Transcript Nonmedical Use of Prescription Stimulants: Cognitive

PRESCRIPTION DRUG DIVERSION
Christian J. Teter, Pharm.D., BCPP
Associate Professor, Psychopharmacology
College Of Pharmacy,
University Of New England
Portland, ME
E-Mail: [email protected]
Maine Pharmacy Association, Spring Conference &Trade Show,
Freeport, Maine (March 20 – 22, 2015)
LEARNING OBJECTIVES
2
1.
2.
3.
Identify which category of prescription medications
demonstrates the highest rates of diversion.
Recognize sources of diversion for prescription
opioids and stimulants.
Describe other problem behaviors that are
associated with prescription drug diversion.
DISCLOSURES
3
Christian J. Teter has no real or potential conflicts of
interest to report.
 The use of prescription medications for ‘off-label’ use
will be discussed during this presentation:

 Example:
among ‘healthy students’ without AttentionDeficit/Hyperactivity Disorder (ADHD)
4
INTRODUCTION
Key Definitions
5

“Medical misuse of prescription medications”


“Diversion of prescription medications”


Refers to use of a prescribed psychotherapeutic medication in a
manner not intended by the prescribing clinician (e.g., taking too
much, intentionally using to get high)
Refers to exchange of prescription medications that leads to use
of these medications by people other than for whom the
prescribing clinician intended
“Nonmedical use of prescription medications”


