Transcript PPT - Beth Rutkowski, MPH

Epidemiological Update on the
Prescription Drug Abuse
Problem
Beth A. Rutkowski, M.P.H.
ILC Call – June 27, 2012
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs
UCLA David Geffen School of Medicine, Dept. of Psychiatry
Goals of the ILC Call
• As a result of participating in this ILC call,
you will be able to:
– Describe the scope of prescription/over-thecounter drug abuse and list key at-risk
populations
– Discuss various strategies to prevent
prescription drug abuse
Prescription (Rx) Drug Abuse:
What’s the Problem?
What is Misuse?
• Misuse = “Non-medical use” or any use
that is outside of a medically prescribed
regimen
• Examples can include:
–
–
–
–
–
Taking for psychoactive “high” effects
Taking in extreme doses
Mixing pills
Using with alcohol or other illicit substances
Obtaining from non-medical sources
Prescription Drugs are
Easy to Obtain
• Easily obtainable from family, friends, and
health care professionals (doctors, dentists,
pharmacists)
• Medicine cabinets are likely source
• Internet – online pharmacies
– Credit card number + access to computer
– No prescription necessary
– Inappropriate identify verification
• Unsafe storage and improper disposal
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Methods of Prescription Diversion:
Four Major Pathways
– Pharmaceuticals manufactured lawfully, but
stolen during distribution
– Medications obtained inappropriately from
legitimate end-users
– Fraudulent prescriptions written on stolen
prescribing pads
– “Doctor shopping” (e.g., a method where
individuals see several doctors in an attempt
to obtain multiple prescriptions without
revealing what they are doing).
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
The Prescription Drug Epidemic is
Unique in Some Ways
• Prescription drugs are not inherently bad
• When used appropriately, they are safe and
vitally needed
• Threat comes from misuse, abuse, and
diversion
• Just because prescription drugs are legal
and are prescribed by an MD, they are not
necessarily safer than illicit substances.
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Factors Fueling the Epidemic
• Increase in legitimate commercial production
and distribution of pharmaceuticals
• Increase in marketing to physicians and
public re: pain medications
• Physicians have become more willing to
prescribe medications, esp. for pain
management
• 150% increase in prescriptions written for
controlled drugs
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Slang Terms
•
•
•
•
•
•
•
•
•
Xbrs / Xanibars (Xanax)
Vic (Vicodin)
Skittles / Triple C’s
Trail Mix
Pharm Party
Parachuting
Smurf Snot
Smurf Coke
Others?
The Fateful Triangle: Pain and
Prescription Opioid Abuse
• Under treatment of pain
•
•
•
•
Increasing availability of opioid analgesics
Increased production and distribution
Increase in the number of prescriptions filled
Increased internet availability
• Increase in abuse of prescription opioids
Twin Epidemics: Prescription Drug
Abuse and Unrelieved Pain
• 50 million Americans live with chronic pain
• An additional 25 million live with acute pain
• Mismanagement of pain has far reaching
societal consequences.
• In fighting illicit misuse, must not hinder
patients’ access to beneficial medical
treatments.
• Prescription drugs are potent and must be
monitored and managed appropriately (N.
Katz, Tufts University).
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Nature of the Link Between Increasing Opioid
Prescribing for Non-cancer Pain and Abuse
Trends in opioid prescribing (2000 and 2005) with
and without MH and SUDs
Insured
• 34.9% with an MH or SUD
• 27.8% without MH and SUD
Arkansas Medicaid
• 55.4% with an MH or SUD
• 39.8% without an MH or SUD
Insured
AR Medicaid
Nature of the Link Between Increasing Opioid
Prescribing for Non-cancer Pain and Abuse
• Chronic use of prescription opioids for NCPC is
much higher and growing faster in patients with MH
and SUDs than in those without these diagnoses
• Clinicians should monitor the use of prescription
opioids in these vulnerable groups to determine
whether opioids are substituting for or interfering
with appropriate MH and substance abuse
treatment
Edlund, Mark et al, Clinical Journal of Pain 2010
Aberrant Drug-Taking Behaviors
Probably more predictive Probably less predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing another
patient’s drugs
• Injecting oral formulation
• Obtaining prescription drugs
from non-medical sources
• Concurrent abuse of related
illicit drugs
• Multiple unsanctioned dose ↑ s
• Recurrent prescription losses
Passik and Portenoy, 1998
• Aggressive complaining about
need for higher dose
• Drug hoarding during periods
of reduced symptoms
• Requesting specific drugs
• Acquisition of similar drugs
from other medical sources
• Unsanctioned dose escalation
1 – 2 times
• Unapproved use of the drug
to treat another symptom
• Reporting psychic effects not
intended by the clinician
Safe Drug Disposal
Americans turned in 276
tons of unwanted or expired
medications during the 4th
National Prescription Drug
Take-Back Day on 4/28/12.
