Transcript Prescription and Over the Counter Drug Abuse

Prescription and Over-the-Counter
Drug Use
Evergreen Annual Conference
March 24, 2011
Jay Jaffee
Minnesota Department of Health
We will address…
The extent of the problem.
How we got here.
-With an emphasis on the 1990s to today
What we have to do.
-Everyone has a role in this.
MN Students Using Chemical Substances One or
More Times in Past Year
2010 Minnesota Student Survey
Note: Tobacco use during the past year was not asked in 2010
60.0
56.5
12th Grade
9th Grade
40.0
32.5
31.5
30.0
20.0
4.0 1.5
2.5 1.5
3.0
1.0
2.0 2.5
0.5 1.0
0.5 0.0
Heroin
1.5
Inhalants
4.5
Tranquilizers/sedatives
1.0
Stimulants/diet pills
2.5
MDMA (Ecstasy)
Oxycontin/percocet/pain
relievers
Marijuana
0.0
3.5
LSD/psychedelics
6.0
2.5
Cocaine/crack
6.5
ADHD or ADD drugs
10.0
Methamphetamine
16.0
Alcohol
Percent
50.0
National Youth Prevalence
• About 20 percent of teens report abusing a
prescription medication at least once in their
lives.
• About 15 percent of teens report abuse of a
prescription pain reliever in the past year.
• About 8 percent of teens have abused OTC
cough medications in the past year.
2009 Partnership for a Drug-Free America Parents and Teens Attitude Tracking
Study Report
National College Students
College students reporting past-year non-medical
use:
• OxyContin – 3.6%
• Vicodin – 6.7%
• Amphetamines – 5.7%
• Ritalin – 3.2%
• Sedatives – 3.7%
• Tranquilizers – 5.0%
2009 Monitoring the Future Survey, University of Michigan
Prevalence of Use
• More than 1.6 million American teens and
young adults misused ADHD drugs during
a 12-month period
• 75,000 became addicted
National Institute on Drug Abuse, February, 2006
ADHD Drugs
According to National Institute on Drug Abuse research:1
• More than 5 percent of students reported using ADHD medication without a
prescription during the past six months.
• 9 percent reported doing this since they began college.
• Nearly 90 percent of these students felt it was effective in helping them study.
• About 2 percent of respondents said they frequently used nonmedical ADHD
medication to get high.
• Most students using nonmedical ADHD medication tend to be white, belong to
a fraternity or sorority, have lower GPAs and engage in substance use and
other risky behaviors.
A National Institutes of Health study of youth prescribed ADHD drugs found no
relationship between having ever received stimulant treatment and the risk of
future alcohol or other substance abuse.2
1. Journal of Attention Disorders, December 2008
2. American Journal of Psychiatry, March 2008
Prevalence of Use
• Of the 9.2 million current users of illicit drugs other than
marijuana in 20091:
- 7.0 million were non-medical users of
psychotherapeutic drugs, of those;
- 5.3 million were non-medical users of pain relievers
• Over 50 million people have used psychotherapeutic drugs
non-medically in their lifetimes, of those2;
- Nearly 35 million have used prescription pain
relievers non-medically
1. National Survey on Drug Use and Health, 2009 (based on people aged 12 and older)
2. National Survey on Drug Use and Health, 2008 (based on people aged 12 and older)
Prevalence of Use
The number of people using prescription
pain relievers non-medically for the
first time increased from:
-600,000 in 1990
-2.2 million in 2009
National Survey on Drug Use and Health, 2009
Risk Factors for Painkiller Addiction
People suffering from chronic pain who have been
prescribed opioid painkillers • 65 years old or younger,
• Using psychiatric medications,
• Or with histories of drug abuse,
• Or depression
were more likely to be addicted to the painkillers.
Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system,
Addiction, September 2010
Prevalence of Use
• One third of drug abuse in the U.S. is
prescription drug abuse.
• “More than 17 percent of adults over 60,
wittingly or not, abuse prescription drugs.”
