Transcript Introducing a New Product - MI-PTE

Implementing Effective
Prescription Drug Abuse
Prevention Strategies
Jim Middleton, Pharmacist
Carol Meyer-Niedzwiecki,
SAC Prevention Director
Today's Goals!
1. Increase knowledge
2. Learn about interventions
3. Obtain tools and develop an action plan
Topics to Get There
National issues with Local Significance
Background Education for the
Layperson
The Misdirection of Assistance
Research, News and Updates
Some of the Challenges:
OVERALL PICTURE – Youth and adult
Prescription drug abuse is rising
We live in a culture of “pain relief”
Youth Perception – Prescription drugs are safer than
'street drugs,' they are 'non-addictive,' and there is
less 'stigma' to their use
Some of the problem
Highly publicized
From the CDC:
Enough painkillers
were prescribed in
2010 to medicate
every American adult
around the clock
for a month.
(Nov, 2011 report)
Some of the Problem
More than 40 people
die
every day from ODs
involving narcotic
pain relievers
(CDC&P)
Some of the Problem
National Data tells us:
14,800 people in the U.S. died from painkiller
ODs in 2008. Greater than threefold increase
from 4,000 deaths in 1999. (CDC&P)
36,450 deaths from prescription and other illegal
drugs in 2008 compared with 39,973 vehicle
crashes. (AP)
Why is there abuse?
The “usual suspects” here:
get high, experimentation, cope, focus, peer pressure,
lose weight, bulk up, self medicate, easy to get,
“It won't happen to me” and the
proliferation of advertising
Monitoring the Future Survey 2010
Annual prevalence of narcotics (other than heroin) amongst
12th Gr: 3.3% (1992) 9.5% (2004)
OXYCONTIN
VICODIN
Gr 8
2.1%
Gr10
4.6%
Gr 12
5.1%
Gr 8
2.7%
Gr 10
7.7%
Gr 12
8.0%
NSDUH
PDs #2 (marijuana #1) illicit drug used
Non-medical use of PDs by persons 12 yrs of age
and older 2.5% (2008) 2.8% (2009)
Use rates overall
higher in 2000's
than 1990's
2002
2010
PAIN RELIEVERS
Youth
3.2%
2.5%
Young adults
4.1%
4.5%
Michigan Data tells us:
BRFSS 2009 (only ask about barbiturate use without a doctor's
prescription)
Ever
In past 30 days
Gr 9
8%
4%
Gr 10
9%
5%
Gr 11
13%
8%
Gr 12
11%
5%
And where are the drugs coming from?
And where are the drugs coming from?
From a friend or relative – 55%
By a direct prescription from a physician – 17.3%
Bought from a friend or relative – 11.4%
Stolen from a friend or relative – 4.8%
From a dealer or stranger – 4.4%
“Other” (ie, robbed a pharmacy, went to Mexico) – 7.1%
And where are the drugs coming from?
Looking at it a different way:
By a direct prescription from a physician – 17.3%
By an indirect prescription from a physician – 71.2%
What We Look For
1. Patients who know more about prescription drugs
than I do
2. Patients who know more about insurance coverage
than I do, or insist they have no prescription
coverage but like particular brands of drugs
3. Very thin, asymptomatic, agitated, toothless 20somethings wanting Sudafed 24-hour capsules
4. And sadly, incoming patients who are perhaps a bit
too friendly
What We Look For
6. Elaborate Excuses, generally involving trips to
Tennessee, an ex-spouse, neighbor's dog, a funeral, a
bathroom sink, a kitchen sink, a neighbor's spouse, a
neighbor's dog, a neighbor's ex-spouse from
Tennessee with a dog....
7. A phone call that starts with “OK, it's like this....”
Overall Causes of Death - US
Compared to motor vehicle accidental
death rates
Accidental Drug Deaths since 1999
Accidental Deaths by Drug
Death by opioids vs sales
Rates in US overall
Consequences of overdoses
Death
Death always reported as a drug
reaction?
– not in Battle Creek
– homicides labeled “result of a gunshot wound”, not
“individual, while on meth, attempted to rob a crack
house and was shot in the process”
Analysis of one (of 57) toxicology
reports (2010)
– 41 year old Caucasian male, Battle Creek
– accidental death, toxicology revealed in blood:
7-Amino Clonazepam
Benzoylecgonine
Acetone
Methadone
Phenylpropanolamine
Amphetamine
“Let's DO something!”
Legislative Updates:
The majority of states now have Prescription Drug
Monitoring Programs (PDMPs)
P.A. 84 (was SB 333): electronic reporting (NPLEx),
effective 1/1/12
P.A. 85: product placement, ID buyer, record sale
H.B. 4564: misdemeanor if purchaser uses fake ID to buy
ephedrine product
H.B. 5089: establish an unused PD repository program.
Participating pharmacies would have to offer disposal
programs for turned in meds
Legislation Can Have Unintended
Consequences
My personal gateway drug...
Rising to the Challenge



The need to balance
access for therapeutic
use vs easy access
for abuse
The body does not
know the difference
between a 'legal' and
an 'illegal' use of a
drug
The body regards all
drugs, foods,
The body uses chemicals to maintain
a healthy balance
Serotonin
Dopamine
Epinephrine
Acetylcholine
Insulin
GABA
Electrolytes
In very tiny quantities
Drugs Affect These Same Chemicals
Serotonin
Dopamine
Epinephrine
Acetylcholine
Insulin
GABA
Electrolytes
In very LARGE quantities
How the brain sees drugs:
So, treat those conditions! (well...)


