, diarrhea
• Irritability, arousal, wakefulness
• Mild increase bp and heart rate
• Mydriasis
• Piloerection (gooseflesh)
Teenagers caught with pills By AMY AUGUSTINEMonitor staffNovember 05, 2009 - 7:28 am What happened at Grimes Field on Oct. 12 was troubling, said police Chief Dave Roarick, who responded about 2 p.m. to a report of suspicious behavior. There, he found a group of teenagers, ages 13 to 19, hanging out with backpacks. Roarick thought that was odd because it was Columbus Day and school wasn't in session. The 19-year-old - Stephen Martel of Hillsboro - was drinking alcohol and arrested. The rest, whom the police have not identified because they are minors, were taken into protective custody, he said. As the teens were brought back to the station, Roarick said the police learned that the majority of them had taken multiple doses of Benadryl, an antihistamine, and that four had mixed it with Prozac, an antidepressant.
"We probably found four or five boxes of Benadryl on them . . . and a baggie containing a lot of Prozac. Some of them had (consumed) alcohol, too," Roarick said. "As we're finding this, one of the girls appeared to be really out of it, acting very, very strange." In the weeks before the incident, Roarick said at least one local store owner called the police to report that the store had been selling a lot of Benadryl. Roarick said he's advised store owners not to sell to kids if they think something "isn't right." The Prozac was provided by a teenager who had a prescription and was present among the group, he said.
Non-Medical Rx Drug MisuseMotivators
• Self medication of symptoms: pain, sleep, mood, memories,
withdrawal if physically dependent• Novelty, experimentation, risk-taking • Enhance performance• Elective use for euphoria/reward• Compulsive use due to addiction• Diversion for profit
Self Medication or Performance Enhancement
• Opioid internet survey 3200 college students – 13.9% reported lifetime non-medical use opioids– 42% of these reported use exclusively for pain– 34% for pain and recreational– 24% recreational only
McCabe SE, Boyd CJ, Teter CJ: Drug Alcohol Depend 2009
• Stimulant internet survey 4580 college students– 8.3% reported lifetime non medical use stimulants– 65% for concentration, 60% to help study, 48% to increase alertness.– 31% to get high, 30% for experimentation
Teter CJ, McCabe SE, LaGrange K, Cranford JA, Boyd CJ. Pharmacotherapy. 2006 Oct;26(10):1501-10.
Generation Rx
• Rx/OTC med abuse is part of teen culture• 18% of teens have non-medically used Vicodin• 20% have tried Ritalin or Adderall without a Rx• 9% used OTC cough syrup to get high• Equal or greater use of OTC/Rx than cocaine, Ecstasy, LSD,
ketamine, heroin, GHB, ice• Believe that Rx Meds safer (50%), less addictive (33%)• Report ease of access: medicine cabinets• “Drugs are fun” and “Drugs help kids when they are having a hard
time”
April 21, 2005. Partnership for a Drug Free America. 17 th annual study of teen drug abuse. N= 7,300, error margin +/- 1.5% (Mooney and Freese, UCLA presentation)
New Non-Medical Users of Rx DrugsNSDUH Ages 12 and over
Past Month Non-Medical Use of Rx Drugs NSDUH, Ages 12 and over
Past Month Drug Use Ages 12-17NSDUH, 2008
Past Month Drug Use Ages 50-59NSDUH, 2008
Specific Drug Used to Initiate Illicit Drug Use~30% initiate with Rx Drugs, NSDUH, 2008
Therapeutic Opioid UseDEA ARCOS Data – U.S.
0
2000
4000
6000
8000
10000
12000
14000
16000
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
gm
s p
er 1
00,0
00
morphine x2.8
oxycodone x8.0
fentanyl x5.6 (x100)
hydrocodone x3.3
methadone x 12.2
0
50000
100000
150000
200000
250000
Opioid AnalgesicRelated ED Visits
DAWN and New** DAWN DataReflects Opioid Misuse/Harm – U.S.
**Methodologic differences do not permit comparisons between new and old DAWN
DAWN Visits by Rx Drug, 2004
MethylphenidateAdderall
SomaFlexeril
TEDS NH – Reflects Addiction
Rx Opioid Deaths in U.S.
Source: U.S. Centers for Disease Control in
Non-Medical Drug UseSources (Opioids)
NSDUH, 2006
Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown.1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s
Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”
Bought/Took from Friend/Relative
14.8%
Drug Dealer/Stranger
3.9%
Bought on Internet
0.1% Other 1
4.9%
Free from Friend/Relative
7.3%
Bought/Took fromFriend/Relative
4.9%
OneDoctor80.7%
Drug Dealer/Stranger
1.6%Other 1
2.2%
Source Where Respondent Obtained
Source Where Friend/Relative Obtained
One Doctor19.1%
More than One Doctor
1.6%
Free from Friend/Relative
55.7%
More than One Doctor3.3%
Opportunities to Address Rx Drug Misuse
Role of Prescribing Prescription Drug Misuse
• What is the right amount of prescribing?
• Is there appropriate care and structure when prescribing controlled substances?
• Do clinicians have the requisite skills and knowledge to identify and manage complications of use?