Prevention Alert Volume 6, Number 4, Center for Substance Abuse Prevention,
3/7/03
Psychotherapeutic Drugs
“drugs that have an effect on the function of the
brain and are often used to treat psychiatric
disorders.”
They include:
• Opioids – prescribed for pain relief
• Central Nervous System Depressants – prescribed
for anxiety or sleep problems
• Central Nervous System Stimulants – prescribed
for ADHD, obesity and sleep disorders
National Institute on Drug Abuse (NIDA)
Psychotherapeutic Drugs
-OpioidsCodeine, fentanyl, morphine, opium, oxycodone,
meperidine, hydromorphone, hydrocodone
Include such brand name drugs as: Darvon,
OxyContin, Tylox, Percoset, Percodan, Demerol,
Vicodin, Dilaudid
Street names: China white (fentanyl), M (morphine),
gum (opium), percs (Percodan/Percoset), hillbilly
heroin (OxyContin), juice (Dilauadid), demmies
(Demerol), etc.
National Institute on Drug Abuse (NIDA)
Consequences
-Opioids• Tolerance – need progressively higher doses to
achieve the same effects
• Physical dependence and addiction
• Severe respiratory depression that can lead to
death
• Withdrawal can include: cold flashes, diarrhea,
insomnia, muscle and bone pain and restlessness
National Institute on Drug Abuse (NIDA)
Psychotherapeutic Drugs
-Central Nervous System DepressantsBarbiturates, benzodiazepenes, fluntrazepan
Include such brand name drugs as: Mebaral,
Nembutal, Seconal, Tuinal, Halcion, Valium,
Librium, and Rohypnol
Street names: barbs (barbiturates), reds (Seconal),
phennies (Phenobarbital), tooies, rainbows,
Christmas trees (Tuinal), downers (any
depressant), tranks (tranquilizers), roofies & rope
(Rohypnol), etc.
National Institute on Drug Abuse (NIDA)
Consequences
-Central Nervous System Depressants• Lowered inhibitions, confusion, dizziness,
impaired judgment, memory and coordination and
drowsiness
• Tolerance
• Physical dependence and addiction
• Severe respiratory depression that can lead to
death
• Withdrawal can include seizures
National Institute on Drug Abuse (NIDA)
Psychotherapeutic Drugs
-Central Nervous System StimulantsAmphetamines, cocaine, methamphetamine,
methylphenidate
Include such brand name drugs as: Dexedrine,
Biphetamine, Desoxyn, Ritalin, and Adderall
Street names: bennies (benzedrine), crosses & speed
(any stimulant), black beauties (Biphetamine),
blow, candy, rock & snow (cocaine); crank,
crystal & ice (methamphetamine); skippy &
vitamin R (Ritalin), etc.
National Institute on Drug Abuse (NIDA)
Consequences
-Central Nervous System Stimulants• Hostility, paranoia, panic, high body
temperatures, digestive problems, irregular
heartbeat, loss of coordination, possible
hallucinations, psychotic episodes,
cardiovascular failure, lethal seizures,
• Tolerance
• Addiction
National Institute on Drug Abuse (NIDA)
Over-the-Counter (OTC) Drugs
Including:
• Cough and cold medications containing
dextromethorphan, alcohol and pseudoephedrine
• Allergy and sleep aids containing alcohol
diphenhydramine and chlorpheniramine maleate.
• Motion sickness medication containing
dimenhydrinate.
• Weight loss, body-building and alertness products
containing caffeine, ephedra, ephedrine and other
stimulants
OTC Slang
• Over-the-counter cough medicine with
dextromethorphan called Dex, syrup, tripleC, robo, vitamin D or tussin.
• Use may be called robo-ing, robo-tripping
and users may be called robo-cops
(reference to Robitussin DM).
• Taking cold and cough pills and tablets
called “skittling” (reference to the Skittles).
