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Overview of Prescription and Non-Prescription Drugs of Abuse

Overview of Prescription and Non-Prescription Drugs of Abuse. Devon A. Sherwood, PharmD , BCPP Assistant Professor University of New England College of Pharmacy. Learning Objectives. Describe the epidemiology and overall impact of medications commonly abused.

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Overview of Prescription and Non-Prescription Drugs of Abuse

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  1. Overview of Prescription and Non-Prescription Drugs of Abuse Devon A. Sherwood,PharmD, BCPP Assistant Professor University of New England College of Pharmacy

  2. Learning Objectives • Describe the epidemiology and overall impact of medications commonly abused. • Explain the pathophysiology of abuse and dependence for commonly abused drugs. • List common over-the-counter (OTC) and prescription (Rx) drugs of abuse. • Identify side effect profiles and withdrawal symptoms of OTC andRxdrugs of abuse. • Review available options for detoxification therapy and abstinence maintenance regarding common drugs of abuse.

  3. Which of the following increases the risk of abuse potential? • Rapid absorption • Potency of drug • Lipophilicity and distribution leads to abrupt offset • Short-half life / duration of effect • All of the above

  4. Which of the following should not be recommended for opiate abstinence? • Clonidine • Methadone • Suboxone • Naltrexone

  5. Laxative Abuse: True or False? • Effective for weight control • True • False • Physical dependency does not occur • True • False • Long term abuse may contribute to colon cancer • True • False

  6. Which of the following herbals when abused is known to cause hallucinations? • Ma-huang • Kratom • Nutmeg • Betel nut • Kava

  7. Which of the following herbals has effects on mu and delta receptors, causing analgesic and addictive properties similar to opiates? • Salvia • Morning Glory • Kratom • Yohimbine • Khat

  8. Epidemiology • In 2010, 23.1 million Americans aged 12 or older (9.1% of US population) needed specialized treatment for a substance abuse problem, but only 2.6 million (11.2%) received it. • It is estimated 22.6 million Americans aged 12 or older (8.9%) were current (past month) illicit drug users • Includes marijuana/hashish, cocaine/crack, heroin, hallucinogens, inhalants or prescription-type psychotherapeutics used nonmedically. 1.) National Survey of Drug Use and Health, SAMHSA, 2013 2.) National Survey on Drug Use and Health 2013; National Institute on Drug Abuse (NIDA), National Institute of Health (NIH) 3.) Monitoring the Future; University of Michigan - http://www.monitoringthefuture.org/

  9. First Specific Drug Associated with Initiation of Illicit Drug Use among Past Year Illicit Drug Initiates Aged 12 or older: 2010 Results from the 2010 National Survey on Drug Use and Health, US Department of Health and Human Services, 2012; http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#Fig5-1

  10. Epidemiology – Psychotropic Rx Drugs • The incidence of nonmedical usage of psychotropic drugs has been increasing over the past 10 years • NSDUH Report from April 11, 2013 identified an increase in nonmedical prescription drug use from the 2011 survey: • 15.7 million (6.3% of US population) use in last year • 6.7 million (2.7% US population) use in last month 1.) National Survey of Drug Use and Health, SAMHSA, 2012 2.) National Survey on Drug Use and Health 2010; National Institute on Drug Abuse (NIDA), National Institute of Health (NIH)

  11. Epidemiology - Psychotropic Rx Drugs • In 2010, about 7 million persons (2.7% of US population) were current users in the past month of psychotherapeutic drugs taken nonmedically • 5.1 million = pain relievers • 2.2 million = tranquilizers • 1.1 million = stimulants • 0.4 million = sedatives. National Survey on Drug Use and Health 2010; National Institute on Drug Abuse (NIDA), National Institute of Health (NIH)

