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OxyContin, Vicodin, and Heroin Abuse: What's a Clinician to Do? Peter A. DeMaria, Jr., M.D., FASAM Tuttleman Counseling Services Temple University Clinical Associate Professor of Psychiatry Temple University School of Medicine Disclosures • Dr. DeMaria serves as a treatment advocate for Reckitt-Benckiser Pharmaceutical • Generic versus Trade drug names • Off-label use of medication College Student Developmental Stage ADOLESCENCE • • • • Invincible Subject to peer pressure Risk-taking Want to be independent Some Factors Affecting Drug Experimentation/Continued Use/Addiction Peer Pressure Genetics Psychiatric problems Stress Availability Boredom Trauma/abuse Curiosity The Life History of A Substance User Abstinence Abstinence Experimentation Abuse Dependence Sobriety Recovery Relapse to Use Core Alcohol & Drug Survey-2005 (A sample of 33,379 undergraduate students from about 53 colleges in the United States) 30 Day Prevalence Rate by Drug Type College Student Opioid Use–CORE Study Year 2006 2005 2004 2003 2002 2001 No. of Students 71,189 33,379 68,000 38,857 54,367 54,444 No. of Colleges 134 53 133 89 125 131 Annual Prevalence 1.3% 1.4% 1.5% 1.7% 1.8% 2.1% 30-day Prevalence 0.6% 0.7% 0.7% 0.8% 0.8% 1.0% If Temple has 33,000 students, then 429 used in the last year & 198 used in last 30 days Monitoring the Future Annual Prevalence for College Students Papaver somniferum (Opium poppy) Patterns of Use • Heroin: $10 bags – Snorted, injected, smoked – Average habit = $80-100/day • Prescription Narcotics (Opioids) – Oxycodone [C-II] • Percocet (~$5/pill) • OxyContin (~$0.50/mg.) – Tylenol w/Codeine #3,4 (~$1-5/pill) [C-III] – Lortab/Vicodin (hydrocodone), [C-III] Prescription Opioid Drugs Percocet OxyContin Tylenol #4 w/codeine Dilaudid Vicodin Lortab Opioids - Intoxication/Withdrawal/Overdose • Intoxication – Rush, nod, miosis, constipation • Withdrawal -Craving -Anxiety -Insomnia -Weakness -Yawning -Lacrimation -Diarrhea -Piloerection -Muscle twitches -Mydriasis -Diaphoresis -Myalgias/arthalgias -Rhinorrhea • Overdose – Classic triad (Miosis, Respiratory depression, Coma) Cycle of Addiction Drug Use Obtain drugs Physical dependence Obtain money for drugs Withdrawal symptoms Need for drugs Consequences of Addiction • • • • • • • • Inability to attend classes/do schoolwork Breakdown of relationships Decrease in self-care Inability to work Financial problems (cash flow) Illegal behavior Medical risks Psychiatric illness Progression of Opioid Use Prescription Opioid Medication Snort Heroin Inject Heroin How People Change Precontemplation Contemplation Preparation Action Maintenance Prochaska J, DiClemente C, Norcross J. In search of how people change: applications to addictive behaviors. Amer Psychol 47:1102-1114, 1992. General Principles of Treatment • • • • • • Comprehensive evaluation Engagement in treatment Treatment setting Detoxification vs. maintenance Counseling (Individual, Group) Self-Help (12 step) Methadone Suboxone® Component(s) Methadone Buprenorphine + naloxone Classification Pure opioid agonist Partial opioid agonist + pure antagonist Prevent WD Yes Cause euphoria No Yes No Block euphoria Safe in OD DEA Regulation Yes Lethal C-II Yes Safer C-III Administration Availability Oral Specialized clinics Dosing visit Daily Sublingual Outpatient physicians’ offices Up to monthly Using Buprenorphine to Treat Opioid Dependent University Students: Opportunities, Successes, and Challenges. • Peter A. DeMaria, Jr., M.D., FASAM Robert C. Sterling, Ph.D. Robin Risler, Psy.D. Jeremy Frank, Ph.D., CAC • Journal of Addiction Medicine • Available on-line: Published Ahead of Print • http://journals.lww.com/journaladdictionmedicine/ toc/publishahead The Temple Experience • Retrospective chart review of treated students. • Time period = 1/04 through 4/08 • 27 students inducted and treated at least 3 months • Average age = 22.37 ± 2.89 years old • 63% Male • 85% Caucasian • 97% Academic juniors or higher • 41% Not involved in a relationship Year in School at Presentation Opioid Use at Admission – Self Report Initial Urine Drug Screen Population Characteristics • Average length of use = 33.4 ± 28.79 months (range = 4-132 months) • 56% Use drugs IV • 67% Smoke tobacco • 56% Dink alcohol • No HIV or HCV infections • Family History – Psychiatric = 52% – Drug & alcohol = 70% • 59% Report a history of past addiction treatment • 30% Report a legal history Psychiatric Diagnosis 15/27 (55.6%) had a history of a psychiatric diagnosis Treatment Characteristics • Average Suboxone dose = 13.8 ± 5.69 mg (range = 4-24 mg). • Well tolerated; no serious adverse events • Most common side effect = constipation • One student became pregnant and delivered Urine Drug Screen Results N = 237 UDS, M = 8.8/student, Range = 0 - 33 Disposition of Admitted Patients Length of Treatment = M = 12.00 ± 11.49 months Range = 1 to 36 months Treatment Received Service Psychiatric Evaluation Medication Management Individual counseling Group counseling Self-Help N (%) Avg. No. + SD Range 27 (100%) N/A N/A 27 (100%) 10.48 ± 9.75 1 - 30 18 (67%) 7.56 ± 5.73 1 - 21 15 (56%) 8.60 ± 5.69 2 - 20 9 (33%) ? ? Predicting Treatment Outcome • Opioid positive UDS at follow-up – Use of heroin → (+) – Use of other substances → (+) – Time in treatment (p = 0.06) → (-) • Time in treatment – No significant indicators Challenges • • • • • • Accept the disease of addiction Commit to sobriety Acknowledge that marijuana is a drug Engage in treatment Finances Managing free time/boredom Study Limitations • • • • • Uncontrolled Retrospective No comparison group Small sample size Limited to one university Conclusions Opioid dependent university students: • Are a unique group of substance users • Can be safely and effectively treated with buprenorphine in a university counseling center