Prescription (Rx) Drug Misuse: Prescription (Rx) Drug Misuse: What’s the Problem?What’s the Problem?

Larissa Mooney, M.D.Larissa Mooney, M.D.Thomas E. Freese, Ph.D.Thomas E. Freese, Ph.D.

What is Misuse?What is Misuse?

MisuseMisuse = “ = “Non-medical useNon-medical use” or any use ” or any use that is outside of a medically prescribed that is outside of a medically prescribed regimenregimen

Examples can include:Examples can include: Taking forTaking for psychoactive “high” effects psychoactive “high” effects Taking in Taking in extreme dosesextreme doses Mixing Mixing pillspills Using withUsing with alcohol or other illicit substances alcohol or other illicit substances Obtaining fromObtaining from non-medical sources non-medical sources

Commonly Misused Rx Commonly Misused Rx DrugsDrugs

Opiates: pain-killersOpiates: pain-killers Ex) Vicodin, Oxycontin, Tylenol Ex) Vicodin, Oxycontin, Tylenol

CodeineCodeine

CNS Depressants CNS Depressants (Sedatives/Tranquilizers): (Sedatives/Tranquilizers): treat anxiety and sleep disorderstreat anxiety and sleep disorders Ex) Xanax, Ativan, Valium, SomaEx) Xanax, Ativan, Valium, Soma

Stimulants: ADHD, weight lossStimulants: ADHD, weight loss Ex) Aderall, Ritalin, Concerta, Ex) Aderall, Ritalin, Concerta,

Dexedrine, FastinDexedrine, Fastin

Classified in 3 classes

Rx Drug Misuse in the Rx Drug Misuse in the U.S.U.S.

6.4 million aged 12+ used a 6.4 million aged 12+ used a Rx drug (non-medically) in the past year Rx drug (non-medically) in the past year

NSDUH, 2006

S edatives

S timulants

T ranquilizersPainkillers

4,700,000

1,800,000

1,100,000

272,000

Number of New Non-medical Users of Therapeutics

Percentage of population with past Percentage of population with past month use of pharmaceuticalsmonth use of pharmaceuticals

Rates of Prescription Narcotic Rates of Prescription Narcotic AbuseAbuse

Nonmedical use of prescription narcotics:2006: 33.5 million (13.6%) over age 121.64 million prescription narcotic users meet diagnostic criteria for opioid abuse or dependence (second only to marijuana [4.17 million]) Hydocodone (Vicodin) is most widely prescribed drug in US.

Los AngelesLos Angeles

Sales sharply increased for Sales sharply increased for oxycodoneoxycodone (84%) and (84%) and hydrocodonehydrocodone (47%) between 2001 and 2005. (47%) between 2001 and 2005.

Codeine, hydrocodoneCodeine, hydrocodone, and , and morphinemorphine were distributed in the were distributed in the largest amountslargest amounts when compared when compared with the grams of other opiates with the grams of other opiates distributed.distributed.

CEWG, 2006

Fatal Drug PoisoningBetween 1999 and 2002, the number of opioid analgesic poisonings on death certificates rose 91.2%*

During this time period, poisoning from opioid analgesics surpassed both cocaine and heroin poisoning as the most frequent type of drug poisoning found on death certificates in the U.S.*

In Florida 2007, 3 times more deaths from prescription drugs than from all illicit drugs combined. **

* Source: Paulozzi, L.J., Budnitz, D.S., Xi, Y, 2006. Increasing deaths from opioid analgesics in the United States. Pharmacoedidemiology and Drug Safety 15, 613-7.

** New York Times, June 14, 2008.

Media AttentionMedia AttentionMedia AttentionMedia Attention

SPLENDID FORWind, Colic, Griping in the Bowels, Diarrhea Cholera and Teething Troubles

Epidemiology of Rx and OTC Epidemiology of Rx and OTC Drug Misuse Among YouthDrug Misuse Among Youth

