Pharmageddon: The Rx Drug Abuse Crisis

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Definitions

What are the most commonly abused prescription drugs?

• Physical dependence: Body adapts to the presence of a drug in which abrupt stopping results in withdrawal. • Psychological dependence: A behavioral pattern characterized by a compulsion to obtain a drug for mood altering effects. • Tolerance: User needs to take more drug to have the desired effect. • Withdrawal: Specific symptoms occur after user stops taking the drug.

1-800-222-1222

Legal basis by which the manufacture, importation, possession, and distribution of certain drugs are regulated by the federal government (1970)

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• Schedule I - high abuse potential, no medical use • Schedule II - high abuse potential, severe dependence liability • Schedule III - less abuse potential, moderate dependence • Schedule IV - limited dependence liability • Schedule V - limited abuse potential

I:

heroin, marijuana, mescaline, methylfentanyl (China White), GHB, LSD, MDMA (Ecstasy), cathinone (khat), methcathinone, psilocybin, Psilocyn, AMT, DMT, 5-MeO-DIPT (foxy), 2C-T-7, BZP, 2 synthetic cannabinoids, 6 synthetic cathinones

II:

oxycodone, amphetamine, cocaine, fentanyl, PCP, Ritalin, methadone, morphine

III:

hydrocodone, anabolic steroids, ketamine, buprenorphine, some codeine products

IV:

Rohypnol (penalties Schedule I), Xanax, Valium, Darvon, Talwin

V:

Phenergan, Lomotil (diphenoxylate), pseudoephedrine Tramadol (Ultram®) is not currently controlled under the CSA

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Not Just Celebrities

Why the increase?

• Deaths caused by Rx drugs now exceed those caused by cocaine, heroin, and methamphetamine combined • “Drug deaths” now exceed deaths by MVAs • More teens abuse prescription drugs than any illicit drug except marijuana

• Acceptability • Accessibility • Availability  72%  in Rxs filled between 1997-2007

• Desire to eliminate unpleasant emotions or stresses • Initiation of Rx drug patterns resulting from medical treatment • “Consumerism”

What is “Pharming?”

Access to Rx drugs

Kids getting high using Rx or OTC drugs

Friends & relatives Internet

Drug dealer

Vicodin

Doctor Andro

Source: SAMHSA, 2008 National Survey on Drug Use and Health (Sept 2009)

Warnings Signs • Pills in medicine cabinet disappearing • Continually “losing” prescriptions • Seeking prescriptions from >1 doctor • Taking higher doses despite warnings • Stealing, forging or selling prescriptions • Excessive mood swings • Sudden drop in performance (school or work) • Weight loss, agitation, insomnia (stimulants)

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Creatine

CNS Depressants • Drugs that depress the overall functioning of the Central Nervous System (CNS) to induce sedation, muscle relaxation, and drowsiness. • Includes: - Alcohol - Opiates/Opioids - Predatory Drugs - Sedatives

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Drugs in Combination Additive Effect: When drug combinations produce the same response as the sum of the drugs individually. 1 + 1 = 2 (ex. benzo + barb before surgery to relax patient)

Classes of Opioids • Endogenous opioids: naturally produced in the body (endorphins) • Naturally occurring from plants: opium alkaloids, such as morphine and codeine • Semi-synthetic: created from natural opiates

Synergism: When two drugs are taken at the same time, their combined effect is greater than the sum of their individual effects.

• Fully synthetic: drugs made in a laboratory which cause the same effect as opium

1 + 1 = 5 (ex. alcohol + opiate could cause coma or death)

• Substances with opioid action: salvia and kratom

Opioid Analgesics (Painkillers)

Opioids

• Morphine1

• Hydrocodone3

• Potent analgesics; widely prescribed

• Codeine1, 3

• Methadone3

• Tolerance develops very rapidly especially with frequent use

•

• Heroin2 •

Hydromorphone2

Propoxyphene3

• Buprenorphine3 • Fentanyl3

• Oxycodone3 1

Natural Semi-synthetic 3 Synthetic 2

Opioid Use and Abuse

• Relatively mild withdrawal syndrome (compared to alcohol/sedatives) • Classic triad of symptoms in overdose:  Respiratory depression  resp arrest  death  Central nervous system (CNS) depression  Constricted pupils (miosis)

Hydrocodone

• Has increased markedly since 1990

• Ex. Vicodin, Lorcet, Lortab

• Coincides with a controversial U.S. campaign against the undertreatment of pain  enormous increase in opioid Rxs

• Always combined with another med (acetaminophen, aspirin, or ibuprofen)

• U.S. has 4.6% of the world’s population but consume ~80% of the world’s opioids

• Often contains 5-10 mg HC + 325-750 mg acetaminophen (e.g. 5/500) • >130M prescriptions written in U.S. in 2010

• Americans consume 99% of the world’s supply of hydrocodone Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician. May-Jun 2009;12(3):507-15.

