Prescription Opioid Abuse Historical AspectsPrescription Opioid Abuse Historical Aspects1990 - Current1990 - Current

Prescription Opioid Abuse Historical AspectsPrescription Opioid Abuse Historical Aspects1990 - Current1990 - Current

Through the efforts of pain control advocates, organized Through the efforts of pain control advocates, organized medicine, scientific journals, & malpractice suits, prescribing medicine, scientific journals, & malpractice suits, prescribing opiates for pain became more common during the last opiates for pain became more common during the last decade of the 20decade of the 20thth Century Century

Opioid therapy became accepted (although often Opioid therapy became accepted (although often inadequately) for treating acute pain, pain due to cancer, & inadequately) for treating acute pain, pain due to cancer, & pain caused by a terminal diseasepain caused by a terminal disease

Still disputed is the use of opioids for chronic pain not Still disputed is the use of opioids for chronic pain not associated with terminal diseaseassociated with terminal disease

2

Evolving Landscape of Drugs of Evolving Landscape of Drugs of AbuseAbuse

Evolving Landscape of Drugs of Evolving Landscape of Drugs of AbuseAbuse

Farming Pharming

Prescription OpioidsPrescription Opioids

Fastest growing drug abuseFastest growing drug abuseUsually used orally but may be crushed & Usually used orally but may be crushed &

snorted or injectedsnorted or injected Injection more likely with OxycontinInjection more likely with OxycontinMore frequent source: medicine cabinets & More frequent source: medicine cabinets &

prescriptionsprescriptionsBelieved to be safer than illicit street drugsBelieved to be safer than illicit street drugs

EpidemiologyEpidemiology

In 2001, 8 million persons abused In 2001, 8 million persons abused prescription pain relievers at least once prescription pain relievers at least once during previous 12 monthsduring previous 12 months

In 2004, this had jumped to 11.4 millionIn 2004, this had jumped to 11.4 million2005 NSDUH, 5% non-medical use of rx pain 2005 NSDUH, 5% non-medical use of rx pain

meds in those 12 and oldermeds in those 12 and olderPrescription meds second only to marijuana Prescription meds second only to marijuana

as most commonly abused drugs (no etoh)as most commonly abused drugs (no etoh)

Potential subpopulations of prescription Opioid Abusers

Potential subpopulations of prescription Opioid Abusers

Persons who abuse or are dependent on only prescription opioids

Abusers of other opioids, e.g., heroin, when they cannot get their drug of choice

Polydrug abusers

Pain patients who develop abuse or dependence problems on these drugs in the course of legitimate medical treatment

Persons who abuse or are dependent on only prescription opioids

Abusers of other opioids, e.g., heroin, when they cannot get their drug of choice

Polydrug abusers

Pain patients who develop abuse or dependence problems on these drugs in the course of legitimate medical treatment

Why Has the Abuse of Prescription Why Has the Abuse of Prescription Drugs Been Increasing?Drugs Been Increasing?

Why Has the Abuse of Prescription Why Has the Abuse of Prescription Drugs Been Increasing?Drugs Been Increasing?

• Increasing numbers of prescriptions (greater Increasing numbers of prescriptions (greater availability)availability)

• Attention by the media & advertising (television Attention by the media & advertising (television and newspaper)and newspaper)

• Easier access (e.g. internet availability)Easier access (e.g. internet availability)• Improper knowledge & monitoring (adverse effects Improper knowledge & monitoring (adverse effects

go unrecognized)go unrecognized)• Others?Others?

• Increasing numbers of prescriptions (greater Increasing numbers of prescriptions (greater availability)availability)

• Attention by the media & advertising (television Attention by the media & advertising (television and newspaper)and newspaper)

• Easier access (e.g. internet availability)Easier access (e.g. internet availability)• Improper knowledge & monitoring (adverse effects Improper knowledge & monitoring (adverse effects

go unrecognized)go unrecognized)• Others?Others?

As Prescriptions Increase, Emergency Room As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster Reports Have Increased at the Same or Faster

RateRate

As Prescriptions Increase, Emergency Room As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster Reports Have Increased at the Same or Faster

RateRate

Num

ber o

f Pre

scrip

tions

(in

1000

s)Nu

mbe

r of P

resc

riptio

ns (i

n 10

00s)

Source: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department MentionsSource: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department Mentions

HydrocodoneHydrocodone

OxycodoneOxycodone

prescriptionsprescriptions

prescriptionsprescriptions

emergencyemergency

emergencyemergency

00

1000010000

2000020000

3000030000

4000040000

5000050000

6000060000

7000070000

8000080000

19941994 19951995 19961996 19971997 19981998 19991999 20002000 2001200100

60006000

1200012000

1800018000

2400024000

ED Men tions

ED Men tions

.