GHBGHB

HeroinHeroin

KetamineKetamine

LSDLSD

MethMeth

EcstasyEcstasy

Cough MedicineCough Medicine

Crack/CocaineCrack/Cocaine

MarijuanaMarijuana 8.6 8.6 millionmillion4.5 million4.5 million

2.4 million2.4 million

2.4 million2.4 million

1.3 million1.3 million

1.9 million1.9 million

1.9 million1.9 million

1.1 million1.1 million

1 million1 million

1 million1 million

Prescription MedicinePrescription Medicine

NSDUH, 2006

New Landscape of Drug Abuse among Teens

High Rates in Non-medical Use of Oxy & VicodinHigh Rates in Non-medical Use of Oxy & Vicodin

0.00.0

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

12.012.0

OxyContin OxyContin Vicodin Vicodin

Per

cen

tP

erce

nt

20022002 20032003 20042004

9.69.610.510.5

9.39.3

4.04.04.54.5 5.05.0

Nearly 1 in 10 12th Graders Abused Vicodin Last YearNearly 1 in 10 12th Graders Abused Vicodin Last Year

Source: Monitoring the Future Study, 2004.Source: Monitoring the Future Study, 2004.

Generation RxGeneration Rx Rx/OTC med abuse has penetrated teen culture 18% of teens have abused Vicodin 20% tried Ritalin or Adderall without Rx 9% abused OTC cough syrup to get high Equal or greater abuse of OTC/Rx than cocaine, Ecstasy,

LSD, ketamine, heroin, GHB, ice Believe that Rx Meds safer (50%), less addictive (33%) Ease of access: medicine cabinets “Drugs are fun” vs “Drugs help kids when they are

having a hard time”

April 21, 2005. Partnership for a Drug Free America. 17April 21, 2005. Partnership for a Drug Free America. 17thth annual study of teen drug annual study of teen drug abuse. N= 7,300, error margin +/- 1.5%abuse. N= 7,300, error margin +/- 1.5%

Misuse of Rx Drugs in CA High Misuse of Rx Drugs in CA High SchoolsSchools

MisuseMisuse of of painkillerspainkillers (no prescription) to (no prescription) to get highget high:: 15% of 11th 15% of 11th gradersgraders 9% of 9th 9% of 9th gradersgraders 4% of 7th graders4% of 7th graders

California Student Survey 2006

Older AdultsOlder Adults

RX Drug Abuse in Older RX Drug Abuse in Older AdultsAdults

Older Adults Older Adults account for account for 1/3 1/3 of of all medications all medications prescribedprescribed in the U.S. in the U.S.

7.2 million 7.2 million (21.7%)(21.7%) receivereceive at least 1 Rx at least 1 Rx annually.annually.

Older adults use Rx drugs Older adults use Rx drugs 3 times more3 times more than the than the general population.general population.

On average, older persons take On average, older persons take 4.5 medications 4.5 medications perper dayday..

2.8 million 2.8 million older adults older adults abuseabuse Rx drugs in the last Rx drugs in the last yearyear..

SAMHSA, 2006; NIDA, 2005

An estimated An estimated one in fiveone in five older adults older adults are negatively affected by combined are negatively affected by combined

difficulties with difficulties with alcoholalcohol andand Rx medication abuseRx medication abuse..

Older AdultsOlder Adults Risks FactorsRisks Factors

Prescribed Prescribed multiple multiple medicationsmedications..

Long-termLong-term prescriptions prescriptions cancan lead to lead to unintentional misuseunintentional misuse -- taking different doses.taking different doses.

PrescribedPrescribed inappropriately inappropriately high doseshigh doses..

Medical Exposure to Rx DrugsMedical Exposure to Rx Drugs

12

18.620.1

27.3

20.4

28.3

19.4

24.8

0

5

10

15

20

25

30

65-69 70-74 75-79 80+

Male Female

Simoni-Wastila et al, 2006

•Older women more likely to be exposed to Rx drugs for medical reasons than men.

