prescription drug diversion christian j. teter, pharm.d., bcpp associate professor,...
Post on 26-Dec-2015
218 Views
Preview:
TRANSCRIPT
PRESCRIPTION DRUG DIVERSION
Christian J. Teter, Pharm.D., BCPP
Associate Professor, Psychopharmacology
College Of Pharmacy,
University Of New England
Portland, ME
E-Mail: cteter@une.edu
Maine Pharmacy Association, Spring Conference &Trade Show, Freeport, Maine (March 20 – 22, 2015)
1. Identify which category of prescription medications demonstrates the highest rates of diversion.
2. Recognize sources of diversion for prescription opioids and stimulants.
3. Describe other problem behaviors that are associated with prescription drug diversion.
LEARNING OBJECTIVES2
DISCLOSURES
Christian J. Teter has no real or potential conflicts of interest to report.
The use of prescription medications for ‘off-label’ use will be discussed during this presentation: Example: among ‘healthy students’ without
Attention-Deficit/Hyperactivity Disorder (ADHD)
3
4
INTRODUCTION
Key Definitions
“Medical misuse of prescription medications” Refers to use of a prescribed psychotherapeutic medication
in a manner not intended by the prescribing clinician (e.g., taking too much, intentionally using to get high)
“Diversion of prescription medications” Refers to exchange of prescription medications that leads
to use of these medications by people other than for whom the prescribing clinician intended
“Nonmedical use of prescription medications” Refers to the non-prescribed use of a controlled,
psychotherapeutic medication Example: nonmedical use of prescription stimulants
(NMUPS)
5
6
1) Sleeping medication (e.g., Ambien®, Halcion®, Restoril®, temazepam, triazolam)
2) Sedative/anxiety medication (e.g., Ativan®, Xanax®, Valium®, Klonopin®, diazepam, lorazepam)
3) Stimulant medication (e.g., Ritalin®, Dexedrine®, Adderall®, Concerta®, methlyphenidate)
4) Pain medication (i.e., opioids such as Vicodin®, OxyContin®, Tylenol 3 with codeine®, Percocet®, Darvocet®, morphine, hydrocodone, oxycodone)
Background
Significant therapeutic
overlap between these categories.
Focus of this lecture (i.e., prescription
stimulants and prescription
opioids).
Why should we be concerned?
7
Considerations: Potential for Addiction
Source: Volkow et al, 1995 (Arch Gen Psych)
Note: both cocaine and MPH inhibit dopamine transporter; similar brain regions.
9
NMUPM PREVALENCE RATES & TRENDS (brief overview)
DIVERSION vs. NMUPM
10
Distribution of Past Year Nonmedical Use of Prescription Medications: 119
U.S. Colleges
Source: McCabe et al 2011
0
5
10
15
20
Medical use only Medical use & nonmedical use Nonmedical use only
Past Year Medical Use and Nonmedical Use of Prescription Medications (College Undergraduates)
Sedative medication
Opioidmedication
Stimulantmedication
Sleeping medication%
rep
ort
ing
pre
scri
pti
on
med
icat
ion
use
Source: McCabe SE. Arch Pediatr Adolesc Med 2008
11
By definition…Rx DRUG DIVERSION is taking
place!
12
Student Life Survey (SLS): 20-Year Trends from 1993 – 2013
13
2003 (N=8460
)
2005 (N=3556
)
2007 (N=1653
)
2009 (N=1058
)
2011 (N=1313
)
2013 (N=3553
)
0
1
2
3
4
5
6
7
8
9
10
22.4 2.6 2.5
2.1 2.32.9
2.6 2.52.1
1.8
3
5.46
6.8 6.9
7.6
9.39.3
7.4
6.6
5.5
44.5
Sleeping Medication Anti-Anxiety MedicationStimulant Medication Pain Medication
Trends in Past-Year Nonmedical Use of Prescription Medications by UM
Undergraduate Students (2003, 2005, 2007, 2009, 2011, and 2013 SLS)
Note: 1993-2001 results were not included because the measure was worded differently. Source: McCabe et al. Addictive Behaviors 2014
0
5
10
15
20
25
30
35
40 37.4
9.3
4.9 4.53 3.4 3.7 4.2
2.3
34.9
11.1
5.8 5.43.4 3.1
1.93.9
2.2
Past-Year Drug Use among UM and U.S. Undergraduate Students (Sources: 2013 SLS and
2012 MTF)
Note: Past-year prevalence rates for inhalants, heroin, crystal methamphetamine use were 1% or less and not shown in this figure.