Refers to the non-prescribed use of a controlled,
psychotherapeutic medication
Example: nonmedical use of prescription stimulants (NMUPS)
Background
6
1) Sleeping medication (e.g., Ambien®, Halcion®,
Restoril®, temazepam, triazolam)
2) Sedative/anxiety medication (e.g., Ativan®, Xanax®,
Valium®, Klonopin®, diazepam, lorazepam)
3) Stimulant medication (e.g., Ritalin®, Dexedrine®,
Adderall®, Concerta®, methlyphenidate)
4) Pain medication (i.e., opioids such as Vicodin®,
OxyContin®, Tylenol 3 with codeine®, Percocet®,
Darvocet®, morphine, hydrocodone, oxycodone)
Significant therapeutic
overlap between these
categories.
Focus of this lecture
(i.e., prescription
stimulants and
prescription opioids).
7
Why should we be concerned?
Considerations: Potential for Addiction
Note: both cocaine and MPH inhibit dopamine
transporter; similar brain regions.
Source: Volkow et al, 1995 (Arch Gen Psych)
9
NMUPM PREVALENCE RATES
& TRENDS (brief overview)
DIVERSION vs. NMUPM
Distribution of Past Year Nonmedical Use of
Prescription Medications: 119 U.S. Colleges
10
Source: McCabe et al 2011
Past Year Medical Use and Nonmedical Use of
Prescription Medications (College Undergraduates)
11
% reporting prescription medication use
Medical use only
Medical use & nonmedical use
Nonmedical use only
20
By definition…Rx DRUG
DIVERSION is taking place!
15
10
5
0
Stimulant
medication
Sleeping
medication
Sedative
medication
Opioid
medication
Source: McCabe SE. Arch Pediatr Adolesc Med 2008
12
Student Life Survey (SLS):
20-Year Trends from 1993 – 2013
Trends in Past-Year Nonmedical Use of Prescription Medications by UM
Undergraduate Students (2003, 2005, 2007, 2009, 2011, and 2013 SLS)
13
10
9.3
9
8
Sleeping Medication
Anti-Anxiety Medication
Stimulant Medication
Pain Medication
9.3
7.6
7.4
6.9
6.86.6
7
6
6
5.5
5.4
5
4.5
4
4
2.9
3
2
2
2.42.6
2.62.5
3
2.5
2.1
2.1
2.3
1.8
1
0
2003
(N=8460)
2005
(N=3556)
2007
(N=1653)
2009
(N=1058)
Note: 1993-2001 results were not included because the measure was worded differently.
2011
(N=1313)
2013
(N=3553)
Source: McCabe et al. Addictive Behaviors 2014
Past-Year Drug Use among UM and U.S. Undergraduate Students
(Sources: 2013 SLS and 2012 MTF)
14
40
35
37.4
34.9
30
UM 2013
US 2012
25
20
15
10
5
11.1
9.3
4.95.8
4.55.4
3 3.4
3.43.1
3.7
1.9
4.23.9
0
Note: Past-year prevalence rates for inhalants, heroin, crystal methamphetamine use were 1% or less and not shown in this figure.
2.32.2
15
DIVERSION
Approached to Divert Medications in Lifetime
(Adolescent medical users approached to divert)
% approached to divert their medication
16
30
25
20
Percentages much
larger among college
students!
15
10
5
0
Sleeping
Medication
(n=108)
Anti-anxiety
Medication
(n=104)
Stimulant
Medication
(n=141)
Opioid
Medication
(n=704)
Source: McCabe et al. Drug Alc Depend 2011
Prevalence of Actual Diversion among College
Students Prescribed Stimulant Medication for ADHD
17
% medical users giving away or selling
their medication
62
60
50
40
30
35
26
20
10
0
Rabiner et al., 2009
(n=115), previous 6
months
Sepulveda et al., 2011
(n=50), previous 12
months
Garnier et al., 2010
(n=81), in a lifetime
Sources: Garnier et al., 2010; Rabiner et al., 2009; Sepulveda et al., 2011
Past Year Diversion of Specific Prescription Stimulants by
College Students Prescribed Stimulant Medication for ADHD
% medical users giving away or selling
their medication
18
50
54
50
40
30
25
Lower
diversion
rates with
extended
release
formulations
20
10
0
0
Adderall® only Adderall XR® only Concerta® only
(n=14)
(n=12)
(n = 8)
Other combos
(n=13)
Source: Sepulveda et al. J Pharm Practice 2011
Sources of Lifetime Nonmedical Use of
Prescription Stimulants [College]
19
Friend from same school
52
35
Friend not from same school
Acquaintance from same school
13
9
Roommate
Boyfriend/girlfriend
6
Acquaintance from other school
9
Sibling
The following sources
were less than 1%:
aunt/uncle, other family,
abroad, and internet.
4
Drug dealer
2
Parent
2
1
0
57
42
19
14
12
Women (n=165)
12
Men (n=217)
7
8
10
20
30
40
Percent of Respondents
50
60
Sources of Lifetime Nonmedical Use of
Prescription Opioids [College]
20
26
Friend not from same school
Parent
36
20
25
Friend from same school
***
***
29
8
8
Roommate
Boyfriend/girlfriend
6
Acquaintance from other school
6
Sibling
3
Other family member
3
1
Drug dealer
0
10
Women (n=321)
8
7
5
Acquaintance from same school
The following
sources were 2% or
less: aunt/uncle
(2%), abroad (1%),
and internet (0.2%).
41
Men (n=319)
***p<.001
5
4
6
***
10
20
30
Percent of Respondents
40
50
Sources of Prescription Opioids among Past Year
Nonmedical Users [High School Seniors 2007-10]
21
Free from friend/relative
From a previous
prescription
Bought from
friend/relative
Stole from friend/relative
Bought from drug
dealer/stranger
Other
0
10
20
30
40
50
Percent of Respondents
The following source was 2% or less: internet.
Source: McCabe et al. JAH 2013
National Survey on Drug Use & Health
(NSDUH; 2013; Public domain)
22
Example: pain
reliever sources for
nonmedical use
• past-year
• users aged 12(+)
• 2012-2013
• Friends/relatives!
Qualitative Quotations
23
WOMEN
MEN
“I was given them by a friend
at a party.”
(White, freshmen)
“From friends with prescriptions, or
from those who have bought large
quantities from people with
prescriptions.”
(White, junior)
“My friends need these drugs
for ADD/ADHD and they give
them out to myself and other
friends.”
(Hispanic, senior)
“A friend has a prescription and
sells the pills to me.”
(White, senior)
Image source: Scientific American. The Quest for a Smart Pill.
Amount Paid for One Prescription Stimulant Pill:
Undergraduate Students (n=225)
24
72
70
% paying each amount per pill
60
50
40
30
20
12
10
3
9
0
$0 (free)
$1
$2 or $3
$4 or $5
1
1
$10
No answer
Source: Arria et al., 2008
25
PROBLEMATIC BEHAVIORS
Drug Abuse Screening Test Results based on
Source of Prescription Opioids [College]
26
% positive screening for drug abuse
No nonmedical use
Parent only
50
***
Peer only
All other sources
***
40
***
***
n=122
n=121
30
20
10
0
n=1901
n=48
n=140
Men
n=131
n=1936
n=78
Women
***p<.001 based on logistic regression using “no medical use” as reference group and adjusting for race/ethnicity, class year and living arrangement
Source: McCabe et al. Addict Behav 2007
Diversion x Medical Misuse among Past-Year
Medical Users of Prescription Stimulants for ADHD
(n=50 undergraduates)
27
% reporting diverting their medication
75
55
50
25
18
0
No Misuse
Medical Misuse
Source: Sepúlveda et al. J Pharm Practice 2011
Diversion by Medical Misuse among Past-Year Medical
Users of Controlled Medications [Secondary (grades 7-12)]
% reporting diverting their medication
28
50
40
37
30
20
13
10
0
Medical Use Only (n=365)
Medical Misuse (n=103)
Source: McCabe et al. Arch Pediatr Adolesc Med 2011
Conclusions
29