Drugs were collected at
5,659 sites around the country.
The DEA has removed more than 1.5 million
pounds, or 774 tons of medication from
circulation since the first take-back event in 2010,
according to the Associated Press.
Safe Drug Disposal
– Medicine Take-Back Programs
• Contact household trash and recycling service or pharmacist
– Disposal in Household Trash
• Mix medicines with an unpalatable substance such as kitty
litter or used coffee grounds
• Place the mixture in a container or sealed plastic bag
• Throw the container in your household trash
– Flushing of Certain Medicines
• A small number of medicines that are especially harmful if
misused
• Includes Opioid Medications
• FDA has a list of Medications that should be flushed
• Studies now showing that does not significantly impact
water
Safe Drug Disposal
Throwing unused prescription drugs in trash
may be best for environment: A new study
– Throwing away unused prescription drugs in the trash
may be the most environmentally friendly option.
– The researchers compared the environmental impact
of flushing medication, throwing it in the trash, and
burning it.
– The study took into account how much of the drugs
would enter the environment, as well as emission
impacts from water treatment, transportation and
burning of waste materials.
Safe Drug Disposal
Throwing unused prescription drugs in trash
may be best for environment: A new study
– Flushing allows the highest levels of drugs to enter the
environment, and creates more air pollution.
– Drug collecting and burning produce far greater
emissions of greenhouse gases and other pollutants,
largely due to the travel required for people to come to
drop-off points, and to ship drugs for incineration.
– Throwing drugs out at home, uses an infrastructure
that already exists for collecting household trash.
Federal Drug Schedules
Federal Controlled Substances Act (CSA) of 1970
• Schedule I: No medical use, high abuse potential
(heroin)
• Schedule II: Accepted medical use, high abuse
potential (OxyContin, Ritalin)
• Schedule III: Accepted medical use, less abuse
potential than I or II (Vicodin)
• Schedule IV: Accepted medical use, less abuse
potential than I-III (Valium, Xanax)
• Schedule V: Accepted medical use, lowest abuse
potential (Robitussin AC)
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Commonly Misused Rx Drugs
Classified in 3 classes
– Opiates: pain-killers
• Ex) Vicodin, OxyContin, Tylenol
Codeine
– CNS Depressants
(Sedatives/Tranquilizers):
treat anxiety and sleep disorders
• Ex) Xanax, Ativan, Valium, Soma
– Stimulants: ADHD, weight loss
• Ex) Aderall, Ritalin, Concerta,
Dexedrine, Fastin
Media Attention
A Global Look at Drug Abuse:
World Drug Report, 2010
SOURCE: UNODC, World Drug Report, 2010.
Drug Prevalence in the
United States
• Marijuana = most commonly abused illicit
drug
• Non-medical use of prescription drugs = 2nd
most commonly abused drug category
• Prescription drug abuse is 3x more prevalent
than illicit use of cocaine, crack, and
hallucinogens
SOURCE: CA ADP, PDM Summary Report, 2009.
Past Year Non-Medical
Psychotherapeutic Use: 2007 vs. 2010
6
2007
2010
5
4
3
2
1
0
Pain Relievers
Tranquilizers
Stimulants
Sedatives
SOURCE: SAMHSA, NSDUH, 2010 Results.
Percentage of US Population with
Past Month Drug Use
SOURCE: SAMHSA, NSDUH, 2010 Results.
Percentage of US Population with
Past Month Use of Pharmaceuticals
SOURCE: SAMHSA, NSDUH, 2010 Results.
Number of New Non-medical Users of
Therapeutics
SOURCE: SAMHSA, NSDUH, 2010 results.
Specific Drug Used When Initiating Drug
Use: NSDUH, 2010
SOURCE: SAMHSA, NSDUH, 2010 Results.
Substance Use and Dependence:
NSDUH, 2010
SOURCE: SAMHSA, NSDUH, 2010 Results.
Treatment Admissions for Primary
Prescription Drug Abuse: U.S.
Opiates/Synthetics
Tranquilizers
Stimulants
Sedative/Hypnotics
8
7
6
(Percent of All Admissions)
5
4
3
2
1
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
SOURCE: SAMHSA, Treatment Episode Data Set, 2009 results.
Californians in Treatment
34%
20%
SOURCE: CA ADP, Fact Sheet: Californians in Treatment, FY 2007-08.
Californians in Treatment
Primary Drug by Gender at Admission
16.9%
18.3%
Alcohol
Female
Male
10.0%
11.0%
Cocaine
10.8%
12.5%
Heroin
12.9%
Marijuana
19.3%
44.8%
Methamphetamine
35.8%
4.5%
3.1%
Other Drug
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
Percent
SOURCE: CA ADP, Fact Sheet: Californians in Treatment, FY 2006-07.