14
15
DIVERSION
16
% a
pp
roac
hed
to
div
ert
thei
r m
edic
atio
nApproached to Divert Medications in Lifetime
(Adolescent medical users approached to divert)
0
5
10
15
20
25
30
SleepingMedication
(n=108)
Anti-anxietyMedication
(n=104)
StimulantMedication
(n=141)
OpioidMedication
(n=704)
Source: McCabe et al. Drug Alc Depend 2011
Percentages much larger
among college students!
17
Prevalence of Actual Diversion among College Students Prescribed Stimulant Medication for ADHD
Rabiner et al., 2009 (n=115),
previous 6 months
Sepulveda et al., 2011 (n=50), previous 12
months
Garnier et al., 2010 (n=81), in a
lifetime
0
10
20
30
40
50
60
26
35
62
% m
edic
al use
rs g
ivin
g a
way o
r se
llin
g t
heir
medic
ati
on
Sources: Garnier et al., 2010; Rabiner et al., 2009; Sepulveda et al., 2011
18
Past Year Diversion of Specific Prescription Stimulants by College Students Prescribed Stimulant Medication for ADHD
Adderall® only (n=14)
Adderall XR® only (n=12)
Concerta® only (n = 8)
Other combos (n=13)
0
10
20
30
40
5050
25
0
54
% m
edic
al use
rs g
ivin
g a
way o
r se
llin
g t
heir
medic
ati
on
Source: Sepulveda et al. J Pharm Practice 2011
Lower diversion rates with extended release formulations
19
Sources of Lifetime Nonmedical Use of Prescription Stimulants [College]
Parent
Drug dealer
Sibling
Acquaintance from other school
Boyfriend/girlfriend
Roommate
Acquaintance from same school
Friend not from same school
Friend from same school
0 10 20 30 40 50 60
1
8
4
9
6
14
13
42
52
2
2
7
12
12
9
19
35
57
Women (n=165)Men (n=217)
Percent of Respondents
The following sources were less than 1%: aunt/uncle, other family, abroad, and internet.
20
Sources of Lifetime Nonmedical Use of Prescription Opioids [College]
6
3
5
5
8
6
8
29
20
41
1
4
3
7
6
10
8
25
36
26
0 10 20 30 40 50
Drug dealer
Other family member
Acquaintance from same school
Sibling
Acquaintance from other school
Boyfriend/girlfriend
Roommate
Friend from same school
Parent
Friend not from same school
Percent of Respondents
Women (n=321)
Men (n=319)
******
***p<.001
***
The following sources were 2% or less: aunt/uncle (2%), abroad (1%), and internet (0.2%).
21
Sources of Prescription Opioids among Past Year Nonmedical Users [High School Seniors 2007-10]
Other
Bought from drug dealer/stranger
Stole from friend/relative
Bought from friend/relative
From a previous prescrip-tion
Free from friend/relative
0 10 20 30 40 50
Percent of Respondents
The following source was 2% or less: internet. Source: McCabe et al. JAH 2013
22
National Survey on Drug Use & Health (NSDUH; 2013; Public domain)
Example: pain reliever sources for nonmedical use• past-year• users aged
12(+)• 2012-2013
• Friends/relatives!
23
“My friends need these drugs for ADD/ADHD and they give them out to myself and other
friends.” (Hispanic, senior)
“From friends with prescriptions, or from those who have bought large
quantities from people with prescriptions.” (White, junior)
“I was given them by a friend at a party.”