Risk of Rx Drug Misuse in Older Risk of Rx Drug Misuse in Older WomenWomen

Live longer: greater likelihood for exposure Live longer: greater likelihood for exposure to Rxsto Rxs

Propensity for care seeking Propensity for care seeking greater greater exposure to Rxsexposure to Rxs

Biology/Metabolic differences Biology/Metabolic differences

Metabolize alcohol & drugs differently Metabolize alcohol & drugs differently than men, and have lower tolerance to Rx than men, and have lower tolerance to Rx drugs and alcoholdrugs and alcohol

Side Effects can be Lethal if…Side Effects can be Lethal if…

Combining Combining Rx & OTCRx & OTC medications. medications. Taking Rx and OTC meds with Taking Rx and OTC meds with alcoholalcohol.. Using Rx and OTC with Using Rx and OTC with other illicit other illicit

drugsdrugs.. Interactions: Interactions: Rx & OTCRx & OTC meds with other meds with other

physical medications (i.e., physical medications (i.e., HIV or HIV or Hepatitis)Hepatitis)

Efforts in CaliforniaEfforts in California Establishment of statewide Establishment of statewide Rx Drug Rx Drug

Task force charged Task force charged with:with: Monitoring trends and strategies Monitoring trends and strategies at the at the

state and local levels.state and local levels.

Developing prevention strategies Developing prevention strategies for Rx for Rx & OTC drug abuse.& OTC drug abuse.

Developing intervention strategies Developing intervention strategies for for Rx & OTC drug abuse in treatment Rx & OTC drug abuse in treatment settings.settings.

Questions?Questions?

Prescription Drug Prescription Drug AbuseAbuse

Larissa Mooney, M.D.Larissa Mooney, M.D.Assistant Professor of Psychiatry Assistant Professor of Psychiatry

UCLA Integrated Substance Abuse UCLA Integrated Substance Abuse ProgramsPrograms

David Geffen School of Medicine at David Geffen School of Medicine at UCLAUCLA

OverviewOverview

Three classes of commonly abused Three classes of commonly abused Rx drugs (opioids, sedatives, Rx drugs (opioids, sedatives, stimulants)stimulants) What are they? What are they? How do they act in the brain and body?How do they act in the brain and body? What are their effects?What are their effects? NeurobiologyNeurobiology

What are opioids? What are opioids?

Opiate: derivative of opium poppyOpiate: derivative of opium poppy MorphineMorphine CodeineCodeine

Opioid: any compound that binds to opiate Opioid: any compound that binds to opiate receptorsreceptors Semisynthetic (including heroin)Semisynthetic (including heroin) Synthetic Synthetic Oral, transdermal and intravenous formulationsOral, transdermal and intravenous formulations

Narcotic: legal designationNarcotic: legal designation

Opioid ReceptorsOpioid Receptors

Receptor typesReceptor types mu, delta, kappamu, delta, kappa

Receptors located throughout bodyReceptors located throughout body Pain relief: central and peripheral nervous Pain relief: central and peripheral nervous

systemsystem Reward and reinforcement: deep brain Reward and reinforcement: deep brain

structuresstructures Side effects: constipation, sedation, itch, mental Side effects: constipation, sedation, itch, mental

status changesstatus changes Receptor interactions Receptor interactions

Full agonistsFull agonists Partial agonistsPartial agonists AntagonistsAntagonists

SOURCE: National Institute on Drug Abuse, www.nida.nih.gov.

Endogenous OpioidsEndogenous Opioids

Produced naturally in body Produced naturally in body Act on opioid receptors Act on opioid receptors Examples: endorphins, enkephalins, Examples: endorphins, enkephalins,

dynorphins, endomorphinsdynorphins, endomorphins Produce euphoria and pain relief;

naturally increased when one feels pain or experiences pleasure

Pain: the Fifth Vital SignPain: the Fifth Vital Sign

JACHO Guidelines 2000:JACHO Guidelines 2000: Mandated pain assessment and treatmentMandated pain assessment and treatment Nurse and physician education requiredNurse and physician education required

When opioids prescribed properly When opioids prescribed properly for pain, addiction rare in patients for pain, addiction rare in patients without underlying risk factorswithout underlying risk factors Vulnerabilities same as for other Vulnerabilities same as for other

addictions: genetic, peer and social addictions: genetic, peer and social influences, trauma and abuse historyinfluences, trauma and abuse history

Pain PathwayPain Pathway

www.ccac.cawww.ccac.ca

Pain Control and Pain Control and AddictionAddiction

“Pseudoaddiction”: Presence of drug-seeking behavior in

context of inadequate pain control Behavior stops with adequate pain reliefBehavior stops with adequate pain relief Description of a clinical interaction (not Description of a clinical interaction (not

a true diagnosis)a true diagnosis) Physical dependencePhysical dependence

with continued use, withdrawal with continued use, withdrawal syndrome produced by rapid dose syndrome produced by rapid dose reduction; occurs via neuroadaptation reduction; occurs via neuroadaptation Not synonymous with addictionNot synonymous with addiction