Increased Media AttentionIncreased Media AttentionIncreased Media AttentionIncreased Media Attention

Commonly known Mechanisms of Diversion

Commonly known Mechanisms of Diversion

• Illegal sale of prescriptions by physicians;• Illegal sale of prescriptions by pharmacists;• “Doctor Shopping” by individuals who visit numerous

physicians to obtain multiple prescriptions; • Illegal substitutions or “shorting” by pharmacists; • Theft, forgery, or alteration of prescriptions

Robberies & thefts from pharmacies & thefts of institutional drug supplies

• Internet sales

• Illegal sale of prescriptions by physicians;• Illegal sale of prescriptions by pharmacists;• “Doctor Shopping” by individuals who visit numerous

physicians to obtain multiple prescriptions; • Illegal substitutions or “shorting” by pharmacists; • Theft, forgery, or alteration of prescriptions

Robberies & thefts from pharmacies & thefts of institutional drug supplies

• Internet sales

Easy Access: Role of the Internet?“Delivered in the Privacy of your Home”

Easy Access: Role of the Internet?“Delivered in the Privacy of your Home”

“Some reasons why you should consider using this pharmacy”

No prescription required!

“Some reasons why you should consider using this pharmacy”

No prescription required!

Changing Methods of DistributionChanging Methods of Distribution

Hand commerce E commerce

Less Often Discussed MechanismsLess Often Discussed Mechanisms

• Residential Burglaries• “Obituary Shopping”• Hotel & residential “sneak thefts”• Supply-chain theft– In-production losses– In-transit losses– Returns/reverse distributors– Employee pilferage

• Residential Burglaries• “Obituary Shopping”• Hotel & residential “sneak thefts”• Supply-chain theft– In-production losses– In-transit losses– Returns/reverse distributors– Employee pilferage

Mechanisms of Diversion by Middle& High School Students

Mechanisms of Diversion by Middle& High School Students

• Thefts from family medicine cabinets• Drug “switching” at home• Drug trading at school• Thefts & robberies of medications

from classmates

• Thefts from family medicine cabinets• Drug “switching” at home• Drug trading at school• Thefts & robberies of medications

from classmates

Types of Painkillers (synthetics typically give better highs)Types of Painkillers (synthetics typically give better highs)

Short acting: Lortab (very common), percocet, vicodinShort acting: Lortab (very common), percocet, vicodin

oxycontin lasts 12 hours; ms contin – morphine sulphate; oxycontin lasts 12 hours; ms contin – morphine sulphate; lasts 12 hrs.lasts 12 hrs.

24-hr ms contin now available(kadian?)24-hr ms contin now available(kadian?)

duragesic fentanyl patch lasts 3 days; check used patches duragesic fentanyl patch lasts 3 days; check used patches for tampering (can get patches on the internet)for tampering (can get patches on the internet)

ultram (not an opiate)ultram (not an opiate)

some may combine soma (a muscle relaxer) and lortab some may combine soma (a muscle relaxer) and lortab gives good popgives good pop

ISSUES IN OPIOID ASSESSMENTISSUES IN OPIOID ASSESSMENT

realize very few chronic pain clients are “addicts”realize very few chronic pain clients are “addicts”

assess for prior and current alcohol/drug problemsassess for prior and current alcohol/drug problems

assess for self-medicating of psych disordersassess for self-medicating of psych disorders

do drug screen; do they already have drug in them? Are do drug screen; do they already have drug in them? Are they diverting their meds to the street? (oxycontin going for they diverting their meds to the street? (oxycontin going for about $1 per milligram)about $1 per milligram)

check pharmacies for multiple rxcheck pharmacies for multiple rx

assess pain level on and off meds – are they helping assess pain level on and off meds – are they helping functioning?functioning?

