Transcript Adult Prescription Drug Abuse

Prescription Drug Abuse
Steve Hanson
Director, Bureau of Treatment
NYS OASAS
Why Prescription Drugs
• They work
• They are fairly easily available
• The culture of Prescription Drugs
– Advertising
– Patient Expectations
– Pharmaceutical Company Promotion
• The Internet
• The Mail
Basic Facts
• 48 million (age 12 and over) used Rx meds for nonmedical purpose - 20% of U.S. population
• 2007 – 1.9 million ED visits related to Drug
misuse/abuse (DAWN report)
• 31% - 582,000 – Rx drugs alone
• 8% - 144,000 – Rx drug + illicit drugs
• 10% - 189,000 – Rx + alcohol
• 52% - 611,000 – involved Rx drugs
Non Medical Use of Rx ED Visits
Per 100,000 (2007)
ED Visits Non-Med use of Rx Drugs
2004-2005
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0
2004
2005
2006
2007
Past Month Illicit Drug Use among Persons
Aged 12 or Older: 2009
Past Month Use of Selected Illicit Drugs among
Persons Aged 12 or Older: 2002-2009
Past Month Use of Selected Illicit Drugs among Young Adults
Aged 18 to 25: 2002-2009
Past Year Initiates of Specific Illicit Drugs among
Persons Aged 12 or Older: 2009
Past Month Nonmedical Use of Types of
Psychotherapeutic Drugs among Persons Aged 12 or
Older: 2002-2009
ED visits non-med use of Rx drugs
Source Where Psychotherapeutics Were Obtained for
Most Recent Nonmedical Use among Past Year Users
Aged 12 or Older: 2005
Percent of Past Year Users
100
Other
Bought on
Internet
80
Drug Dealer/
Stranger
60
1 or More
Doctors
40
Bought/Took
from Friend/
Relative
Free from
Friend/Relative
20
0
Pain Relievers
Tranquilizers
Methamphetamine
Stimulants
8
Two “Types” of Rx Drug Abusers
• The Drug Abuser who
likes Rx drugs.
– Frequently use other
drugs (cocaine, alcohol,
heroin, other non-Rx
drugs)
– Fits the “model” of a
drug abuser.
– “addicted” to high
• The Patient who
becomes dependent on
their medication
– Infrequent use of other
substances – unless can’t
get Rx.
– Don’t fit “model” of drug
user – age, other
behaviors.
– “dependent” on the
drug
Addiction vs. Dependency
• Addiction – use the drug for the high,
euphoria
• Dependent – use the drug to avoid withdrawal
effects
• Can be both
Commonly Abused Rx Drugs
• Opiates/pain killers
• Depressant/anti-anxieties
• Stimulants
Nonmedical Use of Pain Relievers in Past Year among Persons
Aged 12 or Older, by Substate Region: Percentages,
Annual Averages Based on 2004-2006
The Action of
Opiates
Natural Pain Suppression
Artificial Pain Suppression
Opiate Effects
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Analgesia - change in pain perception
Euphoria - whole body orgasm
Sedation - “on the nod”
Respiratory Depression - OD
Cough Suppression
Nausea/vomiting
Constipation
Tolerance
• Rapid tolerance with continued use
• Cell sensitivity thought to be the tolerance
mechanism.
• User now needs to find additional amounts
• Multiple doctors
• Asking friends/relatives
Addiction/Dependency
• Opioids trigger reward system – euphoria –
leads to continued use – addiction
• Withdrawal symptoms are significant – regular
use to avoid withdrawal - dependence
Withdrawal
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Pain
Depression
Alert
Rapid Breathing
Coughing
Nausea/Vomiting
Diarrhea
3-5 days
Oxycontin
• Oxycodone – synthesized from thebaine (part
of opium)
• Oxycontin – 1995
– Crush the tablet for quicker high
– Oral, snort, inject
• Percocet – oxycodone & acetominophen
• Percodan – oxycodone & aspirin
Vicodin
• Hydrocodone and acetominophen
• Lorcet, Lortab
• Schedule III – high psychological/medium
physical
• Pain and post-surgical use (pain)
Issues with Rx Opiate Dependence
• Presence of real pain
• “I’m addicted to vicodin, not alcohol, why do I
have to quit that too?”
• Drug Testing – make sure you test for drug of
choice as well as alternatives.