Opioid WithdrawalOpioid Withdrawal

Dysphoric moodDysphoric mood Nausea or vomitingNausea or vomiting DiarrheaDiarrhea Tearing or runny noseTearing or runny nose Dilated pupilsDilated pupils Muscle achesMuscle aches GoosebumpsGoosebumps SweatingSweating YawningYawning FeverFever InsomniaInsomnia

MorphineMorphine

Routes: oral, intramuscular, intravenous, Routes: oral, intramuscular, intravenous, rectalrectal

Sustained release preparations:Sustained release preparations: MS ContinMS Contin OramorphOramorph KadianKadian Avinza Avinza

CodeineCodeine

Opiate (naturally occurring in poppy)Opiate (naturally occurring in poppy) Low potency Low potency Pain relief via 10% conversion to Pain relief via 10% conversion to

morphinemorphine Most commonly prescribed opioid in the Most commonly prescribed opioid in the

worldworld Probably the most widely used analgesicProbably the most widely used analgesic

(Excluding aspirin)(Excluding aspirin)

Semisynthetic OpioidsSemisynthetic Opioids

Hydrocodone with Tylenol:Hydrocodone with Tylenol: Norco Norco Lortab Lortab Vicodin Vicodin Lorcet Lorcet

Hydrocodone with ibuprofen: VicoprofenHydrocodone with ibuprofen: Vicoprofen Hydromorphone: Dilaudid Hydromorphone: Dilaudid Oxycodone with Tylenol: Percocet Oxycodone with Tylenol: Percocet Oxycodone with aspirin: Percodan Oxycodone with aspirin: Percodan OxyContinOxyContin

OxyContinOxyContin

Used to treat pain associated with arthritis, Used to treat pain associated with arthritis, lower back injuries, and cancerlower back injuries, and cancer

Most commonly in tablet form: 10mg, Most commonly in tablet form: 10mg, 20mg, 40mg, 60mg, and 80mg tablets 20mg, 40mg, 60mg, and 80mg tablets

Dosed every 12 hours, half-life 4.5 hoursDosed every 12 hours, half-life 4.5 hours Abuse: may be chewed, crushed, snorted or Abuse: may be chewed, crushed, snorted or

injectedinjected Eliminates time-release coatingEliminates time-release coating Enhances euphoria, “rush” Enhances euphoria, “rush” Increases risk for serious medical consequencesIncreases risk for serious medical consequences

Synthetic OpioidsSynthetic Opioids MethadoneMethadone Demerol (meperidine)Demerol (meperidine) FentanylFentanyl Suboxone/Subutex (buprenorphine)Suboxone/Subutex (buprenorphine) TramadolTramadol

Complex mechanism of actionComplex mechanism of action Nonscheduled, less abuse potential Nonscheduled, less abuse potential

Opiates and Reward

Opiates bind to opiate receptors in Opiates bind to opiate receptors in the nucleus accumbens: increased the nucleus accumbens: increased dopamine releasedopamine release

DextromethorphanDextromethorphan

Over-the-counter cough suppressantOver-the-counter cough suppressant Structurally related to morphineStructurally related to morphine Mechanism: NMDA antagonistMechanism: NMDA antagonist Dissociative psychedelic properties in Dissociative psychedelic properties in

excess doses (like ketamine, PCP)excess doses (like ketamine, PCP)

Sedative-HypnoticsSedative-Hypnotics

Used to treat anxiety and sleep Used to treat anxiety and sleep disordersdisorders

Mechanism: enhances GABAMechanism: enhances GABA acts to slow normal brain functionacts to slow normal brain function

BarbituratesBarbiturates PhenobarbitalPhenobarbital PentobarbitalPentobarbital Fioricet Fioricet

(butalbital/acetaminophen/caffeine)(butalbital/acetaminophen/caffeine)