Prescription Drug-Related
Emergency Department Visits
• Out of 4.5 million drug-related ED visits in 2009:
• 1.1 million associated with non-medical use of
prescription drugs (24.6% of all drug-related
visits)
• Pain relievers (47.8%) were the most
common type of medications involved in
medical emergencies associated with
nonmedical use of pharmaceuticals.
• Pain relievers seen more commonly
were oxycodone (13.7%), hydrocodone
(8.0%), and methadone (5.8%).
SOURCE: SAMHSA, Drug Abuse Warning Network, 2009 Results.
Prescription Drug Use
Among Teens
Young Brains Are Different
from Older Brains
 Alcohol and drugs affect the brains of
adolescents and young adults differently than
they do adult brains
– Adolescent rats are more sensitive to the
memory and learning problems than adults*
– Conversely, they are less susceptible to
intoxication (motor impairment and
sedation) from alcohol*
 These factors may lead to higher rates of
dependence in these groups
*Hiller-Sturmhöfel., and Swartzwelder (NIAAA Publication 213)
Prescription Drug Abuse among
U.S. High School Seniors
• More than 12% of high school seniors said they
had used opioid-based prescription drugs for
non-medical purposes at least once in their
lifetime.
• Eight percent did so within the past year.
• Reasons for use included: to relax, relieve
tension, get high, experiment, relieve pain, or
have a good time with their friends.
• Those who used the drugs for reasons other
than pain relief were more likely to use other
addictive drugs and have signs of addictive
disorders.
SOURCE: Join Together Online, August 6, 2009; NIDA, MTF Survey, 2008.
Past Month Drug Use among 12-17 Year Olds
SOURCE: SAMHSA, NSDUH, 2010 Results.
Age Distribution of Prescription
Drug Misuse in the Past Year
SOURCE: SAMHSA, NSDUH, 2006 Results.
Generation Rx
• Rx/OTC med abuse has penetrated teen culture
and remains high and relatively unchanged
–
–
–
–
17% report lifetime abuse of Rx medicines
12% report lifetime abuse of OTC cough/cold medicine
10% report past year abuse of Vicodin or OxyContin
64% agree that “anyone can access Rx medicines in
the medicine cabinet (up from 50%)
– Fewer parents report communicating the risks of
getting high
– More than 1 in 10 parents (15%) say they’ve used an
Rx medication not prescribed for them at least once in
the past year (a 25% increase from 2010).
SOURCE: PDFA, Participant Attitude Tracking Study, 2011 Results.
Sources Where Pain Relievers were Obtained:
Past Year Non-Medical Users Aged 12 or
Older: 2010
4.8%
Friend/Relative for Free
Bought from Friend/Relative
Took from Friend/Relative
Prescription from One Doctor
From Drug Dealer or Stranger
From Internet
Other/unknown
17.3%
11.4%
4.4%
0.4%
6.7%
55.0%
SOURCE: SAMHSA, NSDUH, 2010 results.
Over-the-Counter Drug Misuse
among Young Adults
• 3.1 million 12-25 year olds reported lifetime use of
OTC cough and cold medications to get high
• 1 million reported past year use
• Even gender distribution
• Female 12-17 year olds more likely to misuse OTC
drugs than male counterparts
• 82% of lifetime OTC drug users also reported
lifetime use of marijuana
• Lower rates of lifetime use of hallucinogens,
ecstasy, or inhalants
SOURCE: CA ADP, Rx Drug Summary Report, 2009.
Lifetime AOD Use in 9th & 11th grades,
2007 vs. 2009
47
46
Alcohol
63
25
27
Marijuana
66
42
41
4
4
4
3
Methamphetamine
4
Ecstasy
6
Grade 9 %
2007-08
8
Grade 9 %
2009-10
11
18
18
Prescription Drugs
Grade11 %
2007-08
23
22
Grade11 %
2009-10
29
27
Total Drugs Except Marijuana
33
36
37
36
Total Drugs*
50
48
54
54
Total AOD
67
0
10
20
30
40
50
60
70
70
80
SOURCE: WestEd, California Student Survey, 14th Biennial Survey (2009-10).
Current (Past 30 Days) Use
2007 vs. 2009
27
24
Alcohola
42
37
16
12
Binge Drinkingb
29
23
Grade 9 %
2007-08
15
Grade 9 %
2009-10
14
Marijuana
24
24
Grade11 %
2007-08
Grade11 %
2009-10
4
4
4
3
Methamphetamine
18
17
Any illegal drug or pill
26
27
0
10
20
30
40
50
SOURCE: WestEd, California Student Survey, 14th Biennial Survey (2009-10).
