Prescription Drug Abuse: Prevalence and Prevention

1. Prescription Drug Abuse: Prevalence and Prevention Robert Pack, PhD, MPH Community Medicine

2. Outline • Overview • Prevalence • Prevention • What NIDA says • Other thoughts • Our own research study on predictors • Discussion

3. “Sam” • Close friend • Charming, funny, fit, good looking • In 2004: married father of two; BS in horticulture; worked as a pharmacy tech (10 hrs a week) • Addicted for 12 years; starting with Xanax & Soma

4. Sam’s addiction • Carefully regimented sequence • Ate set amounts of food at set times • Certain drugs before food and after • Slept three hours a night • Up to 40-50 Lorcet 10/325’s a day • 4 Xanax 2 mg (plus a valium 10, an ativan 2mg and a Clonipin 1mg) and 40-60 Soma (Carisoprodol) at set times during the day; plus all manner of other stuff • OD’d twice but was not hospitalized; friends took care of him • Day job: prescription drug seeker and a stay-at-home dad to his young daughter

5. Sam the dealer • Sold Ambien and Xanax to neighborhood housewives • Sold Adderall to students and young professionals • Sold Vicodin and Lortab to everyone • 40-50,000 pills in his garage (on the floor, in tupperware) • Half dozen pistols (on the floor, in tupperware) • $50,000 in cash (on the floor in a small toy safe) • Cameras on every corner of the house that fed into a central security system in the garage (command and control) • Attack dogs in the backyard • The wrong people were starting to know who he was • Claims to have never stolen from the pharmacy

6. Sam’s wife • Caught him once in 2000 and threatened divorce if it happened again • Forced counselor visits • Stayed away from the command center in the garage “because of the mice” • “Naïve” until… • Sam fell asleep at dinner and would not wake up • More about Sam later….

7. Epidemiology

8. NHSDUH • Household computerized (ACASI) survey of incidence and prevalence of non-medical use of licit drugs and use of illicit drugs • Licit (i.e., psychotherapeutic, mind-altering) drugs • Pain relievers (opioids) • Tranquilizers (barbiturates) • Stimulants (amphetamines) • Sedatives (benzodiazepines) • •Illicit drugs • Such as marijuana or hashish, Cocaine, Heroin etc. SOURCE: Zacny (2004). Trends in abuse of prescription drugs. http://www.painandchemicaldependency.org

9. Prescription Opioids Ranked on Non-Medical Lifetime Use • 1,2. Darvon, Darvocet, or Tylenol with Codeine: 19 million people • 3. Vicodin, Lorcet, or Lortab: 13 million people • 4. Percocet, Percodan, or Tylox: 9.5 million people • 5. Demerol: 3 million people • 6. Morphine: 2 million people • 7. OxyContin: 2 million people • 8. Dilaudid: 1 million people SOURCE: Zacny (2004). Trends in abuse of prescription drugs. http://www.painandchemicaldependency.org

10. More than 6.3 Million Americans Reported Current Use of Prescription Drugs for Nonmedical Purposes in 2003

11. Dependence: NSDUH data • About 259,000 people are dependent on prescription stimulants • About 900,000 people in the US are dependent on opioids • About 1,100,000 – cocaine • About 8,000,000 – marijuana • About 70,000,000 – tobacco

12. Annual Numbers of New Nonmedical Users of Psychotherapeutics: 1965–2001 SOURCE: http://www.oas.samhsa.gov/nhsda/

13. Dependence or Abuse of Specific Substances among Past Year Users of Substances: 2002 SOURCE: http://www.oas.samhsa.gov/nhsda/

14. Substances for Which Persons Aged 12 or Older Received Treatment in the Past Year: 2002 SOURCE: http://www.oas.samhsa.gov/nhsda/

15. Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002 SOURCE: http://www.oas.samhsa.gov/nhsda/

16. What about youth?

17. Percent of Students Reporting Past Month Use of Any Illicit Drug Has Decreased * 17% Decline 2001 to 2004 Percent * P < .05

18. Issues of Concern Percent of 12th Graders Reporting Nonmedical Use of OxyContin and Vicodin in the Past Year Remained High 12.0 10.5 9.6 9.3 10.0 8.0 Percent 6.0 5.0 4.5 4.0 4.0 2.0 0.0 OxyContin Vicodin 2002 2003 2004 No year-to-year differences are statistically significant.

19. Past Month Use of Selected Illicit Drugs Among Youths, by Age: 2003

20. NIDA estimates • Annual abuse of Vicodin was 9.5 percent among 12th-graders in 2005, ranking it among the most commonly abused drugs for 12th-graders in the “annual use” category. • From 2002 to 2005, annual prevalence of OxyContin use significantly increased among 12th-graders. • Likely due to increased availability during that time • Since 2001, there has been a 25 percent increase in annual abuse of sedatives/barbiturates among 12th-graders

21. 2003 Monitoring the Future • Among twelfth graders in the US, annual prevalence of Vicodin use was second only to marijuana use. • Young people frequently mix prescription drugs with other drugs of abuse, such as marijuana and alcohol, putting them at risk for drug interactions and overdose. • Prescription of methylphenidate and other stimulants to treat attention-deficit hyperactivity disorder (ADHD) has also increased in recent years.

22. The situation in WV? • No denominator based epidemiologic studies • Anecdotes abound in the press in local lore

23. Data-based WV indicators • According to West Virginia’s Department of Health and Human Resources (DHHR 2003), in 2000, pharmaceutical-related treatment admissions were more common than admissions for any other drug except for marijuana. • The DHHR also reports that West Virginia’s problem is growing over time with the number of prescription treatment admissions increasing by approximately 42 percent between 1998 and 2003 (DHHR 2003).

