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Phillips, Cory Prescription Drug Abuse

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  • MMWRPrescription drugs involved in 20,000 cases
  • HC Professionals Beware of Prescription Medication Abuse and DiversionSemisynthetic opioids not converted to morphine demonstrate variable urine test detection and will usually not test positive at standard doses (must usually be >2000 ng/mL conc for detection)Codeine and heroine readily detectable.
  • Drug-facilitated assaultDiversion- some of are pts are put on an addicting mediction which helps them and taken off or their doctor does not think they should get it and so they are going to buy it elsewhereAddiction- behavioral syndrome characterized by psychologic dependence and abnormal drug-related behaviorsPseudoaddiction- Usually result of undertreated pain; attempts to obtain more medications as a result of unrelieved pain or fear of running out of analgesicsTolerance- Learned cellular response requiring higher dose of analgesic to achieve the level of pain relief previously accomplished by a smaller dosePhysical Drug Dependence- normal physiological response to continuous opioid therapy, with the appearance of withdrawal syndrome with the drug is abruptly discontinued
  • Prescription Drug Abuse: Insight Into the Epidemic
  • NSDUH (National Survey on Drug Use and Health)Marijuana > Pain relievers > Inhalants > Tranquilizers/Hallucinogens/Inhalents
  • Base decision on judgment and situationKnow your bad doctors and bad prescriptionsPsychosocial and family counseling
  • Eliminate SA so they do not use more than prescribed and not controlled ATC. Palliative Care of the Terminally Ill Drug Addict
  • Addiction- behavioral syndrome characterized by psychologic dependence and abnormal drug-related behaviorsPseudoaddiction- Usually result of undertreated pain; attempts to obtain more medications as a result of unrelieved pain or fear of running out of analgesicsTolerance- Learned cellular response requiring higher dose of analgesic to achieve the level of pain relief previously accomplished by a smaller dosePhysical Drug Dependence- normal physiological response to continuous opioid therapy, with the appearance of withdrawal syndrome with the drug is abruptly discontinued
  • Knowledge, Attitudes, and Practices of Pharmacists Regarding Addiction
  • Remoxy- ER Oxycodone contained in highly viscous liquid formulation matrix. Intended to resist abuse by crushing, freezing and crushing, or dissolution in water, alcohol, or common liquids. Gel is vicous sucrose acetate isobutyrate which is designed to be difficult to snort or inject. Embeda- morphine suphate with sequestered naltrexone Capsule with naltrexone core that is not released unless unless crushed or dissolved, naltrexone is released and mixed with morphine, thus blunting theeuphoric effects of morphine. (approved 2009) Tramadol for mod-sever nociceptive/neuropathic pain- still abused Acurox- IR oxycodone fomulated with niacin which causes unpleasant effects (warmth, flushing, itching, sweating, chills) if excess number of tablets are swallowed.

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  • 1. Cory Phillips PharmD Candidate BUCOPhttp://www.dps.state.ia.us/DNE/oxycontin.shtml http://3-ecom-.mcguffmedical.com/products/4528.aspx
  • 2.  Controlled prescription drug abuse by Americans has nearly doubled from  7.8 million in 1992 to 15.1 million in 2003  ED visits involving nonmedical use of opioid analgesics  Increased 111% from 2004 to 2008 (CDC, SAMHSA)  Deaths due to prescription drug abuse  Increased 55% from 1999 to 2003  >36,000 people died of drug overdoses in 2008 (CDC)  Economic costs  Overall cost of painkiller abuse > $70 billion a year  Lost productivity costs ~ $42 billion a year  Criminal justice costs ~ $8.2 billion a year Morbidity and Mortality Weekly Report. Center for Disease Control and Prevention. Emergency Department Visits Involving Nonmedical Use of Selected Prescription drugs: United States, 2004-2008; 59(23). www.cdc.gov/mmwr. Accessed Feb 20, 2012.Controlled Prescription Drug Abuse at Epidemic Level: The National Center on Addiction and Substance Abuse (CASA) at Columbia University. J Pain & Palliative Care. 2006; 20(2): 61-61. http://www.casacolumbia.org. Accessed Feb 20, 2012.
