Transcript Prevention and Treatment of Prescription Drug Misuse on the

MULTIPLE ARTICLES ON SCOPE OF
THE PROBLEM
• “Prescription Drug Abuse Rises on
Campuses”—ABC News
• “Report: Prescription Drug Deaths
Skyrocket”—Foxnews.com
• “Stimulant Abuse Rises on the College
Campus”—The Columbus Dispatch
• “Prescription Drug Abuse on the Rise in
America”—Chicago Tribune
2009 CDC STATISTICS
• 3433 H1N1 swine flu deaths
• 1385 deaths from alcohol poisoning
• 28,754 prescription drug overdose deaths
HOW COMMON IS MISUSE?
• World Health Association estimates about 50%
of people do not take prescription drugs as
prescribed (higher with controlled substances)
• Maryland study found 35.8% of college students
reported that they had diverted a drug at least
once in their lifetime.1
• Prescription stimulants --61.7% diversion rate
• Prescription opiates--35.1% diversion rate
• 33.6% of students freely shared medication
• 9.3% of students sold medication
1
J Clin Psychiatry. 2010 March; 71(3): 262–269
REASONS FOR PRESCRIPTION
DRUG ABUSE
• Stimulants—cramming, delaying sleep,
weight loss, Sleep Disorders, ADHD
symptoms, recreational, dependency
• Opiates—pain (especially athletes),
anxiety, insomnia, recreational,
dependency
• Benzodiazepines—anxiety, insomnia,
recreational, dependency
REASONS FOR COADMINISTRATION/CO-ABUSE
• Combining stimulants with alcohol to drink
longer and counteract sedation
• Combining opiates or benzodiazepines
with alcohol to increase intoxication
(dramatically increases rate of overdose)
• Combining benzodiazepines with
stimulants to decrease anxiety from
stimulants
TRUE OR FALSE
• Many more people overdose from
illegal drugs than prescription drugs
• Most people that misuse prescription
drugs do not have their own
prescription
TRUE OR FALSE
• Taking a stimulant such as Adderall
would help anyone study
• Students who take stimulants such as
Adderall get better grades
• Mixing stimulants such as Adderall
with alcohol will help you drink more
and stay awake so you will have less
problems from alcohol
CONSEQUENCES OF
ABUSE/DEPENDENCE
• Medical risks (cardiac and stroke risks,
liver damage, nasal perforation, bloodborne diseases, overdose)
• Psychiatric illness (depression, anxiety,
psychosis, sleep disturbance)
• Inability to function at work or school
• Relationship problems
• Financial problems
• Illegal behavior
PREVENTION OF
PRESCRIPTION DRUG ABUSE
MINIMAL
ABUSE
MAXIMUM
CARE
• Treatment algorithms to treat ADHD,
Anxiety Disorders, Sleep Disorders, and
pain (Minimal Abuse/Maximum Care)
• Student education on scope of problem
and how to care for controlled substances
• Legal consequences for criminal behavior
(e.g. selling meds, forging scripts, etc.)
• Enforcement of medical standards
MINIMAL
ABUSE
TREATMENT OF ADHD
MAXIMUM
CARE
• Initial Phone Screening to refer students to
proper treatment setting
• Brain Booster Workshop and ADHD
Workshop to educate students on
behavioral interventions and medication
risks
• Attention Problem Evaluation (APE) to
screen for other causes of inattention and
create comprehensive treatment plan
BRAIN BOOSTER WORKSHOP
• 60 minute long workshop that details
behavioral interventions to treat attention
problems
• This includes sleep hygiene, usage of the
Miami planner, and techniques to help with
focus while studying
• Open to all full time Oxford Campus
students
• Required for all students seeking
treatment of ADHD unless they have had
extensive exposure to behavioral
treatments in the past
ADHD WORKSHOP
• One hour psychoeducational workshop
required prior to ADHD treatment for ALL
students seeking medication
• Includes education about ADHD and
procedures for taking medication
• Education about risks and benefits of
medication including suggestions for
avoiding misuse and diversion
• Providing lockboxes
This year …
1. Lock boxes distributed in the community
with targeted populations: pediatric, adult and
students
2. Assessed Rx abuse on campus via Miami
Nursing Department
3. Applied for grant to help fund additional
Lock Boxes
4. Pharmacy selling lock boxes to students
1. Survey says!
23 out of 34 students completed the follow up Lock box survey
Of these, 23 students:
- 5 have had their medications lost or previously stolen (21%)
-18 said they used the lock box daily (78%)
-22 agreed that passing these lock boxes out free of charge to
students was very helpful (95%)
1. Survey says!
Of the 18 students that use the lock box daily:
-13 had looked at the messaging about prescription drug abuse
(72%)
-14 agreed the messaging helped them understand the
importance of taking medications as prescribed (77%)
-17 stated that they would not make any changes to the
messaging (94%)
Comments from students
“It would be helpful to give the lockbox to every student when
they are initially prescribed a controlled substance.”
“Great idea for students living in dorms.”
“Less likely to have medications stolen because someone
would not go through the “extra hoop” to steal the box.”