Sedative-Hypnotics Sedative-Hypnotics Cont’dCont’d

BenzodiazepinesBenzodiazepines Librium (chlordiazepoxide HCL)Librium (chlordiazepoxide HCL) Valium (diazepam)Valium (diazepam) Restoril (tempazepam) Restoril (tempazepam) Klonopin (clonazepam)Klonopin (clonazepam) Ativan (lorazepam)Ativan (lorazepam) Xanax (alprazolam)Xanax (alprazolam)

Non-benzo hypnoticsNon-benzo hypnotics Ambien (zolpidem)Ambien (zolpidem) Sonata (zaleplon)Sonata (zaleplon) Lunesta (eszopiclone)Lunesta (eszopiclone)

SomaSoma Cross-tolerance with alcohol (GABA related)Cross-tolerance with alcohol (GABA related)

Sedative-Hypnotic Sedative-Hypnotic EffectsEffects

SedationSedation Slurred speechSlurred speech IncoordinationIncoordination Unsteady gaitUnsteady gait Impaired attention or memoryImpaired attention or memory Stupor or coma Stupor or coma Overdose risk increased with opioids Overdose risk increased with opioids

or in combination with other or in combination with other sedatives, including alcohol sedatives, including alcohol

Sedating Drugs and Sedating Drugs and OverdoseOverdose

Other Sedative-Hypnotic Other Sedative-Hypnotic RisksRisks

No significant adverse medical No significant adverse medical consequences of long-term useconsequences of long-term use

Amnesia Amnesia Difficulty with recent memoryDifficulty with recent memory

Tolerance, physiological Tolerance, physiological dependence, addictiondependence, addiction Addiction risk factors same as for other Addiction risk factors same as for other

drugs of abusedrugs of abuse

Sedative-Hypnotic Sedative-Hypnotic WithdrawalWithdrawal

Increased pulse, blood pressure, or Increased pulse, blood pressure, or sweatingsweating

Hand tremorHand tremor Nausea or vomitingNausea or vomiting Transient hallucinations or illusionsTransient hallucinations or illusions AgitationAgitation AnxietyAnxiety SeizuresSeizures

Protracted WithdrawalProtracted Withdrawal

Abstinence syndromeAbstinence syndrome AnxietyAnxiety Muscle twitchingMuscle twitching Low moodLow mood SweatingSweating HeadacheHeadache DerealizationDerealization

Rebound insomniaRebound insomnia Especially with short-acting Especially with short-acting

benzodiazepinesbenzodiazepines

Sedative-Hypnotic Sedative-Hypnotic NeurobiologyNeurobiology

SourceSource: :

www.ccforum.comwww.ccforum.com

Prescription StimulantsPrescription Stimulants Stimulants (i.e., amphetamines) are often Stimulants (i.e., amphetamines) are often

prescribed to treat individuals diagnosed prescribed to treat individuals diagnosed with attention-deficit hyperactivity with attention-deficit hyperactivity disorder (ADHD). disorder (ADHD).

Substantial amounts of pharmaceutical Substantial amounts of pharmaceutical amphetamines are diverted from medical amphetamines are diverted from medical use to non-prescription use.use to non-prescription use.

Amphetamines increase wakefulness and Amphetamines increase wakefulness and alertness and have been used by:alertness and have been used by: The military, by pilots, truck drivers, and The military, by pilots, truck drivers, and

other workers to keep functioning past their other workers to keep functioning past their normal limitsnormal limits

Source: Erowid.org

Short-Term EffectsShort-Term Effects

EuphoriaEuphoria Increased energy/productivityIncreased energy/productivity Increased concentrationIncreased concentration Decreased appetiteDecreased appetite Increased libido Increased libido Decreased sleepDecreased sleep

RitalinRitalin When used to treat ADHD, patients may When used to treat ADHD, patients may

report increased attention, decreased report increased attention, decreased impulsivity, and decreased hyperactivity. impulsivity, and decreased hyperactivity.

Milder stimulant that works by affecting Milder stimulant that works by affecting the levels of chemicals the levels of chemicals (neurotransmitters) in the nervous (neurotransmitters) in the nervous system.system.

May also be used in the treatment of May also be used in the treatment of depression in certain casesdepression in certain cases

Long-acting form: ConcertaLong-acting form: Concerta

* WebMD

AdderallAdderall

Adderall is used to treat attention deficit Adderall is used to treat attention deficit hyperactivity disorder (ADHD). hyperactivity disorder (ADHD).