Consequences
Possible side-effects of excessive DXM* use:
Loss of balance
Increased pulse
Cerebral hemorrhages
Stroke
Permanent coma
Hypothermia
Loss of consciousness
Brain damage
Loss of muscle control
Seizures
Severe high blood pressure Mania
*Dextromethorphan
Consequences
Many cough and cold medications also contain acetaminophen. Large
doses can cause liver damage.
From 1998 to 2003, acetaminophen was the leading cause of acute liver
failure in the United States, with 48% of acetaminophen-related cases
associated with accidental overdose.*
In January 2011 the FDA asked drug manufacturers to limit the strength
of acetaminophen in prescription drug products (usually with opioids)
to 325 mg. per dosage unit. No recommendation for OTC products.
Acetaminophen is not recommended for people who have more than three
alcoholic drinks per day.
* Drs. Larson, Davern, et al, Hepatology, December, 2005
Consequences
Recommended adult daily dose of acetaminophen is
4000 milligrams or 4 grams.
• A 6 ounce bottle of NyQuil contains 6 grams of
acetaminophen.
• NyQuil also contains 180 milligrams of
dextromethorphan.
– The recommended adult daily dose is 120 milligrams
Consequences
Some allergy, cold and skin rash medications
contain chlorpheniramine maleate - can
cause brain damage or death in large doses.
Motion sickness medications like Dramamine
contain dimenhydrinate - can cause
hallucinations in large doses.
Consequences
Some weight-loss products contain sibutramine, an appetite
suppressant that's a chemical cousin of amphetamines.
-It can cause heart attacks, strokes and heart palpitations,
especially in people with a history of high blood pressure
or heart problems.
Some contain phenolphthalein, a laxative, which is now being
withdrawn from the market because of cancer risks.
Some weight-loss and body building products contain
hydroxycitric acid, linked to liver problems in at least one
medical journal study.
-The FDA has recalled at least 14 Hydroxycut products
Food and Drug Administration, 2009
Poly-drug Use
• Prescription or OTC drugs and alcohol,
marijuana and other drugs
• Stimulants with depressants – “Speedball”
• Even Viagra with alcohol or illicit drugs
Why the Increase in Use?
• Many people want a quick fix!
• Many experience a high demand for performance:
- At school
- In athletics
- In the business world…
• They are perceived as “safe and legal” products
• They are readily available and accessible
• There is extensive marketing of these products
Safe and Legal Products
In a survey of the perceptions of over 1200 college
freshmen:
• Nonmedical use of prescription painkillers and
stimulants is safer than taking cocaine but riskier
than smoking marijuana or drinking alcohol
• Those who perceived use as relatively harmless
were 10 times more likely to use them as those
who viewed them as highly hazardous
Prevention Science Journal, September 2008
Readily Accessible
• More than half of all insured Americans are
taking prescription medicines regularly for
chronic health problems
• Americans buy much more medicine per
person than any other country
Medco Health Solutions Inc, 2008
Readily Accessible – Families,
Friends and Homes
• Prescription and OTC drugs are in most of
our homes.
• Many young people taking them from their
own or other people’s homes.
• There are reports of visitors to real estate
open houses and garage sales taking them.
• Many people offer remedies to others
Readily Accessible - Stores
• Many OTC medications are prominently displayed,
depending on the season.
– They are easily purchased or stolen.
• Medications containing ephedrine and pseudoephedrine are now behind the counter by federal law.
– Oregon and Mississippi require a prescription for any drugs
containing pseudo-ephedrine.
• Some states have considered putting medications
containing dextromethorphan behind the counter.
– One Maryland supermarket chain banned sales of
medications containing dextromethorphan to people under
age 18.
Readily Accessible - Prescriptions
•
•
•
Physicians report that half of the requests they receive
for advertised drugs are inappropriate choices for the
patients.