  12. NIDA-NIH: http://www.nida.nih.gov/tib/prescription.html

  13. Epidemiology • Monitoring the Future Study (NIH grant in 2011) • Any prescription drug abused in 12th grade = 15.2% 1.) National Survey on Drug Use and Health 2011; National Institute on Drug Abuse (NIDA), National Institute of Health (NIH) 2.) Monitoring the Future; University of Michigan - http://www.monitoringthefuture.org/

  14. DSM-IV-TR Diagnosis Review:Substance Related Disorders • Substance Use Disorders: • Dependence • Abuse • Substance Induced Disorders • Intoxication • Withdrawal • PolysubstanceDependance

  15. Substance Abuse • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following (one symptom in 12 months): 1.) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 2.) Recurrent substance use in physically hazardous situations 3.) Recurrent substance-related legal problems 4.) Continued substance use despite having persistant or recurrent social or interpersonal problems caused or exacerbated by the effects of substance abuse

  16. Substance Dependence • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period: 1.) Tolerance: A need for markedly increased amounts of the substance to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of the substance 2.) Withdrawal: As manifested by the characteristic withdrawal syndrome for the substance, or the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

  17. Substance Dependence 3.) Substance is taken in larger amounts or over a longer period than was intended 4.) Persistent desire or unsuccessful efforts to cut down or control substance use 5.) A great deal of time is spent in activities necessary to obtain the substance 6.) Important social, occupational, or recreational activities are given up or reduced because of substance use. 7.) The substance use continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely caused or exacerbated by the substance.

  18. Risk Factors for Addictive Disorders • Ineffective parenting • Chaotic home environment • Lack of mutual attachments/nurturing • Inappropriate behavior in the classroom • Failure in school performance • Poor social coping skills • Affiliations with deviant peers • Perceptions of approval of drug-using behaviors in the school, peer, and community environments www.drugabuse.gov

  19. Protective Factors • Strong family bonds • Parental monitoring • Parental involvement • Success in school performance • Prosocial institutions • (ie. family, school, religious organizations) • Conventional norms about drug use http://www.yanksarecoming.com/wp-content/uploads/2009/12/BubbleBoy1.jpg www.drugabuse.gov

  20. DRUG ADDICTION IS A COMPLEX ILLNESS www.drugabuse.gov

  21. www.drugabuse.gov

  22. www.drugabuse.gov

  23. www.drugabuse.gov

  24. www.drugabuse.gov

  25. www.drugabuse.gov

  26. Common Prescription Drugs of Abuse • Opiates • Anxiolytics/ sedatives • Benzodiazapines • Barbiturates • Non-benzodiazepines • Stimulants

  27. Opiate Usage • Studies have shown properly using opiates exactly as prescribed is safe, manages pain effectively, and has a low chance of addiction. • Taken by persons not prescribed the medication, using more than recommended or using an alternate route than prescribed (snorting, smoking or injecting) carries a high risk of addiction and/or overdosage NIDA Infofacts: Prescription and Over the Counter Medications; http://www.nida.nih.gov/infofacts/PainMed.html

  28. NIDA-NIH: http://www.nida.nih.gov/tib/prescription.html

  29. Opiate Actions • Opiate enters the brain and influences a range of mechanisms • Mu, delta & kappa agonists • Boosts the activity of dopamine • Pleasure circuit • Blocks pain • Slows the heart beat • Constricts the pupils • Decreases breathing • Sometimes causing breathing cessation • Potentially death

  30. Opiates/Opiods Pharmacotherapy: A Pathophysiologic Approach

  31. Opiates • Withdrawal • “Flu-like” symptoms: • Runny nose • Tear secretion • Yawning • Sneezing • Nausea • Vomiting • Diarrhea • Mydriasis • General effects • Sedation • Anxiety • Lack of interest • Slurred speech

  32. Oxycontin® • One of the most commonly abused prescription drugs • 80mg Oxycontin tablet = 16 Percocet tablets • Propagated by illicit transactions, theft, and overprescribing (ie. “Pain clinics”) • Sustained-release delivery is thwarted by cracking, chewing, smoking and injecting

  33. http://www.prescriptionbuyers.com/freeboard/ubbthreads.php/topics/1045193/NEW_OXYCONTIN_MARKINGS_SEPT_20. Accessed April 1, 2012.