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Opiate + Acetaminophen (APAP) • Names ending in “cet” likely contains APAP  Percocet® (oxycodone + APAP) and Percodan® (oxycodone + aspirin)  Ultacet® (tramadol + APAP) and Ultram® (tramadol)  Fioricet® (butalbital, caffeine + APAP) and Fiorinal® (butalbital, caffeine, aspirin)  Lortab® and Lorcet® BOTH contain hydrocodone + APAP

Oxycodone

• Maximum amount of APAP in a prescription product will be limited to 325 mg; dosing parameters will not change • Deadline: January 14, 2014 • Manufacturers are modifying dosing and removing concentrated infant drops • J&J changed max dosing on Tylenol Extra Strength from 8 tabs/day (4 G) to 6 tabs/day (3 G); still advising not to exceed 4G/day

New OxyContin® Formulation

• Ex. Oxycontin, Percocet, Percodan, Tylox • AKA: “Pharmaceutical heroin” • Produced in a 12-hr timed-release tablet; 10-80 mg oxycodone is released • Abusers crush the pill to bypass the timerelease mechanism (outer layer) • Endocet and Percocet: contain 325 mg APAP + 5-10 mg oxycodone (APAP↓)

New OxyContin® Formulation* Strength

Changes to APAP Products

Color of tablet

10 mg

White

15 mg

Gray

20 mg

Pink

30 mg

Brown

40 mg

Yellow

60 mg

Red

80 mg

Green

• 500,000 people abused oxycodone in 2008 • April, 2010 FDA approves new formulation of controlled-release tab; available 08/15/10 • Drug is coated in a plastic-like polymer • Designed to discourage misuse and abuse by preventing med from being cut, broken, chewed, crushed or dissolved • Still can be abused by taking large doses

Tramadol (Ultram, Ultracet) • Unique synthetic opioid analgesic • Originally thought to have weak opiate effects and little potential for abuse (1995) • Only available non-scheduled opiate • Drug-drug interactions can occur (when combined with other serotoninergic drugs) • High doses can cause seizures

*Tablets changed from “OC” to “OP.” The number on each tablet corresponds to the milligram dosage.

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Morphine Sulfate • Ex. Roxanol, Kadian, MS Contin • Used to treat moderate to severe pain • Available as short-acting or extended release • Embeda®: MS and naltrexone (crushing or chewing tab may precipitate withdrawal in opioid-dependent individuals)

Methadone • Developed to treat heroin dependence; now widely prescribed for pain

Question I have a patient taking Tylenol with Codeine®. His urinalysis (UA) came back with 7500 ng/ml of codeine and 7267 ng/ml of morphine. Why would morphine show up in his urine? He denies taking morphine. Does Tylenol with Codeine® contain morphine?

Fentanyl • Ex. Duragesic, Actiq, Sublimaze, Abstral

• Much longer half-life than other opiates; does not provide a quick or potent high

• “Synthetic heroin”- 80 x stronger than morphine, faster acting than high grade heroin, lasts twice as long

• “Fastest Growing Cause of Narcotic Deaths” (New York Times 08/17/08)

• Manufactured illicitly as powder or tablets; often sold or mixed with heroin

• Benzos strengthen the depressive effect

• Not detected in routine drug screens

Buprenorphine • Ex. Subutex/Suboxone • Only drugs that can be prescribed in a physician’s office to treat opiate addiction • Suboxone contains buprenorphine and naloxone (if an abuser crushes and injects or snorts the tablet, naloxone precipitates withdrawal symptoms); still susceptible to abuse!

Benzodiazepines (BDZ)* • Most benzo names end in "pam" or "am“ (clonzepam/Klonopin, alprazolam/Xanax, lorazepam/Ativan, diazepam/Valium) • Used for anxiety, insomnia, alcohol withdrawal, skeletal muscle spasms, treat seizure disorders, inducing amnesia for uncomfortable procedures • Usually classified by how long effects last (ie. midazolam is short-acting; diazepam longacting) * Zolpidem: low toxicity, similar to BDZs

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Benzos cont’d • Rapid tolerance; highly addictive • Withdrawal may be severe (similar to alcohol): anxiety, panic attacks, insomnia, extreme dysphoria, seizures, psychotic behavior, suicide, death • Benzos + other CNS depressants (ex. EtOH, opioids) may lead to coma or death • Treatment is supportive/symptomatic care

Skeletal Muscle Relaxants • Commonly used in patients with low back problems, sprains & strains or other MSDs* • Soma (carisoprodol) can cause physical dependence; withdrawal s/s if stopped suddenly • Flexeril (cyclobenzaprine) • Robaxin (methocarbamol) • Abuse patterns, along with symptoms of and treatment for, are similar to that of benzo’s *MSD: musculoskeletal disorders •:

“Holy Trinity” • Prescriptions written for a drug cocktail:  Vicodin (hydrocodone)  Soma (carisoprodol)

Urine Testing for Drugs of Abuse* Alcohol Amphetamines Benzodiazepines Flunitrazepam Cannabinoids

 Xanax (alprazolam)

• AKA: “party pack", "Las Vegas Cocktail“ • Abusers say “imitates heroin rush”

Cocaine GHB Opiates Phencyclidine (PCP)

12-24 hrs 2-4 days 1-14 days 36 hrs Occ use 1-7 days Chronic use 1-4 weeks 12-48 hrs 4 hrs (blood) 12 hrs (urine) 1-3 days Occ. Use 1-8 days Chronic use up to 30 days

*Actual figures will vary due to metabolism, excretion, and laboratory.