Adderall is a combination of stimulants Adderall is a combination of stimulants (amphetamine and dextroamphetamine). (amphetamine and dextroamphetamine).

It increases the ability to pay attention, It increases the ability to pay attention, focus, and control behavior problems.focus, and control behavior problems.

This drug may also be used to treat This drug may also be used to treat certain sleeping disorders (narcolepsy).certain sleeping disorders (narcolepsy).

Medical RisksMedical Risks

Norepinephrine release causes Norepinephrine release causes constriction of blood vessels, elevated constriction of blood vessels, elevated blood pressure and rapid heart rateblood pressure and rapid heart rate

Increased activity levelsIncreased activity levels Dangerously high body temperaturesDangerously high body temperatures Increased risk of seizures Increased risk of seizures Potentially fatal arrhythmias, heart Potentially fatal arrhythmias, heart

attack, or stroke attack, or stroke

Psychiatric Symptoms Psychiatric Symptoms

Psychiatric symptoms associated with use of Psychiatric symptoms associated with use of larger doses of amphetamines include larger doses of amphetamines include depression, anxiety, psychosis, and suicidal depression, anxiety, psychosis, and suicidal ideation ideation

Symptoms may depend on differences in Symptoms may depend on differences in sensitivity, frequency and quantity of use, sensitivity, frequency and quantity of use, and method of administrationand method of administration

Abstinence syndrome may occur (dysphoria, Abstinence syndrome may occur (dysphoria, anhedonia, irritability, anhedonia, irritability, insomnia/hypersomnia, anxiety, low energy)insomnia/hypersomnia, anxiety, low energy)

Neurobiology of Neurobiology of StimulantsStimulants

Medications to Treat Medications to Treat AddictionAddiction

Addiction is a chronic, relapsing brain Addiction is a chronic, relapsing brain disease characterized by compulsive use disease characterized by compulsive use despite harmful consequencesdespite harmful consequences

Medications as part of Medications as part of comprehensive comprehensive treatment plantreatment plan

Treatment approaches:Treatment approaches: Medications (Bio) Medications (Bio) Therapy, lifestyle changes (Psycho-Social)Therapy, lifestyle changes (Psycho-Social)

Thorough evaluation and diagnosis Thorough evaluation and diagnosis essentialessential

Pharmacotherapy in Pharmacotherapy in Substance Use DisordersSubstance Use Disorders

Treatment of withdrawal (“detox”) Treatment of withdrawal (“detox”) Treatment of psychiatric symptoms or Treatment of psychiatric symptoms or

co-occurring disorders co-occurring disorders Reduction of cravings and urgesReduction of cravings and urges Substitution therapySubstitution therapy

Opioid Detoxification Opioid Detoxification

Medications used to alleviate Medications used to alleviate withdrawal symptoms:withdrawal symptoms:

- Opioid agnonists (methadone, - Opioid agnonists (methadone, buprenorphine) buprenorphine) - Clonidine - Clonidine - Other supportive medications- Other supportive medications

anti-diarrheals, anti-nausea agents, anti-diarrheals, anti-nausea agents, ibuprofen, muscle relaxants, anti-ibuprofen, muscle relaxants, anti-anxiety medicationsanxiety medications

Opioid Substitution GoalsOpioid Substitution Goals

Reduce symptoms & signs of Reduce symptoms & signs of withdrawalwithdrawal

Reduce or eliminate cravingReduce or eliminate craving Block effects of illicit opioidsBlock effects of illicit opioids Restore normal physiologyRestore normal physiology Promote psychosocial rehabilitation Promote psychosocial rehabilitation

and non-drug lifestyleand non-drug lifestyle

OOH O

N

OH

CH3 CH2CH2 CH N

CH3CH3

CH3

O

Methadone: Methadone: Clinical PropertiesClinical Properties

Synthetic opioid agonist Synthetic opioid agonist Analgesic, CNS depressantAnalgesic, CNS depressant Effects last 24 hours; once-daily dosing Effects last 24 hours; once-daily dosing

maintains constant blood level maintains constant blood level Prevents withdrawal, reduces craving Prevents withdrawal, reduces craving

and use and use Facilitates rehabilitationFacilitates rehabilitation Clinic dispensing limits availability Clinic dispensing limits availability