Nonmedical use of prescription medications has been
a relatively recent public health issue among many
populations
Secondary and college students
 Residents of Maine
 General population


Much of this nonmedical use of prescription
medications is driven by diversion
Conclusions
30

Diversion: Peer sources

Most individuals obtain diverted prescription medications
from friends and family



No strong evidence that individuals obtain prescription medications
directly via the internet
Evidence suggests that a majority of individuals (specifically students)
obtain prescription medications for free (e.g., from peers)
Diversion: Medication misuse

Strong relationship between misusing a prescribed
medication and diverting prescribed medication
Treatment Considerations
31

Need to reduce nonmedical use and diversion of
prescription medications must be balanced against the
need for clinicians and patients to have access to
medications for legitimate medical purposes

Example: prescription stimulants are highly effective at
treating core symptoms of ADHD; large effect sizes
Treatment Recommendations
32

When prescribing controlled medications to
adolescents and young adults:







Designate gatekeeper at home/school
Educate regarding secure location for storage
Discuss diversion (more in depth w/ ADHD meds)
Screen for SUDs, especially those with a history of nonmedical use
and/or medical misuse
Consider medications with less risk for abuse/diversion
Limit/monitor medication quantity and refills
Educate regarding proper disposal of medications
For More Information (Selected References):
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1.
2.
3.
4.
5.
6.
7.
8.
9.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., and Schulenberg, J. E., (2013). Monitoring the Future national survey results on drug use,
1975– 2012: Volume 2, College students and adults ages 19–50. Ann Arbor: Institute for Social Research, The University of Michigan.
McCabe, S.E., Cranford, J.A., Boyd, C.J., Teter, C.J. (2007). Motives, diversion and routes of administration associated with nonmedical use
of prescription opioids. Addictive Behaviors, 32(3):562-575.
McCabe, S.E. (2008). Screening for drug abuse among medical and nonmedical users of prescription drugs in a probability sample of
college students. Archives of Pediatrics & Adolescent Medicine, 162(3):225-231.
McCabe, S.E., Cranford, J.A., Teter, C.J., Rabiner, D., Boyd, C.J. (2011). Use, misuse and diversion of scheduled controlled prescription
medications by college students. In H.R. White, D. Rabiner (Eds.), College Substance Use: Etiology, Consequences and
Prevention. Thousand Oaks, CA: Sage.
McCabe, S.E., West, B.T., Teter, C.J., Ross-Durow, P., Young, A., Boyd, C.J. (2011). Characteristics associated with the diversion of
controlled medications among adolescents. Drug and Alcohol Dependence, 118(2-3):452-458.
McCabe, S.E., West, B.T., Boyd, C.J. (2013). Leftover prescription opioids and nonmedical use among high school seniors: A multi-cohort
national study. J Adolescent Health, 52(4):480-485.
McCabe, S.E., West, B.T., Teter, C.J., Boyd, C.J. (2014). Trends in medical use, diversion, and nonmedical use of prescription medications
among college students from 2003 to 2013: Connecting the dots. Addictive Behaviors 39(7):1176-1182.
Sepúlveda, D.R., Thomas, L.M., McCabe, S.E., Cranford, J.A., Boyd, C.J., Teter, C.J. (2011). Misuse of prescribed stimulant medication for
ADHD and associated patterns of substance use. Journal of Pharmacy Practice, 24(6):551-560.
Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of
National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2014.
Assessment Questions
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QUESTION #1: Which of the following characteristics is
consistently associated with individuals who divert their
prescription medications?
a. Gender
b. Medication misuse
c. Polypharmacy
d. Race/Ethnicity
Assessment Questions
35
QUESTION #2: The most common source for obtaining
prescription drugs to use nonmedically is which of the
following:
a.
Friends/Relatives
b.
Altered prescriptions
c.
Drug Dealers
d.
Internet Websites
Assessment Questions
36
QUESTION #3: Which of the following methods is the
most common pathway for obtaining prescription
drugs to use nonmedically?
a.
Doctor shopping
b.
Theft/take without asking
c.
Purchase from someone
d.
Obtain for free
QUESTIONS (?)