Transcript presentation ( format)

DISCLOSURES
• Dr. Hersh serves as a Treatment Advocate
for Reckitt-Benckiser Pharmaceutical
• Generic drug names are listed with Trade
names with the exception of Pill
Identification
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
DRUG OVERDOSES
• Drug induced death now outnumbers
suicide, injury by fire arms, and
homicide
• Emergency room visits from
prescription drug overdoses doubled
from 2004 to 2009
• Overdose deaths from painkillers have
risen from less than 2,901 in 1999 to
11,499 in 2007
• By 2007, more teenagers used opioid
analgesics recreationally than used
marijuana1
Center for Disease Control
1
FAMOUS CELEBRITY DEATHS
• Marilyn Monroe
• Health Ledger
• Michael Jackson
• Anna Nicole Smith
• Elvis Presley
• Whitney Houston?
PRESCRIPTION OPIOID DRUGS
Percocet
OxyContin
Tylenol #4 w/codeine
Opana
Vicodin
Lortab
PRESCRIPTION STIMULANT
DRUGS
Adderall
Ritalin
Concerta
Vyvanse
Adderall XR
PRESCRIPTION SEDATIVE
HYPNOTICS
Xanax
Klonopin
Ambien
Ativan
WHAT IS PRESCRIPTION DRUG
ABUSE?
• Taking prescription medication without a
prescription
• Taking more prescription medication than
prescribed (also called misuse)
• Taking prescription medication with
unintended routes of administration
(intranasal or I.V.)
WHAT IS PRESCRIPTION DRUG
ABUSE, CONTINUED
• Diverting prescription medication (selling
it, trading it, or giving it away)
• Harmful consequences from a controlled
substance (DSM-IV)
• Obtaining controlled substances from
different doctors (Doctor Shopping)
WHAT IS DEPENDENCY?
• Tolerance and withdrawal symptoms
• Decline in normal activities
• Unsuccessful attempts to cut down or
control use
• Use for longer period or larger amounts
than intended
• Use consumes lot of time to acquire
and/or recover from effects
• Continued use despite physical
and/or psychological problems
HOW COMMON IS ABUSE ON THE
COLLEGE CAMPUS?
• Ohio State University surveyed 5000
students in 2008 General Survey
• Opiates--9.2% at least once per year
(higher in intramural sports participants)
• Sedatives--5.1% at least once per year
• Stimulants--4.4% at least once per year
HOW COMMON IS MISUSE?
• World Health Association estimates about
50% of people do not take prescription
drugs as prescribed
• 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
• Prescription opiates--35.1% diversion
• 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
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 attend classes/do schoolwork
• Inability to work and financial problems
• Relationship problems
• Criminal behavior
MINIMAL
ABUSE
MAXIMUM
CARE
PREVENTION OF
PRESCRIPTION DRUG ABUSE
• Interdisciplinary treatment protocols to treat
ADHD, Anxiety Disorders, Sleep Disorders,
and pain (Minimal Abuse/Maximum Care)
• Help physicians say “NO!”
• 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
INTERDISCIPLINARY
TREATMENT OF ADHD
MAXIMUM
CARE
• Initial Phone Screening
• Attention Problem Evaluation (APE)
• ADHD Workshop
• Behavioral Interventions
• Miami University Learning Center Planner
• Medication
• Academic Coaching and Therapy
INITIAL PHONE SCREENING
• Front desk staff refers all students with
ADHD symptoms to phone screening
• Counselor does brief phone screening
to refer students to proper treatment
setting
• Students may be sent for an Attention
Problem Evaluation, to the Learning
Center, to the ADHD workshop, or for
a complete initial evaluation
ATTENTION PROBLEM EVALUATION
(APE)
• Semi-structured interview to
gather basic information
• Includes diagnostic criteria for ADHD
• Includes screening out other causes of
inattention such as medical causes, Sleep
Disorders, Substance Use Disorders, and
other psychiatric disorders
• Includes comprehensive treatment plan
ADHD WORKSHOP
• One hour psychoeducational workshop
required prior to ADHD treatment for ALL
students seeking medication
• Includes education about ADHD,
behavioral interventions, use of the Miami
University Planner, sleep hygiene, and
procedures for taking medication
• Education about risks and benefits of
medication including suggestions for
avoiding misuse and diversion
BEHAVIORAL INTERVENTIONS FOR
ADHD
• How to keep a planner
• How to use cell phone to keep
track of appointments
• How to improve sleep hygiene
• Treating college like a full time job
• Minimizing distractions
THE MIAMI UNIVERSITY LEARNING
CENTER PLANNER
• The planner is an essential part of this
approach
• Every student being treated for ADHD has
this planner
• Teaches block scheduling, grade tracking,
and syllabus tracking
• Provides list of resources including
workshops at the learning center
• Helps students with study skills and
procrastination
MEDICATION
• Stimulants are used according to the
weekly planner
• The effective dose is found and used
throughout the remainder of treatment
• The prescriber delineates times the
student will take the medication and gives
only amount needed for the month
• Techniques are implemented to prevent
tolerance to stimulants (i.e. drug holidays,
discontinuing caffeine)
ACADEMIC COACHING AND
THERAPY
• Coaching and/or therapy can be required
for medication use
• Academic Coaching
Weekly Sessions
Utilizes the Miami University Planner
Provides accountability
• Therapy
Address Comorbities (anxiety, substance
use, eating disorders, etc.)