CH3 CH2CH2 CH N

CH3CH3

CH3

O

Buprenorphine for Buprenorphine for Opioid DependenceOpioid Dependence

FDA approved 2002, age 16+FDA approved 2002, age 16+ Mandatory certification from DEA Mandatory certification from DEA Mechanism: partial opioid agonistMechanism: partial opioid agonist Office-based, expands availabilityOffice-based, expands availability Analgesic propertiesAnalgesic properties Ceiling effect Ceiling effect Lower abuse potential Lower abuse potential Safer in overdose Safer in overdose

Buprenorphine Buprenorphine FormulationsFormulations

Sublingual administration Sublingual administration Subutex (Buprenorphine)Subutex (Buprenorphine) Suboxone (4:1 Bup:naloxone) Suboxone (4:1 Bup:naloxone) Dose: 2mg-32mg/day Dose: 2mg-32mg/day Once-daily dosing Once-daily dosing

MYTH: Patients are still MYTH: Patients are still addictedaddicted

FACT:FACT: Addiction is pathologic use of Addiction is pathologic use of a substance and a substance and maymay or or may notmay not include physical dependence.include physical dependence.

Physical dependence on a Physical dependence on a medication for treatment of a medication for treatment of a medical problem medical problem does notdoes not mean mean the person is engaging in the person is engaging in pathologic use and other behaviors. pathologic use and other behaviors.

Medications for Sedative-Medications for Sedative-Hypnotic DependenceHypnotic Dependence

Taper: slowly decrease dose to Taper: slowly decrease dose to minimize withdrawal symptomsminimize withdrawal symptoms

May first convert to longer-acting May first convert to longer-acting agent agent

Use non-addictive medications for Use non-addictive medications for residual anxiety symptomsresidual anxiety symptoms SSRIs and other antidepressantsSSRIs and other antidepressants Other anti-anxiety agentsOther anti-anxiety agents

Treatment of Stimulant Treatment of Stimulant DependenceDependence

Behavioral therapies effective for Behavioral therapies effective for treating stimulant dependence treating stimulant dependence

At this time, there are no FDA-At this time, there are no FDA-approved medications for the approved medications for the treatment of stimulant dependence. treatment of stimulant dependence.

Outpatient taper: slowly decrease doseOutpatient taper: slowly decrease dose Medications to treat withdrawal Medications to treat withdrawal

symptoms symptoms AnxietyAnxiety DepressionDepression

* NIDA

Medications for Stimulant Medications for Stimulant DependenceDependence

Medications used to treat stimulant-Medications used to treat stimulant-induced psychiatric symptoms:induced psychiatric symptoms: AntidepressantsAntidepressants AntipsychoticsAntipsychotics Anti-anxiety agentsAnti-anxiety agents Medications to treat agitation, violenceMedications to treat agitation, violence

ER and outpatient settingsER and outpatient settings Medications to treat co-occurring Medications to treat co-occurring

psychiatric disorderspsychiatric disorders

In ConclusionIn Conclusion

Addiction is a serious, chronic and relapsing Addiction is a serious, chronic and relapsing disorder, but treatments are available disorder, but treatments are available

Medications should be considered as part of Medications should be considered as part of a comprehensive treatment plan, addressing a comprehensive treatment plan, addressing both disordered physiology and disrupted both disordered physiology and disrupted liveslives

Medications should be considered for Medications should be considered for treatment of: psychiatric sx’s, addictive d/o’s, treatment of: psychiatric sx’s, addictive d/o’s, and co-occurring d/o’sand co-occurring d/o’s

Emerging research supports use of meds in Emerging research supports use of meds in individuals with SUDs and psychiatric individuals with SUDs and psychiatric comorbiditycomorbidity

Thank you! Thank you!

Larissa Mooney, M.D.Larissa Mooney, M.D.

lmooney@mednet.ucla.edulmooney@mednet.ucla.edu

Thomas E. Freese, Ph.D.Thomas E. Freese, Ph.D.

tfreese@mednet.ucla.edutfreese@mednet.ucla.edu

UCLA Integrated Substance Abuse UCLA Integrated Substance Abuse ProgramsPrograms