24. Data-based WV indicators • Specific characteristics in West Virginia. • Nationally, only 2.8% of admissions were for treatment of dependence on opiate-like drugs, but in West Virginia they accounted for 12.2% of admissions. • Also, on average, West Virginia admissions are younger and more likely to be white and female (SAMHSA 2004).

25. Data-based WV indicators • In terms of crime, in 2002, West Virginia had more arrests for prescription-based opiates than for cocaine (Turley and Hutzel 2003). • About half (49.2%) of these arrests were for sales and distribution (more than cocaine, methamphetamine, or marijuana)

26. Some media

32. Some peer reviewed literature

33. Gender differences • Women are up to 48% more likely to be prescribed an abusable prescription drug • However, men and women are about equally likely to abuse • Except in 12-17 year olds • Females are more likely than males to abuse psychotherapeutic drugs • Men and women are also equally likely to become addicted NIDA Research Report, (2005) Prescription Drugs Abuse and Addiction

34. College students & stimulants • Cross sectional study of 10,904 college students – across the nation • Lifetime prevalence of non-medical prescription stimulant abuse was 6.9% • Past year prevalence was 4.1% • Past month was 2.1% • Predictors: • Male, white, Greek affiliated, and lower GPA Esteban McCabe, Knight, et al ; 2005. Addiction, 99, 96-106.

35. College students & pain meds • Cross-sectional web-based survey of 9161 college students at one university in the midwest US • Men: lifetime: 17.4%; past year: 10.1% • Women: lifetime: 15.7%; past year: 8.7% • Predictors: previously prescribed pain meds, living in a house or apt., lower GPA Esteban McCabe, Teter & Boyd (2004) Drug & Alcohol Depend. 77, 37-47.

36. PDA & Youth in Europe • Cross-sectional survey of 3,021 youth (12-24 yrs) in Europe • Lifetime prevalence of illicit use of PD was 4.5% • Young women have higher rates of use • Young men have higher rates of abuse Lieb, Pfister, et al (1998), Eur Addict Res 4, 67-74.

37. Opioids as gateway? • Qualitative study of 10 heroin detox pts • Oxycontin abuse was linked to experimentation and use of heroin • Half of the ten addicts reported abusing prescription opioids, most notably Oxycontin, before initiating heroin use. • Most reported that heroin was more readily available and less expensive than Oxycontin and that they would never have tried heroin had they not become addicted to opioids • Severe limitations to this study • Useful for discussion only Siegal, et al (2003) American Family Physician 67(5): p. 939

38. Risk perception Inverse correlation between risk perception and use of illicit substances by youth

39. 12th Graders’ Past Year Marijuana Use vs. Perceived Risk of Occasional Marijuana Use Percent

40. Youth: Risk Perception for Prescription Drugs • Two in five teens (40 percent or 9.4 million) agree that Rx medicines, even if they are not prescribed by a doctor, are “much safer” to use than illegal drugs; • Nearly one-third of teens (31 percent or 7.3 million) believe there’s “nothing wrong” with using Rx medicines without a prescription “once in a while;” • Nearly three out of 10 teens (29 percent or 6.8 million) believe prescription pain relievers – even if not prescribed by a doctor – are not addictive; and • More than half of teens (55 percent or 13 million) don’t agree strongly that using cough medicines to get high is risky. • Source: Partnership for a Drug Free America

41. Qualitative study of prescription drug abusers at Chestnut Ridge Hospital

42. Methods • Identified 30 self-identified prescription drug addicted inpatients at CRH • Primary DOC were prescription drugs • Nominated by CRH staff • Informed consent • Took about 9 months in 2004 • Interviewed with a tape recorder • Semi-structured interview

43. Methods (cont.) • Transcribed the interviews • Coded the transcriptions using a preliminary coding dictionary • Modified the dictionary over time • Came up with a preliminary model to test in a quantitative study

44. Preliminary model of prescription drug abuse

45. Domains • Physical • Cognitive • Social • Behavioral

46. Physical • Back Pain (Rx) • Other Pain (Rx) • Accidents (orthopedic injury) (Rx) • Headaches • Cramping (Rx) • Surgeries (Rx) • Other forms of illness • Other drug craving/addiction • Self medication (pill addiction) • Something is wrong with me

47. Depression (Rx) Boredom Curiosity Self-loathing Self-esteem (lack of) Anxiety (Rx) Loss and avoidance of responsibilities Fear of stepping into life Entitlement Fear of Discomfort Self-Control Thinking about using drugs When things get bad Self-efficacy Cognitive

48. Peer Influence: Friends trying to influence you Your influence on others Accessibility: Street Docs: Unwitting Resigned to the fact “Candyman" Family: Childhood environment Present family life Education Pharmacy: Community Chain Community acceptance of problem Legitimacy rationalization b/c of Rx Friends Trade, i.e. sex, money, for drugs Social compensation for staying sick Hidden/invisible network Observational Learning Social

49. Reinforcers: Really high - a search for a better high Numbness Peer acceptance Maintaining baseline - more consistent high Clean high Nurturing by others Consequences: Loss of control Divorce Job loss Relationship destruction Doctor shopping Full-time occupation Networking Withdrawal Side effects Behavior

50. Plans for the data • Quantitative study • Test prevalence in community • Develop prevention programming