– Yet physicians fill about two-thirds of such requests,
including about 6% that might actually be harmful.1
Spending on prescription drugs in the U.S. increased
from $40.3 billion in 1990 to $234.1 billion in 2008.2
From 1999 to 2009 the number of prescriptions
dispensed rose 39% (from 2.8 billion to 3.9 billion)
compared to a U.S. population growth of only 9% over
the same period.2
1. FDA Weighs Limits for Online Ads, Journal of the American Medical Association, January 2010
2. Kaiser Family Foundation, 2010
Readily Accessible - Prescriptions
• More than 40 percent of physicians did not ask
about prescription drug abuse when taking a
patient’s health history.
• One-third did not regularly call or obtain records
from the patient’s previous (or other treating)
physician before prescribing controlled
(substances).
• 47.1 percent said that patients commonly tried to
pressure them into prescribing a controlled drug.
Controlled Prescription Drug Abuse at Epidemic Level, Center on Addiction and Substance Abuse, July, 2005
Readily Accessible - Prescriptions
• Nearly thirty percent of pharmacists did not
regularly validate the prescribing physician’s
information (DEA number) when dispensing
controlled drugs.
• Three-fifths (61 percent) did not regularly ask if
the patient is taking any other controlled drugs
when dispensing a controlled medication.
• From 1992 to 2002, prescriptions written for
controlled drugs increased more than 150 percent
Controlled Prescription Drug Abuse at Epidemic Level, Center on Addiction and Substance Abuse, July, 2005
Readily Accessible - Prescriptions
• Over the past 10 years, drug and device companies
have increased their funding medical education
meetings by over 300 percent, according to
industry figures.
• Companies now provide more than half of the
$2.5 billion spent annually on medical education.
• Companies can see a return of $3 in sales for
every $1 spent on medical education, according to
an industry study.
U.S. Department of Health and Human Services, July 2009
We All Have a Role in This!
Among persons aged 12 or older who used pain relievers non-medically in
the past 12 months:
• 55.3 percent reported in that they got them from a friend or relative for
free.
• 9.9 percent bought the drugs from a friend or family member.
• 5.0 percent stole them from a friend or relative.
• 17.6 percent reported they got the drugs from just one doctor.
• Only 4.8 percent got the pain relievers from a drug dealer or other
stranger, and
• Only 0.4 percent reported buying the drug on the Internet.
National Survey on Drug Use and Health, 2009
We All Have a Role in This!
According to recent research in Utah:
97 percent of individuals who misused painkillers like
Vicodin and OxyContin said that they got the drug from a
friend or relative with a prescription.
• 85.2 percent said friends or relatives gave them the drug
willingly.
• 9.8 percent said they took the drug from friends or
relatives without their knowledge.
• 4.1 percent of those surveyed said they had bought the
drug.
Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, Feb. 19, 2010
Extensive Marketing
Advertising
Print
• First appeared in magazines in doctors’ offices
• Then in magazines and newspapers for the public
Broadcast – even “info-mercials”
• U.S is one of two industrialized countries allowing broadcast ads for
prescription drugs
• Pharmaceutical companies have increased their spending on direct-toconsumer advertising 330 percent since 1996*
– They spend almost $30 billion annually to promote their products
– FDA has been issuing fewer warnings to pharmaceutical firms about their ads.
– In 2006, only 21 warning letters were issued, compared to 142 in 1997.