Treatment of Attention Problems
MINIMAL
ABUSE
MAXIMUM
CARE
Attention Problem Phone Screening
Acute Attention
Problems
Initial
Evaluation
Chronic Attention
Problems
Attention Problem
Evaluation
Previous ADHD Diagnosis
Previous Records
Confirming ADHD
No ADHD
Diagnosis
New ADHD
Diagnosis
Behavioral
Interventions
ADHD Workshop
Academic
Coaching
Medication Evaluation
MINIMAL
ABUSE
MAXIMUM
CARE
INTERDISCIPLINARY
TREATMENT OF ANXIETY DISORDERS
• Refer to anxiety management workshops
and/or individual therapy
• 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
Treatment of Anxiety
MINIMAL
ABUSE
Everyday anxiety?
At least 6 months
Situational Anxiety?
Under 6 months
Performance anxiety?
Therapy
SSRI or
Therapy
Buspar 5 mg BID
Follow up 1 month
MAXIMUM
CARE
Inderal 10-30 mg prn
Follow up 1 month
Anxiety Workshop
Toastmasters
Panic attacks?
Insomnia?
Zolpidem 10 mg #10
Follow up 1 week
Lorazepam .5 mg #10
Follow up one week
Therapy
Monitor every 3 months
Monitor every 3 months
.
Monitor every month
INTERDISCIPLINARY
TREATMENT OF SLEEP DISORDERS
MINIMAL
ABUSE
MAXIMUM
CARE
• Refer to anxiety management
workshops and/or individual therapy
• Referral to sleep disorders clinic for
concerns about narcolepsy or sleep
apnea
• Try behavioral techniques (sleep
hygiene, white noise, etc.)
• Consider non-controlled substances
• Limit amounts of controlled substance
such as zolpidem (10 per month)
Treatment of Sleep Disorders
MINIMAL
ABUSE
Difficulty falling asleep?
MAXIMUM
CARE
Difficulty staying asleep?
Abnormal sleep schedule?
Stressful event Room Noises? Snoring?
or
Large Neck?
performance anxiety?
Enlarged tonsils?
Sleep Hygiene Handout
White noise machine
Zolpidem 10 mg #10
Sleep Study
Anxiety
Trazodone 50 mg prn
or
Zolpidem CR 12.5 #10
MINIMAL
ABUSE
INTERDISCIPLINARY
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 student know options for treatment
Inpatient vs. outpatient treatment
WHY TREAT OPIATE DEPENDENCE ON
THE COLLEGE CAMPUS?
• Shortage of community providers
• Inpatient treatment not very effective
• Improves retention of students
• Prevents overdose
• Decrease criminal behavior
• Decrease the spread of infectious disease
(e.g. HIV, HCV/HBV, STI)
• Treatment is effective and rewarding
QUALIFICATIONS FOR PRESCRIBING
BUPRENORPHINE/NALOXONE
• Be licensed to practice medicine
• Have the capacity to refer patients for
psychosocial treatment
• Limit their practice to 100 patients
receiving buprenorphine at any given time
• Be qualified to provide buprenorphine
Certification in addiction specialty or
completion of an 8 hour training course
• Receive a DEA license waiver
CHEMICAL PROPERTIES OF
BUPRENORPHINE/NALOXONE
• Partial opioid agonist; ceiling effect at
higher doses (safer than most opioids in
overdose)
• Blocks effects of other agonists (can’t
get high off opioids while on
buprenorphine)
• Binds strongly to opioid receptor, long
acting (once daily dosing)
BUPRENORPHINE/NALOXONE
TREATMENT PROTOCOL
• Pretreatment Screening
Can be over phone or in person
Make sure student is appropriate
• Intake
Complete history and physical
Check for other drug use (i.e. benzo’s)
• Induction
Dose and monitor with COWS
Watch for precipitated withdrawal
BUPRENORPHINE/NALOXONE
TREATMENT PROTOCOL
• Stabilization
Follow up the next day and 1 week
Consider initial supervised administration
• Maintenance
Monthly appointments, weekly therapy, and
regular urine screens
• Medically Supervised Withdrawal
Wait until ready
Taper over the course of several months
BUPRENORPHINE/NALOXONE
IN COLLEGE HEALTH PRACTICE
DeMaria et. al. J Am Coll Health. 2008 Jan-Feb;56(4):391-3.
The implementation of buprenorphine/naloxone in college health practice
CONCLUSIONS
• Prescription Drug Abuse is a growing
problem on the college campus
• Creating interdisciplinary treatment
protocols may help in prevention
• When prevention is not effective it is
important to not enable the problem and
help those receptive to treatment
• Buprenorphine/Naloxone is a safe and
effective treatment for opiate dependence
that can be given on the college campus