Assessing Need for Narcotics (opioids)Assessing Need for Narcotics (opioids)

check compliance with medical tx – if client only wants check compliance with medical tx – if client only wants narcotics, be suspicious…are they willing to sign a narcotics, be suspicious…are they willing to sign a “medication use” agreement/contract?“medication use” agreement/contract?

are there secondary gain issues involved? (e.g., workmens are there secondary gain issues involved? (e.g., workmens comp.) poorer pain tx outcomes are associated with those comp.) poorer pain tx outcomes are associated with those in litigation.in litigation.

type and dosage of drug currently taking; in some, type and dosage of drug currently taking; in some, tolerance is so high that withdrawal symptoms (increased tolerance is so high that withdrawal symptoms (increased pain) may occur when taking a typical dosepain) may occur when taking a typical dose

rural vs. urban setting: rx drug abuse worse in rural areasrural vs. urban setting: rx drug abuse worse in rural areas

Assessing Need for Narcotics (opioids)Assessing Need for Narcotics (opioids)

Treatment IssuesTreatment Issues

AgeAge AdolescentAdolescent AdultAdult ElderlyElderly

Drug HistoryDrug History New onset of drug abuseNew onset of drug abuse RelapserRelapser Chronic poly substance Chronic poly substance

abuserabuser

RouteRoute OralOral IntranasalIntranasal InjectorInjector

ComorbidityComorbidity PsychiatricPsychiatric Chronic painChronic pain

Who is the Patient

Assessing Need for NarcoticsAssessing Need for Narcotics

chronic opioid tx not appropriate for:chronic opioid tx not appropriate for: those with active addictions those with active addictions those who use etoh (liability)those who use etoh (liability) those who refuse other types of txthose who refuse other types of tx when QOL not improved after use of medswhen QOL not improved after use of meds

for those with previous narcotics problemsfor those with previous narcotics problems opioids not given for lengthy amounts of timeopioids not given for lengthy amounts of time need to be in tx / NAneed to be in tx / NA client may underestimate risk of relapseclient may underestimate risk of relapse

Treatment OptionsTreatment Options DetoxificationDetoxification

To antagonist maintenance (naltrexone, nelmefene, To antagonist maintenance (naltrexone, nelmefene, depot naltrexone)depot naltrexone)

To residential therapeutic communityTo residential therapeutic community

To abstinence–oriented programs (counseling, 12 step To abstinence–oriented programs (counseling, 12 step programs)programs)

MaintenanceMaintenance

Methadone, LAAMMethadone, LAAM

BuprenorphineBuprenorphine

Opiate AddictionOpiate AddictionPharmacotherapyPharmacotherapy

AgonistsAgonists Methadone, LAAMMethadone, LAAM Partial AgonistsPartial Agonists BuprenorphineBuprenorphine AntagonistsAntagonists NaltrexoneNaltrexone Anti-WithdrawalAnti-Withdrawal Methadone; BuprenorphineMethadone; Buprenorphine

Clonidine: rapid detox Clonidine: rapid detox using using Buprenorphine, Naltrexone, Buprenorphine, Naltrexone,

& Clonidine& Clonidine Anti-CravingAnti-Craving Clonidine or LofexidineClonidine or Lofexidine

Advantages of BuprenorphineAdvantages of Buprenorphine Buprenorphine binds more tightly to the receptor than any Buprenorphine binds more tightly to the receptor than any

other opiateother opiate It is a partial mu agonist, occupying that receptor only 70%- It is a partial mu agonist, occupying that receptor only 70%-

also kappa antagonistalso kappa antagonist Ceiling effect protects against overdose–but also limits Ceiling effect protects against overdose–but also limits

degree of agonist effect–ceiling effect approximately 32 mgdegree of agonist effect–ceiling effect approximately 32 mg Withdrawal easier than from methadone or heroinWithdrawal easier than from methadone or heroin Maintained patients describe;Maintained patients describe;

““Clear headedness”Clear headedness” Increased energyIncreased energy Improved sleep & mood stabilityImproved sleep & mood stability Easier to engage in therapyEasier to engage in therapy

Other Forms of Pain ManagementOther Forms of Pain Management

epidural nerve blocksepidural nerve blocks

radio frequencies; zap radio frequencies; zap nerve and deadens for nerve and deadens for up to 6 monthsup to 6 months

electrical stimulation: electrical stimulation: blocks pain signalsblocks pain signals

relaxation techniquesrelaxation techniques

BiofeedbackBiofeedback

physical therapy / physical therapy / chiropracticchiropractic

AcupunctureAcupuncture

morphine pump in bodymorphine pump in body

other medicationsother medications AntidepressantsAntidepressants NeurontinNeurontin FlexorilFlexoril