Total Lifetime AOD Use and Recreational
Cold/Cough Medicine
54
54
Total AOD
70
67
Grade 9 %
2007-08
26
Grade 9 %
2009-10
21
Over the Counter Cold/Cough Medicine
25
Grade11 %
2007-08
23
Grade11 %
2009-10
60
58
Total AOD and Cold/Cough Medicine
74
70
0
10
20
30
40
50
60
70
80
Prescription Drug Use
Among Older Adults
Potential Issues for Older Adults
• Prescription drug abuse begins with misuse due
to inappropriate prescribing or lack of
compliance
• Age-related physiological changes (metabolism
and response)
• Greater likelihood of undiagnosed psychiatric
and medical comorbidities
• Difficulties with complying with complex drug
regimens
• Drug interactions
SOURCE: CA ADP, Rx Drug Summary Report, 2009.
Rx Drug Abuse among Older Adults
• Older Adults account for 13% of US population
but use 1/3 of all medications prescribed.
• 7.2 million (21.7%) receive at least 1 Rx annually.
• Older adults use Rx drugs 3 times more than the general
population.
• On average, older persons take 4.5 medications per day.
• Nationally, 9.2 million (4.9%) of older adults abused Rx
drugs in the last year while in California, 812,000 (3.7%).
SOURCES: SAMHSA, 2006; NIDA, 2005
Preventing Prescription
Drug Abuse
Existing Campaigns
–
–
–
–
–
–
–
Above the Influence, Nat’l Youth Anti-Drug Media
Campaign, Parents – the Anti-Drug (ONDCP)
SAMHSA’s Prevent Prescription Drug Abuse
The Buzz Takes Your Breath Away Permanently
(FDA)
A Family Guide to Keeping Youth Mentally Healthy
and Drug Free (SAMHSA)
Community Prevention Initiative
• Prevention Tactics
• My Prevention Community – free social utility
network
Partnership for a Drug-Free America
Local Campaigns?
ONDCP’s Prescription Drug
Abuse Prevention Plan
• 4 elements to the Administration’s approach
to reducing Rx drug abuse:
– Education (e.g., proper Rx opioid prescribing
practices, parent/patient education, naloxone
education)
– Monitoring (e.g., PDMPs)
– Disposal (e.g., Secure and Responsible Drug
Disposal Act of 2010, Rx Drug Take Back Days)
– Enforcement (e.g., pill mills, rogue pharmacies,
illegal pain clinics)
SOURCE: ONDCP, 2012 Nat’l Drug Control Strategy (p. 46-50).
Key Roles in Preventing
Prescription Drug Abuse
• Physicians and Other Health Care Providers
– Screen appropriately
– Help patients recognize potential problems
– Note changes in increases in amount of
medication needed or unscheduled refill
requests
– Be aware of “doctor shopping”
SOURCE: NIDA Research Report Series, 2005.
Assessing Potential Prescription
Drug Abuse: Four Simple Questions
• Have you ever felt the need to cut down on
your use of prescription drugs?
• Have you ever felt annoyed by remarks
your friends or loved ones made about your
use of prescription drugs?
• Have you ever felt guilty or remorseful
about your use of prescription drugs?
• Have you ever used prescription drugs as a
way to "get going" or to "calm down?"
SOURCE: About.com, 2009.
Key Roles in Preventing
Prescription Drug Abuse
• Pharmacists
– Information on appropriate use of medication
– Side effects and interactions
– Monitor prescriptions for falsification or
alterations
– Be aware of “doctor shopping”
SOURCE: NIDA Research Report Series, 2005.
Key Roles in Preventing
Prescription Drug Abuse
• Patients
– Follow prescribed directions
– Be aware of drug interactions
– Discuss dosing changes or cessation of use with
prescribing physician
– Disclose use of all medications and dietary
supplements
SOURCE: NIDA Research Report Series, 2005.
Role of
Medical Community
• An estimated 70 percent of
Americans (approx 191million)
visit their primary care physician at
least once every two years.
• Care for patients by prescribing needed
medications
• Identify prescription drug abuse when it
exists
• Help patients recognize abuse problems
• Support patients in seeking appropriate
treatment.
Role of Prescription Drug
Monitoring Program
Community
• Collection and analysis of
controlled substance data
• Identification and investigation
of illegal prescribing,
dispensing and procurement
• Physician access can help decrease
extent of doctor shopping
• Operational in 37 states
CURES: CA’s Prescription Drug
Monitoring Program
• Name: Controlled Substance Utilization Review
and Evaluation System (CURES)
• Overseen by: CA Dept. of Justice, Bureau of
Narcotic Enforcement
• Schedules Monitored: II, III, and IV
• Number of Prescriptions Collected Annually:
21 million (100 million entries to date)
• Number of Controlled Substance Dispensers:
155,000
• Website: http://caag.state.ca.us/bne/trips.htm
For more information, contact:
Beth Rutkowski, MPH
[email protected]
www.psattc.org
www.uclaisap.org
Thank you for your time
and attention!