“Awesome program and works very well
for securing prescription drugs.
“It’s too risky to tell friends I am on these medications because
during finals everyone wants it”
What is the next step?
We didn’t get the grant!
So, we encouraged our
pharmacy to start selling lock
boxes at cost to anyone who
needs/wants one!
MINIMAL
ABUSE
TREATMENT OF
ANXIETY DISORDERS
MAXIMUM
CARE
• Anxiety management workshops and/or
individual therapy first
• Try non-addictive substances first (SSRI’s,
buspirone, and beta blockers)
• If benzodiazepines are needed, limit
amount of benzodiazepines (i.e. 10 per
month)
• Monitor frequently for signs of misuse and
diversion
MINIMAL
ABUSE
TREATMENT OF
SLEEP DISORDERS
MAXIMUM
CARE
• Try behavioral techniques (sleep
hygiene, white noise, etc.)
• Consider non-controlled substance
such as trazodone
• Limit amounts of controlled substance
such as zolpidem (10 per month)
• Referral to sleep disorders clinic for
concerns about narcolepsy or sleep
apnea
MINIMAL
ABUSE
TREATMENT OF PAIN
MAXIMUM
CARE
• Referrals and communication with
surgeons, PCP’s, physical therapy,
and/or counselors
• Preference for non-controlled
substances such as NSAID’s
• Limit supply of opiates for severe,
acute pain
• Meet frequently and monitor for signs
of misuse and diversion
PREVENTION DOESN’T ALWAYS
WORK!
DIAGNOSIS OF PRESCRIPTION
DRUG ABUSE/DEPENDENCE
• History (non-judgmental stance, admission
of problems, wanting help)
• Pain, Anxiety Disorders, Sleep Disorders,
and ADHD (ask about self-medicating)
• DSM-IV criteria (abuse vs. dependence)
• Drug seeking behavior)
• Signs of intoxication or withdrawal
• Prescription drug monitoring system
• Urine drug tests
SCREENING TOOLS
• Comprehensive Drug Use Screening and
Assessment: NIDA-Modified ASSIST
• Interactive online screening tool, includes
tobacco, alcohol, prescription, and illicit drugs
• Generates a numeric Substance Involvement
Score that suggests the level of medical
intervention necessary
Http://www.drugabuse.gov/nidamed/screening
MANAGEMENT OF PRESCRIPTION
DRUG ABUSE AND DEPENDENCE
• Identify “Stage of Change”
• Pre-contemplation—Security if needed
Don’t enable the problem--Contact all
physicians prescribing to the student and
make them aware of problem
• Contemplation and Action
Non-judgemental stance—disease model
Let them know options for treatment
Inpatient vs. outpatient treatment
TREATMENT OF OPIATE DEPENDENCE
ON THE COLLEGE CAMPUS
• Opiate Dependence is a growing problem
on the college campus
• Improves retention of students
• Prevents overdose
• Treatment is effective
• Decrease criminal behavior
• Decrease the spread of infectious disease
(e.g. HIV, HCV/HBV, STI)
MEDICATION ASSISTED
TREATMENT OF ADDICTION
• Using medication, in conjunction with
counseling and peer support groups to
treat addiction
• Can help with harm reduction (prevention
of hepatitis C, overdose deaths,
criminality)
• Can be used to help people achieve
abstinence
BUPRENORPHINE/NALOXONE
• Partial opioid agonist; ceiling effect at higher
doses (safer than most opioids in overdose)
• Can be lethal for unexposed or if combined with
sedatives
• Blocks effects of other agonists (difficult to get
high off opioids while on buprenorphine)
• Binds strongly to opioid receptor, long acting
(once daily dosing)
• Has withdrawal syndrome (needs to be tapered
off slowly)
BUPRENORPHINE/NALOXONE
IN COLLEGE HEALTH PRACTICE
Overall Percent of Positive UDS
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
100%
52%
44%
19%
41%
17%
22%
9%
Opioid
Cocaine
Initial UDS
Illicit BZ
Marijuana
Follow-up
DeMaria et. al. J Am Coll Health. 2008 Jan-Feb;56(4):391-3.
The implementation of buprenorphine/naloxone in college health practice
NALTREXONE
• Naltrexone is effective for preventing
relapse on opiates
• Works by blocking the effects of opiates at
the opiate receptor
• Available in oral (Revia) and monthly
injectable (Vivitrol) forms
• No tolerance or dependence
• Can stop at any time when ready
TREATMENT OF STIMULANT USE
DISORDER
• No FDA approved medications to treat
prescription stimulant abuse
• Stimulant induced psychosis often
managed with antipsychotics and safe
environment
• Supervised administration of stimulants if
required for ADHD or narcolepsy
• May be difficult to experience withdrawal
and complete coursework
TREATMENT OF BENZODIAZEPINE
USE DISORDER
• Outpatient taper is risky, consider inpatient
treatment
• Education on dangers of mixing
benzodiazepine with alcohol and opiates
• Using medications such as SSRI’s,
hydroxyzine, and clonidine to help with postacute withdrawal symptoms
• Regular urine drug testing
• Communication with parents