  34. Long Term Opiate Effects • Physical/Psychological addiction • Injection-related problems • Infectious diseases • HIV / AIDS • Hepatitis B and C • Collapsed veins • Bacterial infections • Abscesses • Physical injuries

  35. Opiate Addiction Treatments • Detoxification • Taper off opiate + opiate substitute • Clonidine(Catapres®) • Buprenorphine Formulations (Buprenex®, Suboxone®) • Maintenance of Opiate Abstinence • Methadone • Buprenorphine/Naloxone • Naltrexone

  36. Clonidine (Catapress®) • Attenuates the sympathetic response to withdrawal • Causes a rapid and significant decrease in withdrawal signs and symptoms • Usual oral dose is 0.1-0.2mg Q6h PO • Watch BP!

  37. Methadone Programs • Use methadone as an opiate substitute • Medication is taken orally • Suppresses withdrawal for 24 to 36 hours and relieves cravings • Detox: 15-40 mg/day not to exceed 21 days • Maintenance: 20-120 mg/day

  38. Drug Addiction Treatment Act of 2000 (DATA 2000) • Physicians must be credentialed to do office-based detoxification • No more than 30 patients at a time for the first year licensed, then can petition for up to 100 patients per the DATA 2000 waiver • Buprenorphine/Naloxone (Suboxone®)approved in October 2002 • Use buprenorphinemonotherapy only in pregnancy http://samhsa.gov: Buprenorphine Clinical Guide

  39. Buprenorphine/Naloxone (Suboxone®) • A mixed opiate agonist / antagonist • Ceiling effect if dosed too high • Safer for respiratory depression • Suboxone® is a 4:1 ratio of buprenorphine to naloxone (if taken po only!!) • Usual dose • 4-24mg sublingually daily

  40. Suboxone® • Safe and effective for office-based detox • 16mg buprenorphine daily • Up to 21% avoided outside opiates vs. 5.8% on placebo (p<0.001) • Retention rates in programs < methadone • High dose buprenorphine may suppress heroin use > methadone • Doses > 8mg/d have best success • QOD dosing also successfulNEJM 2003;349:949-958. / Cochrane Database of Systematic Reviews 2003;(2):CD002207. / Addiction 2003;98(4):441-452.

  41. Naltrexone (Revia®, Vivitrol®) • Competitive antagonists at opioid receptor sites • Not to be used during active withdrawal • Studies with long acting depot form Vivitrol® in Russia demonstrated extraordinary outcomes regarding drug abstinance, treatment retention, and decreased cravings

  42. Naltrexone (Revia®, Vivitrol®) • Must wait 7-14 days or withdrawal will occur • Reduces opiate cravings • Increases risk for unintentional overdoses • Studies show a reduction in (re)incarcerations when used with behavior therapy • Compliance and motivation are major factors • 32-58% successful in compliant patients • Abstinence rates diminish over timeCochrane Database of Systematic Reviews 2003;(2):CD001333.Drug & Alcohol Dependence 1997;47(2):77-86. / Drugs 1988;35(3):192-213.

  43. Which of the following should not be recommended for opiate abstinence? • Clonidine • Methadone • Suboxone • Naltrexone

  44. Naloxone (Narcan®) • Short acting opiate receptor blocker • Not used for abstinence • Counteracts the effects of opiods and can be used to treat overdose • Dosing for overdose of opiate: 0.4 – 2mg IV, repeat every 2 to 3 min prn • No response after 10mg = reconsider diagnosis! • May administer IM or SUBQ if IV route is unavailable Micromedex Healthcare Series: Drugdex® Drug Point

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