  • 3.  Higher degree of purity  Made under strict rules and regulations Known dose  Safer  Can avoid accidental overdosing Legally available  Easy to obtain Hard to detect in routine urine drug testing Less social stigma  Less percieved potential harm Certain legal biases in their favor  Illicit drug abuse – felony  Prescription drug abuse- misdemeanor Prescription drugs are profitable  Cash most important factor in diversion of pain medications Chandra A, Ozturk A. Health Professionals Beware of Prescription Pain Medication Abuse and Diversion. Hospital Topics. 2004; 82: 34-36.
  • 4.  The Drug Abuse Warning Network (DAWN)  Public health information system that tracks the impact of drug use, misuse, and abuse in the US by monitoring drug-related hospital ED visits DAWN describes nonmedical use of Rx or OTC drug as  Taking a higher-than-recommended dose  Taking a drug prescribed for another person  Documented misuse or abuse Addiction (APS, AAPM, ASAM)  A primary, chronic, neuroiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations…  Characterized by behaviors that include one or more of the following  Impaired control over drug use  Compulsive use  Continued use despite harm  Cravings Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.
  • 5. Category MOA Drug Classes Indications Common AEsOpioids Antagonists at Prescription Acute or Analgesia, sedation, euphoria,(narcotics) opioid receptors (μ, pain relievers chronic pain respiratory depression, physical κ, δ) relief dependence, GI dysmotility, pruritisSedative- Enhance effect of Sedatives, Sleep aide, CNS depression, slurred speech,Hypnotics GABA-mediated BZDs, BARBs, insomnia, ataxia, incoordination, stupor, chloride channels “downers” or seizure coma, cardiac dysrhythmia sleeping pills disordersStimulants Enhance release of Amphetamine Narcolepsy, HTN, tachycardia, seizure, catecholamines s,“uppers” or ADHD, hyperthermia, agitation, (DA & NE); “speed”, short-term anorexia, ischemia, stimulation of prescription weight rhabdomyolysis peripheral α-and β- diet pills reduction adrenergic receptorsTranquilizers Enhance effect of Anxiolytics, Anxiety and CNS depression (less GABA-mediated BZDs, muscle panic compromise in mental status chloride channels relaxants disorders than with sedative-hypnotics), and central DA slurred speech, ataxia, receptors incoordination, stupor, coma, cardiac dysrhythmia Hernandez SH, Nelson LS. Prescription Drug Abuse: Insight into the Epidemic. Clin Pharma & Thera. 2010; 88(3): 307-317.
  • 6. Hernandez SH, Nelson LS. Prescription Drug Abuse: Insight into the Epidemic. Clin Pharma & Thera. 2010; 88(3): 307-317.
  • 7.  Illicit drug abuser  Patient Prescription drug abuser  Neighbor Druggie  Healthcare Worker Junkie  Employee Stoner  Colleague Drug Addict  Friend Abuser  Family member Abusing patient  Spouse  Grandmother  Mother  Father  Child Cory Phillips
  • 8.  Multidisciplinary approach Assessment of substance use history Set realistic goals for therapy Evaluate and treat comorbid psychiatric disorders Recognizing specific drug abusive behaviors Use written agreements (controversial)  Patient may not be mentally competent for agreement Guidelines for prescribing Consider the therapeutic impact of tolerance Apply pharmacological principles to treating pain Use 12-step programs Urine toxicology screens Kirsh KL, Passik SD. Palliative Care of the Terminally Ill Drug Addict. Cancer Investigation. 2006; 24: 425-431.
  • 9.  Choose an opioid based on ATC dosing Choose LA agents when possible Limit or eliminate the use of SA or “breakthrough” doses Use non-opioid adjuvants when possible and monitor for compliance with those medications Use nondrug adjuvants whenever possible  Relaxation techniques  Distraction  Biofeedback  Transcutaneous Nerve Stimulation (TNS)  Communication about thoughts and feelings of pain Limit the amount of medication given at any one time Utilize pill counts and urine toxicity screens as necessary If compliance is suspect or poor, refer to an addiction specialist Kirsh KL, Passik SD. Palliative Care of the Terminally Ill Drug Addict. Cancer Investigation. 2006; 24: 425-431.
  • 10.  Cross-sectional, multivariable, descriptive analysis  Age, gender, race, financial status, employment, current smoking, drinking, past-year illicit drug use, depression, chronic pain. Veterans (N= 6,377) Mean age 56.5 yo Majority caucasian, unmarried, and unemployed Found associations between prescription drug abuse and  Younger age  Depression or probable depression  Smoking  Illicit drug use  Chronic pain Younger individuals using illicit drugs or having a history of addiction or a mental illness at higher risk of abusing prescription drugs Becker WC, Fiellin DA, Gallagher RM, Barth KS, Ross JT, Olsin DW. The Association Between Chronic Pain and Prescription Drug Abuse in Veterans. Pain Med. 2009; 10(3): 531-536.