FDA announced it will study whether style of ads distracts consumers from
warnings about the drugs' risks (August, 2007)
*The New England Journal of Medicine, August 2007
FDA Draft Guidelines on
Advertising and Promotion
Television ads for drugs and medical devices should:
• Avoid distracting images and music that can reduce viewers'
comprehension of potential side effects
• Use similar type styles and voice-overs when conveying benefits and
risks
• Not use contrasting colors to highlight information, nor alter the
location and timing of risk details and other factors that can influence
how well viewers understand a product
• Not use busy scenes, frequent scene changes and moving camera
angles “(that) can misleadingly minimize the risks of the product being
promoted by detracting from the audience's comprehension”
• Not speed up an announcer's description of risks
Draft Guidance for Industry Presenting Risk Information in Prescription Drug and Medical Device
Promotion , FDA, May 2009
Extensive Marketing
• Internet
– Many prescription and over-the-counter ads on a
variety of websites
• In-Store
– End caps, positioning on shelves, displays
• Marketing to youth including social media sites
like Facebook, e-mail and text messaging
• Word-of-mouth
One Example:
The Marketing of OxyContin
• Purdue Pharma introduced OxyContin in1996
• Targeted the highest prescribers for opioids across the
country
• Bonus system for sales reps ranging from $15,000 to
nearly $240,000 ($40 million total in 2001)
• Distributed 34,000 “starter” coupons
• Branded promotional items for physicians (fishing
hats, stuffed toys and music CDs)
The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,
American Journal of Public Health, February, 2009
The Marketing of OxyContin
• From 1996 to 2000, increased internal sales force
from 318 to 671
• Sales grew from $48 million in1996 to almost
$1.1 billion in 2001
• In 2001, the company spent $200 million to
market and promote OxyContin.
• By 2004 OxyContin had become a leading drug of
abuse in the United States
The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,
American Journal of Public Health, February, 2009
The Marketing of OxyContin
• Aggressively promoted OxyContin in the
“non-malignant” pain market which is much
larger than the cancer market.
• Minimized the worries about the risk of
addiction.
• From 1995 to 2001, the number of patients
treated for opioid abuse in Maine increased
460 percent.
The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,
American Journal of Public Health, February, 2009
The Marketing of OxyContin
• On May 10, 2007, Purdue Frederick Company Inc, an
affiliate of Purdue Pharma, along with 3 company
executives, pled guilty to criminal charges of misbranding
OxyContin by claiming that it was less addictive and less
subject to abuse and diversion than other opioids, and
• They were ordered to pay $634 million in fines.
• The 3 executives have been barred from doing business
with Medicare or any taxpayer-funded healthcare program
for 12 years.
The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,
American Journal of Public Health, February, 2009
And the Results Are…
The amount of five major painkillers sold at retail
establishments rose 90 percent between 1997 and
2005.1
– More than 200,000 pounds of codeine, morphine,
oxycodone, hydrocodone and meperidine were
purchased at retail stores in 2005
– enough to give more than 300 milligrams of painkillers
to every person in the country
Hydrocodone with acetaminophen was the most commonly
prescribed drug in 2008 - 124 million retail prescriptions.2
1. Associated Press analysis of Drug Enforcement Administration data, August 2007
2. IMS National Prescription Audit, IMS Health, 2010
And the Results Are…
• US residents have more than tripled their spending
on prescription pain killers for outpatient use from
$4.2 billion in 1996 to $13.2 billion in 20061.
• The average amount spent per pain killer purchase
more than doubled during the same period, from
$26 to $571.
• The percent of treatment admissions involving
prescription pain relievers more than quadrupled
from 2.2% in 1998 to 9.8% in 2008.2
1. Agency for Healthcare Research and Quality, Published in JAMA, March 25, 2009
2. Treatment Episode Data Set (TEDS); Substance Abuse and Mental Health Services Administration, 2010
And the Results Are…
• More than 19 million prescriptions for ADHD
drugs were filled in 2002
-up 72 percent from 1995.1
• Use of antidepressant drugs in the United States
doubled between 1996 and 2005,
– 6% or 13 million people in 1996
– 10% or 27 million people in 20052
1. Prevention Alert Volume 6, Number 4, Center for Substance Abuse Prevention, 3/7/03
2. Archives of General Psychiatry, August 2009
And the Results Are…
From 2000-2004 prescription use of ADHD drugs
among adults ages 20-44 doubled.
During the same period prescription use of ADHD
drugs rose:
• 113 percent among women 20-44,
• 104 percent among women 45-64,
• 56 percent among youth, and
• Sales increased from $759 million to $3.1 billion.