Anti-anxietals/Anxiolytics
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Panic Disorder
Phobias / social phobia
Obsessive Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Generalized Anxiety Disorder
The neuroses – treated by Freud
Benzodiazepines
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Share a chemical structure
Librium – 1960
Valium - #1 Rx drug 1972-78, 3x #2
Xanax
Ativan
Very profitable
Benzodiazepines
Very Long Acting
Halazepam (Paxipam)
Prazepam (Centrax )
Flurazepam (Dalmane )
Short Acting
Alprazolam (Xanax )
Temazepam (Restoril )
Oxazepam (Serax )
Lorazepam (Ativan )
Intermediate Acting
Very Short Acting
Clonazepam (Klonipin )
Triazolam (Halcion )
Chlordiazepoxide (Librium )
Diazepam (Valium )
Effects of Benzodiazepines
Anxiety control (e.g., panic attack)
Relaxation
Drowsiness & sleep
Control seizures
Reduced muscular coordination
Dulled physical sensations
Tolerance to effects develops
Benzodiazepines (cont.)
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Action – most increase GABA
Safe – Ld very high
Anticipation/placebo effect
Problems – work so well, people don’t want to
stop.
• Side effects – dose related – cognitive
impairment, amnesia, slurred speech
• Long Withdrawal
Drug Court/Treatment Issues
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People with true anxiety disorder
Anxiety can be a major relapse trigger
Stressful situations in early recovery
Strong craving for relief
To medicate or not to medicate…
Why Prescription Drug Users May Believe
That They Are “Different”
• “I had/have real pain, I wasn’t using these to
get high like those drug addicts”
• “My doctor prescribed these for me. It wasn’t
my idea”
• “I never robbed anyone or did those things
that addicts do.”
• “I have to take something for this pain!”
What the Rx Drug User Might Have Trouble
Relating To
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“Hitting Bottom”
Changing People, Places & Things
Change your “Lifestyle”
You must be completely abstinent from
everything else – alcohol included
• Going to meetings all of the time.
Drug Court/Treatment Issues
• Urine testing – ensuring that the panel used
includes the drugs that the participants take
• Medication needs – people suffering from a
medical/psychiatric condition that needs to be
medicated – which medications are “okay”
• Withdrawal risks
COMMUNITY SUPERVISION
• Difficult population to supervise
• Unique strategies of supervison
• Training needs of the supervision officer.
Supervision
• Must be unrelenting in the monitoring of
prescription drug use
• All prescriptions must be reported
• Must work with physician to determine need
for medication.
• Connect with addictionologist to monitor
withdrawal, medication assisted treatment,
and on-going pain treatment.
Letter for Physician
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To Medical Treatment Provider/Doctor:
Your patient, ___________________________ is a participant in the Drug Court Program, a
court ordered substance abuse treatment program. He/She has been assigned to this
program due to ongoing and significant substance dependence.
Your patient has provided documentation indicating that you have prescribed medication
with addictive properties as part of his/her treatment. Please verify your knowledge and
approval of this patient’s prescribed medication and that you feel the current course of
treatment is necessary and no other alternative form of treatment exists.
To ensure that this is a valid prescription and you have received this letter, the participant
must return this letter with the information below completed.
Physicians Name_________________________________ (Please print and/or type)
Address
___________________________________
Phone Number___________________________________
DEA# _________________________________________
Signature_______________________________________
Sincerely,
Supervision
• Monitoring prescription pills.
• Random searches of person and property.
• Monitor DEA database to determine multiple
prescriptions.
• Obtain release of information from each
physician to facilitate communication between
Dr. and team.
Supervision
• On-going communication between
supervision officer and treatment
• Monitoring of drug use through random,
frequent drug testing
• Not only testing for illegal drug use, but for
MAT drugs.
Skills for Supervision Officer
• Must understand the disease model of
addiction.
• Be aware of relapse signs and/or triggers.
• Motivational Interviewing- to engage clients
buy in, by developing discrepancies and
gauging client’s readiness to change.
Skills of Supervision Officer
• Clear communication with treatment provider.
• Provide immediate sanction/incentive for
each drug test.
Opiate Addicts in Drug Court
• Decision must be made by entire team that
the person will be allowed in the program.
• Understanding that some clients will be on
pain medication for the rest of their lives, and
our job is to monitor that client is taking
medicine as prescribed.
Opiate Addicts in Drug Court
• This population is a growing threat to the safety of
our community. The availability of prescription drugs
and the on-going abuse must be addressed.
• Drug Courts are here to change the lives of addicts,
while offering protection to the community through
accountability and on-going collaboration of the
courts and treatment.
• While the opioid client is difficult to monitor,
choosing to not deal with them is not the
answer.
• Drug Courts must continue to develop
methods to monitor these clients and not
allow them to go unsupervised just because
they are hard to monitor.