Add Dopamine to control Parkinsonism, you can develop
signs of mental illness
Block Dopamine to control Schizophrenia, you can
develop symptoms that look like Parkinsonism
The primitive brain is very compact
(the Limbic system)
Dopamine is a pleasure transmitter
– Increased levels result from chocolate, CNS
stimulants
– Increasing the levels artificially leads to mania
(Parkinson's patients developing gambling obsession)
At what age do we introduce
our children to drugs?
Define “drugs”
Children aren't stupid! Really!!!
– Survey of parents thought their children on Ritalin
or Adderall were at least 97% compliant with
treatment
– reality was 75%
The Drugged Society and Its
Consequences
– “Oh, I take my husband's Xanax all the time. That
doesn't interact with my Ambien, does it?”
–
(call received Saturday, 19 Feb 2011)
So we try to rise to the challenge,
but maintain a proper balance



For example, in the 1880s, morphine abuse was
nearly epidemic
We needed a heroic replacement to treat pain
but not cause the addiction
The best chemists of the day worked on the
problem – lo and behold, they created.......
Heroin!
Unregulated Marketing 1905
Unregulated Marketing 1905
Regulated Marketing - 1919
In the 1930s
Scientists were searching
for a drug that would
work to control seizure
disorders (epilepsy)
Sometimes you just have to wonder...
Narcotic Analgesia
– Opiates have a natural
product base – opium
poppy
– Opioids are the product
of the chemist's bench –
ie meperidine (Demerol)
Consider these effects on
– Migraine
– GI disorders
– Bone pain (calcitonin breaks down bone)
– Estrogen-receptor type breast cancer
– Ability to control pain – the same 'benefit' will
require larger and larger doses
Relaxation in a tablet...
– The “Benzos” - benzodiazepines
– It all began with chlordiazepoxide (Librium), then
diazepam (Valium), then lorazepam (Ativan), then
chlorazepate dipotassium (Tranxene)... then
alprazolzam (Xanax) …. a 50 year legacy of
pharmacotherapeutic alternatives to facing stressors
in our lives...
GABA – gamma amino butyric acid
- “butyric” for “butter” (butter is 3-4% butyrate)
- hmmm.... dairy products to relax us.....
What Parents and Educators Should
Look for
– Sedation or erratic behavior of sudden onset
– Constipation and stomach complaints
– Loss of weight, loss of teeth, bleeding or infected
gums
– Sudden interest in who in the family is ill, perhaps
with cancer
– A need to refill your prescription meds early,
especially if they have a sticker that reads “May
Cause Drowsiness or Sedation”
The Duty to Warn

Ancillary labels
–

The wrong education provided?
HIPAA challenges
–
The hearing impaired in a
public arena
The Right to be Pain Free

A JCAHO mandate

A State of Michigan mandate

Question: What is the definition of pain?
–

Whatever the patient says it is!
Sources for pain management
–
–
Where did the notion originate?
Is a dental office an appropriate starting point?
•
OxyContin as a first-line pain treatment for 14 year
olds?
Diversion Flags
What is observed....
Free Speech and Marketing
Free Speech and Marketing
Drug Take-Back Programs
– Collects unused drugs
– Offers a method of removing controlled
substances from easy access
– Drugs do not enter the water supply, but are
incinerated as medical waste (at 3000 degrees)
– Typical day of take back brings in 200,000 –
300,000 tablets
– Drug companies are VERY supportive of this
Misdirected Solutions
And
Why We Are Here
Control of Pseudoephedrine (Sudafed)
The Problem:
– no requirement for general oversight
– county-by-county monitoring of logs and usage varies
wildly
– monitoring often gets cut with budget challenges
(Kalamazoo county)
– user can hop from one pharmacy to the next
The Challenged Response to the
Challenge
- The Problem:
Narcotic Prescriptions are being prescribed at an
overwhelming volume and are becoming harder to
track....
- The Solution:
Cut the triplicate-script program, extend the amount of
time to fill powerful narcotics and stimulants, and
allow for multiple prescriptions – to make access
more convenient
The Challenged Response to the
Challenge
- The Problem:
Abuse of Vicodin/Norco/Lortab type narcotics is
leading to liver damage due to the amount of
acetaminophen in each tablet
- The Solution:
Don't control the hydrocodone use – restrict the
amount of acetaminophen in each tablet
The Challenged Response to the
Challenge
- The Problem:
Sudafed sales are directly related to the number of
meth labs being created. Making Sudafed/pseudoephedrine a prescription seems to be the only real
solution
- The Solution (in Michigan):
Keep Sudafed as an OTC but subscribe to a
'signature log' database without useful oversight –
and cut police
The Challenged Response to the
Challenge
In other words, you may see a reduction in meth labs,
because there's nobody to go after them!
The Challenged Response to the
Challenge
- The Problem:
Overmarketing prescription drugs directly to the
consumer and mail-order distribution has escalated
the amount of drugs available for misuse or abuse
- The Solution
Encourage take-back programs coordinated by
volunteers
The Challenged Response to the
Challenge
- The Problem:
A 'top-down' solution runs into the danger of
becoming manipulated, diverted, or politicized
- The Solution:
You. Here. Today.
“Bottom's up!”