Medco Health Solutions, September 2005
And the Results Are…
• More than 164 million prescriptions were written
in 2008 for antidepressants, totaling $9.6 billion in
U.S. sales, according to IMS Health
• Promotional spending for antidepressants
increased slightly between 1999 ($0.98 billion)
and 2005 ($1.02 billion),
– But, there was a marked increase in the percentage of
spending on direct-to consumer advertising, from 3.3
percent ($32 million) to 12 percent ($122.00 million)
Archives of General Psychiatry, August 2009
And the Results are…
• 81 percent of American children who visited a doctor for
help combating sleep problems were given some form of
prescription medication, despite the fact that no sleeping
pills are currently approved for use in children
• 7 percent of the patients were recommended diet and
nutritional counseling,
• 22 percent were offered behavioral therapy
• 17 percent of patients were offered mental health and stress
management treatment
Milap C. Nahata, Pharm.D., Gregg Jacobs, M.D., Sleep, Aug. 1, 2007
And the Results are…
ED visits caused by misuse of pharmaceuticals are
rapidly increasing while visits caused by illicit
drugs remain steady.
Estimated ED visits from all drug use was:
• 1.6 million in 2004
– 1 million were from illicit drugs
• 2.3 million in 2009
– 1 million were from illicit drugs
Substance Abuse and Mental Health Services Administration (SAMHSA) 2011
And the Results are…
• Unintentional poisoning deaths (95% are drug
overdoses) increased from 12,186 in 1999 to 26,389 in
2006.
• During that time, prescription drugs overtook cocaine
and heroin combined as the leading cause of lethal
overdoses
• Opioid painkillers were involved in more than half the
deaths,
– but deaths from drugs such as sleeping pills, antidepressants,
and tranquilizers increased 84 percent during the same
period.
Centers for Disease Control and Prevention, 2008 and 2010
And the Results are…
• The leading cause of accidental poisonings among
American children can be found in the family medicine
cabinet.
• More than 71,000 children 18 and younger are seen in
emergency rooms annually for unintentional overdoses of
prescription and over-the-counter drugs.
• More than two-thirds of emergency department visits are
due to poisoning from prescription and over-the-counter
medications -- more than double the rate of childhood
poisonings caused by household cleaning products, plants
and the like.
American Journal of Preventive Medicine , September 2009
And the Results Are…
• A vast array of pharmaceuticals -- including antibiotics,
anti-convulsants, mood stabilizers and sex hormones -have been found in the drinking water supplies of at least
41 million Americans
• The presence of prescription drugs -- and over-the-counter
medicines such as acetaminophen and ibuprofen could
have long-term consequences for human health.
• Bottled water and home filtration systems don't necessarily
avoid exposure. They do not typically treat or test for
pharmaceuticals, according to the industry's main trade
group.
Analysis of scientific reports and public water system databases by Associated Press, March 2008
Prevention Strategies
• Primary prevention – A drug is a drug is a drug!
• Use a comprehensive approach
– Educate everyone
• Youth, families, older adults, providers, pharmacists, merchants
• Use consistent and persistent messages
– Make substances less accessible
• Secure prescription and OTC medications at home and in stores
• Encourage and make easy disposal of unused medications
• Address Internet availability
– Examine norms
– Implement and enforce policies
• Enforce laws about use and possession including operating vehicles
under the influence
Prevention Strategies
Address issues like mental health, obesity,
stress and performance in healthy,
appropriate ways:
– Treatment and therapy
– Healthy choices
Resources
• Minnesota Prevention Resource Center
http://www.emprc.org/ or 800/782-1878 or
763-427-5310
• National Institute on Drug Abuse
www.nida.nih.gov
• Prevention Online www.health.gov
• Minnesota Department of Health
www.health.state.mn.us/alcohol
Resources
• Do the Right Dose
http://asyouage.samhsa.gov/dotherightdose/
• Minnesota Pharmacists Association
www.mpha.org
• Medline Plus (drugs, supplements, and herbal
information)
www.nlm.nih.gov/medlineplus/druginformatio
n.html
Contact Information
Jay Jaffee
[email protected]
651-201-5496
Or go to our website:
www.health.state.mn.us/alcohol