Opioids for Pain
• Acute pain generally adequately treated– Unused (?excess) pain meds may lend to diversion
• Terminal pain treatment mixed (?)– Lingering concerns regarding higher opioid doses– Discarding of excess meds a problem following death
• Chronic non-terminal pain– Few options for optimum interdisciplinary care– Balance challenging: overuse and underuse of opioids– Significant opportunities for misuse and diversion in this
context– Need for enhanced structure and monitoring
Stimulants
• Over prescribed, under prescribed, or just about right?
• Does the educational context dictate the need for treatment?
• Are resources adequate to address behaviors with non-med approaches?
• Do we too often use medications to counter side effects of other medications?
Sedative Hypnotics
• Would greater parity for mental health care reduce use and improve outcomes?
• What role should life individual self management play in reducing, anxiety, stress and improving sleep?
• Could we make better use of alternative medications?
• Basic universal precautions to be used with all patients treated with opioids
• Comprehensive pain, psych, substance assessment
• Risk stratification (low, medium, high)• Routine informed consent and agreement• Regular monitoring of pain, med use, mood, and
function, including drug screens• Clear and consistent documentation
(Gourlay, Heit 2004)
Care in Prescribing Universal Precautions
Care in PrescribingTreatment Structure Variables
Beyond Universal PrecautionsManaging Challenging Clinical Encounters
• Setting of care to match risk level
• Selection of treatments
• Supply of medications
• Supports for recovery
• Supervision and monitoring
Savage, 2004 and 2008
Examples of Clinical Tools in Evolution
• Risk screening tools (SOAPP, ORT)
• Misuse screening tools (COMM, PDQ)
• Documentation tools (PADT)
• Clinical management decision trees (Utah Guidelines)
• Mentors (PCSS)
Examples of Clinical Tool Initiatives• State of Utah Guidelines with clinical tools
http://www.useonlyasdirected.org/uploads/65026_UDOH_opioidGuidlines.pdf
• ASAM Physician Clinical Support System www.pcss-mentor.org – Methadone prescribing– Buprenorphine prescribing
• Many private websites– www.painedu.org – www.emergingsolutionsinpain.com– www.pain-topics.org– www.painknowledge.org– www.partnersagainstpain.com
• NIDA web based tools– In evolution
Clinical Needs to Manage Complex Patients
• Education in pain management • Education in addiction medicine• Reimbursement for collaborative interdisciplinary
care• More balanced reimbursement for time versus
procedures– Increased primary care time– Increased mental health
• Clinical guidelines
State Prescription Drug Monitoring Programs (PDMPs)
© 2009 Research is current as of June 30, 2009. THE NATIONAL ALLIANCE FOR MODEL STATE DRUG LAWS (NAMSDL). 1414 Prince St. Suite 312, Alexandria, VA 22314. NJ changed to active PMP by Savage. (Became active 8-09.
AK
AL
AR
CACO
ID
IL INIA
MN
MO
MT
NENV
ND
OH
OK
OR
TN
UT
WA1
AZ
SD
NM
VA
WYMI
GA
KS
HI
TX
ME
MS
WI2NY
PA
LA
KYNC
SC
FL
NHMARICTNJDEMD
VT
WV
States with operational PDMPs States with enacted PDMP legislation, but program not yet operational
1Washington has temporarily suspended its PMP operations due to budgetary constraints.2Legislation has been proposed in Wisconsin that ,if passed, would establish a PDMP.
Goals of PMPs
• Improve clinical care and public health through identification of doctors shoppers– Increase confidence in clinical prescribing – Identify persons in need of SUD treatment– Reduce public health harm from diverted
opioids
• Facilitate investigation of possible controlled substance diversion
Basic PMP Structure• Pharmacies submit data to a secure database
that tracks at minimum– Drug, drug dose and dose units – Date and place dispensed– Prescriber and patient
• Prescribers and dispensers may query • Law enforcement may query: established case
vs proactive screening • Advisory board oversees procedures and
protocols, reviews and revises system• Outcomes data collected, used to revise and
improve program
Regulatory REMS Requirements Risk Evaluation and Mitigation Strategies
• Encourages careful decision making and tightly managed control of higher risk drugs
• FDA currently finalizing plans for opioid REMS– ? All schedules vs schedule II vs other– ? Educational requirements– ? Registration of patients– ? Specialty pharmacy requirements
• FDA has negotiated Onsolis REMS– All the above requirements– May generalize similar drugs
Public Education
• Key messages– Dangers of opioid misuse (balanced with
positives of appropriate use)– Locking of medications– Need to dispose of unused medications
• Periodic collections vs• Permanent collection sites
Public Education >Dangers of misuse >Lock meds >Discard unused med
Public Policy >PMPs >REMS >Drug disposal >Parity payment MH and Addiction >(CME reqs)
Justice/Law Enforcement >Use of PMP info to aid investigation s >Drug diversion programs >Drug courts >Drug tx in prisons
Clinical Practice >Clinical tools >Practice guidelines >Systems support >Interdisciplinary care for pain
>Tamper proof scripts
> MH/addiction care
Professional Education >Undergraduate: pain and addiction medicine >CME: opioid issues, other pain tx
Pharmacy Practice >ID of CS drug purchasers >Disseminate drug risk information >Availability of drug safes
A Comprehensive Approach to
Prescription Drug Misuse