DHHS Guidelines* (Workplace) 1. Marijuana (tetrahydrocannabinol or THC) 2. Cocaine (benzoylecgonine) 3. Opiate** 4. Phencyclidine 5. Amphetamines *Five mandated drugs of abuse for workplace drug testing, Department of Health and Human Services **Synthetic or semi-synthetic opioids are often excluded (ie. oxycodone, fentanyl, methadone)

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Stimulants • Increases basically every metabolic function (cardiovascular and CNS most vulnerable) • Rapid development of tolerance and high risk for dependence, binging • Causes euphoria,  alertness,  energy, elevated mood,  appetite, improved task performance, wakefulness/insomnia, initial sense of improved cognition

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Attention Deficit Disorder (ADD) AD/Hyperactivity Disorder Drugs •  diagnosis ADHD =  access to stimulants • S&S of ADHD are easily accessible online

ADD/ADHD Drugs • Most commonly abused: Adderall & Ritalin • Stimulants trigger an increase of dopamine:

 Pts know what to tell Dr in order to receive RX

 “messenger” that activates the rest of the cells in the brain to pay attention

• Taken to get high, lose weight or stay awake and  mental alertness (“neuroenhancement”)

 Makes person more alert, focused, interested, and motivated

• May be swallowed, or tabs crushed and snorted, or dissolved in water and used IV • Causes  vital signs, agitation, N/V, tremors

Chemical Structure

• AKA: “Study Pill,” “Ivy League Crack” • Schedule II drugs • Class B Felony

Dextromethorphan • Abused as a hallucinogen; similar to PCP and ketamine • >120 OTC products contain dextromethorphan (DM or DXM) • Large doses of cough syrup taken (8-12 oz); often causes vomiting • Effects vary with the amount taken

Meth contains an additional methyl group attached to its nitrogen (better penetration into the brain)

Coricidin HBP Cough & Cold*

Getting High on Benadryl

• AKA: Triple C, Red Devils, Skittles

• Popular antihistamine and OTC sleep aid

• Contains 30 mg DM per tab

• At high doses, diphenhydramine causes hallucinations and delirium

 Therapeutic dose= 30 mg q 6-8 hr  Abusers: 250-1500 mg in one dose

• #1 stolen product from pharmacies • Mucinex® becoming popular • OTC meds are perceived as “no risk” * Coricidin HBP Cold and Flu® is commonly mistaken for the Cold and Cough and contains acetaminophen!

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• Instructions for robotripping/dexing on the Internet; also “skittling”

• Teens use Benadryl as a cheap high; many describe the experience as being unpleasant • Potent anticholinergic; overdosage can lead to serious cardiac dysthythmias, coma and death

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What Can You Do?

State of Iowa Efforts

• Be involved in your child’s life!

• Prescription Drug Monitoring Program (PMP)

• Talk to your kids about Rx and OTC drugs

– Used to deter and identify illegal activity:

• Make your values clear by setting a good example

• Prescription forgery

• Be sure your child understands that sharing or selling Rx medicine is illegal

• “Doctor shopping”

• Properly dispose of unused or outdated medicine • “Teen proof” your house and ask friends to do the same!

What’s in a Standard Drink?

• Indiscriminate prescribing

• Governor's Office of Drug Control Policy  Rx Abuse Reduction Task Force; convened Aug 2011 – Reducing Prescription Drug Abuse in Iowa: A State Strategy— report released Jan 2012  www.TakeADoseOfTruth.com

Alcohol-Caffeine Drinks • Fruit-flavored drink; aka “blackout in a can”

Amount of pure alcohol in a drink

One standard drink equivalent One 12 oz mug of beer*

One 5 oz glass of wine

One 1 oz shot of whiskey

• 23.5 oz can containing 12% alcohol by volume (equivalent of ~5 beers) Four Loko Cost: $2.50/can

• FDA banned in Nov 2010; back on market Jan 2011 after caffeine removed

Vodka Red Bull • AKA: Vod-Bomb, Birch, Vod Bull, “DVR” (double vodka red bull) • Popular among 18–30 yo

Vod-Bomb

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• Ratio of Vodka to Red Bull varies but usually 2:3 (6 oz vodka in 8.3 oz can Red Bull) • Users may not realize how much they’re affected by the alcohol

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