  • 11.  Listening  Considerations Clinical judgment  Prescriber creditials Screening for abusers  Indication  Controlled substance Identifying the problem  Non-controlled substance Identifying and treating co-  Abuse potential morbidities  Potential for harm Exhibiting  Alternative therapies empathy/understanding  Tolerance Aiding in therapy  Behaviors modification  Past medical history Education on addiction  Life expectancy  Safe and effective opioid Referral to addiction services, prescribing? counseling, recovery centers, support groups, etc… Hale, KM, Murawski MM, Huerta J. Pharmacist Roles in Combating Prescription Drug Abuse. JAPhA. 2009; 49(5): 589-590.
  • 12.  Appearances may be decieving Common characteristics  Escalated use  Continually running out of medication before scheduled follow-up  Frequently “losing” medication  Inability to clearly describe drug use pattern  Pseudoaddiction behaviors  Provider shopping  Pharmacists can identify from observation or databases  Frequent local ER visits  Several prescribers  No regular PCP or they are ‘out of town’  Seek treatment after hours or times when the clinic is typically busy  Scamming  Present as complimentary then, if resisted, threatening  Request of specific controlled substance  Avoid physical examination, history taking, diagnostic testing, or provide a vague medical history Gerhardt AM. Identifying the Drug Seeker: The Advanced Practice Nurse’s Role in Managing Prescription Drug Abuse. JAANP. 239-243.
  • 13. What are we doingwrong? What can we do better?  Seek to help first Lying to patients  Listen first, refuse later Hanging up on patients  What is the context in which this patient is asking for this medication? Not listening to patients  Does he/she have a home pharmacy? Gossiping about patients  Can I verify the patient?  Is this a chronic pain/cancer Not differintiating patient? between patients who  Does the patient need a dose reduction or increase? need help and true  Does the patient need to be weaned off this med? addiction or diversion  Does the patient need to see his/her doctor?  GIVE THE BENEFIT OF THE DOUBT Cory Phillips
  • 14.  Active surveillance of abused and misused prescription opioids using poison center data: A pilot study and descriptive comparison  Poison Center data timely, geographic, and specific indicator of opioid abuse  Poison Center data comparable to DAWN  Hydrocodone (55% v 39% cases); Oxycodone (39 % v 35% cases)  Poison Center highest rates of abuse in 18-25 yoa  DAWN ED visits highest in 35-44 yoa  Involve 2 substances (2nd being ETOH)  Kentucky leads nation in highest misuse and abuse rates (DEA) followed byVirginia  Researched-Abuse, Diversion, and Addition-Related Surveillance (RADARS®) Study  Abuse localized in rural, suburban, and small urban areas  Hydrocodone and ER/IR oxycodone most widely abused drugs in the country  Abuse of all opioids grown throughout this study (3 ½ years) Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.Cicero TJ, Dart RC, Inciardi JA, Woody GE, Schnoll S, Munoz Alvaro. The Development of a Comprehensive Risk-Management Program for Prescription
  • 15. Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.
  • 16. Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.
  • 17.  Pharmacists (1st line)  Study on knowledge, attitudes, and professional practices of pharmacists regarding addiction  Questionnaire (25 items; 484 pharmacists; Florida)  67.5% had participated in 2 h or less of addiction/substance abuse education in pharmacy school  29.3% had no addition education  53.7% had never referred a patient to a drug treatment center Closer monitoring and relations with pain patients Increased awareness, education, and rehabilitation efforts Abuse-deterrent and tamper-resistant opioid formulations  May be costly  Need more studies Risk-Management Programs (last-line)  Drug Enforcement Agency (DEA) Controlled Prescription Drug Abuse at Epidemic Level: The National Center on Addiction and Substance Abuse (CASA) at Columbia University. J Pain & Palliative Care. 2006; 20(2): 61-61. http://www.casacolumbia.org. Accessed Feb 20, 2012.
  • 18. Schneider, JP, Matthews M, Jamison RN. Abuse-Deterrent and Tamper-Resistant OpioidFormulations: What is their Role in Addressing Prescription Opioid Abuse? CNS Driugs. 2010; 24(10): 805-810.
  • 19.  NIDA Web Page for healthcare professionals  Publications, clinical practice, research  www.nida.nih.gov/medstaff.html. Commonly Abused Prescription Drugs  Street names for Rx drugs, DEA schedule, intoxication effects, and potential health consequences  www.nida.nih.gov/DrugPages/PrescripDrugsChart.html The NIDA Research Report- Prescription Drugs: Abuse and Addiction  www.nida.nih.gov/ResearchReports/Prescription/Prescriptio n.html Monitoring the Future  An ongoing study of the behaviors, attitudes, and values of American secondary school students, college students, and young adults  Provides information on the latest drug use trends  www.monitoringthefuture.org. Volkow ND. Teen Prescription Drug Abuse: A Major Health Concern. Tn Med. 2009: 28-29.
  • 20.  Vanderbilt Addiction Center  http://www.mc.vanderbilt.edu/root/vumc.php?site=add ictioncenter Parthenon Pavillion  http://www.usnodrugs.com/Tennessee/Nashville/Parth enon_Pavilion_CMC The Ranch  http://www.recoveryranch.com/ Cumberland Heights  http://www.cumberlandheights.org/home.aspx
  • 21.  Who will you turn away? Who will you turn in? Who will you help? http://www.sheknows.com/sheknows- cares/articles/806066/emotional-support-for- breast-cancer-patients-and-survivors-fosters-hope  Who will you help?  Who will you turn away?  Who will you turn in? http://opioids.com/oxycodone/oxycon.html
  • 22. 1. Becker WC, Fiellin DA, Gallagher RM, Barth KS, Ross JT, Olsin DW. The Association Between Chronic Pain and Prescription Drug Abuse in Veterans. Pain Med. 2009; 10(3): 531-536.2. Chandra A, Ozturk A. Health Professionals Beware of Prescription Pain Medication Abuse and Diversion. Hospital Topics. 2004; 82: 34-36.3. Cicero TJ, Dart RC, Inciardi JA, Woody GE, Schnoll S, Munoz Alvaro. The Development of a Comprehensive Risk- Management Program for Prescription Opioid Analgesics: Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS). Pain Med. 2007; 8(2): 157-170.4. Controlled Prescription Drug Abuse at Epidemic Level: The National Center on Addiction and Substance Abuse (CASA) at Columbia University. J Pain & Palliative Care. 2006; 20(2): 61-61. http://www.casacolumbia.org. Accessed Feb 20, 2012.5. Gerhardt AM. Identifying the Drug Seeker: The Advanced Practice Nurse’s Role in Managing Prescription Drug Abuse. JAANP. 239-243.6. Hale, KM, Murawski MM, Huerta J. Pharmacist Roles in Combating Prescription Drug Abuse. JAPhA. 2009; 49(5): 589-590.7. Hernandez SH, Nelson LS. Prescription Drug Abuse: Insight into the Epidemic. Clin Pharma & Thera. 2010; 88(3): 307-317.8. Hughes AA, Bogdan GM, Dart RC. Active Surveillance of Abused and Misused Prescription Opioids Using Poison Center Data: A Pilot Study and Descriptive Comparison. J Clin Tox. 2007; 45: 144-151.9. Kehoe Jr WA. Substance Abuse: New Numbers Are a Cause for Action. Ann Pharma. 2008; 42: 270-272.10. Kirsh KL, Passik SD. Palliative Care of the Terminally Ill Drug Addict. Cancer Investigation. 2006; 24: 425-431.11. Lafferty L, Hunter TS, Marsh WA. Knowledge, Attitudes, and Practices of Pharmacists Concerning Prescription Drug Abuse. J Psychoactive Drugs. 2006; 28(3): 229-232.12. Morbidity and Mortality Weekly Report. Center for Disease Control and Prevention. Emergency Department Visits Involving Nonmedical Use of Selected Prescription drugs: United States, 2004-2008; 59(23). www.cdc.gov/mmwr. Accessed Feb 20, 2012.13. Schneider, JP, Matthews M, Jamison RN. Abuse-Deterrent and Tamper-Resistant Opioid Formulations: What is their Role in Addressing Prescription Opioid Abuse? CNS Drugs. 2010; 24(10): 805-810.14. Volkow ND. Teen Prescription Drug Abuse: A Major Health Concern. Tn Med. 2009: 28-29.15. Wysowski DK. Surveillance of Prescription Drug-Related Mortality Using Death Certificate Data. Drug Safety. 2007; 30(6): 533-540.