(White, freshmen)
“A friend has a prescription and sells the pills to me.”
(White, senior)
WOMEN MEN
Image source: Scientific American. The Quest for a Smart Pill.
Qualitative Quotations
24
Amount Paid for One Prescription Stimulant Pill: Undergraduate Students (n=225)
$0 (free) $1 $2 or $3 $4 or $5 $10 No an-
swer
0
10
20
30
40
50
60
7072
3
129
1 1
% p
ayin
g e
ach
am
ount
per
pill
Source: Arria et al., 2008
25
PROBLEMATIC BEHAVIORS
26
n=1901 n=48 n=140 n=131 n=1936 n=78 n=122 n=121
Drug Abuse Screening Test Results based on Source of Prescription Opioids [College]
0
10
20
30
40
50
Men Women
No nonmedical use Parent only Peer only All other sources
***
******
***
% p
osi
tive
scr
een
ing
fo
r d
rug
ab
use
***p<.001 based on logistic regression using “no medical use” as reference group and adjusting for race/ethnicity, class year and living arrangement
Source: McCabe et al. Addict Behav 2007
27
No Misuse Medical Misuse0
25
50
75
18
55
Diversion x Medical Misuse among Past-Year Medical Users of Prescription Stimulants for ADHD
(n=50 undergraduates)%
rep
ort
ing
div
erti
ng
th
eir
med
icat
ion
Source: Sepúlveda et al. J Pharm Practice 2011
28
13
37
0
10
20
30
40
50
Medical Use Only (n=365) Medical Misuse (n=103)
Diversion by Medical Misuse among Past-Year Medical Users of Controlled Medications [Secondary (grades 7-12)]
% r
epo
rtin
g d
iver
tin
g t
hei
r m
edic
atio
n
Source: McCabe et al. Arch Pediatr Adolesc Med 2011
29
Conclusions
Nonmedical use of prescription medications has been a relatively recent public health issue among many populations Secondary and college students Residents of Maine General population
Much of this nonmedical use of prescription medications is driven by diversion
30
Diversion: Peer sources Most individuals obtain diverted prescription
medications from friends and family No strong evidence that individuals obtain prescription
medications directly via the internet Evidence suggests that a majority of individuals
(specifically students) obtain prescription medications for free (e.g., from peers)
Diversion: Medication misuse Strong relationship between misusing a prescribed
medication and diverting prescribed medication
Conclusions
Need to reduce nonmedical use and diversion of prescription medications must be balanced against the need for clinicians and patients to have access to medications for legitimate medical purposes Example: prescription stimulants are highly
effective at treating core symptoms of ADHD; large effect sizes
Treatment Considerations
31
When prescribing controlled medications to adolescents and young adults: Designate gatekeeper at home/school Educate regarding secure location for storage Discuss diversion (more in depth w/ ADHD meds) Screen for SUDs, especially those with a history of
nonmedical use and/or medical misuse Consider medications with less risk for abuse/diversion Limit/monitor medication quantity and refills Educate regarding proper disposal of medications
Treatment Recommendations32
33
For More Information (Selected References):
1. Johnston, L. D., O’Malley, P. M., Bachman, J. G., and Schulenberg, J. E., (2013). Monitoring the Future national survey results on drug use, 1975– 2012: Volume 2, College students and adults ages 19–50. Ann Arbor: Institute for Social Research, The University of Michigan.
2. McCabe, S.E., Cranford, J.A., Boyd, C.J., Teter, C.J. (2007). Motives, diversion and routes of administration associated with nonmedical use of prescription opioids. Addictive Behaviors, 32(3):562-575.
3. McCabe, S.E. (2008). Screening for drug abuse among medical and nonmedical users of prescription drugs in a probability sample of college students. Archives of Pediatrics & Adolescent Medicine, 162(3):225-231.
4. McCabe, S.E., Cranford, J.A., Teter, C.J., Rabiner, D., Boyd, C.J. (2011). Use, misuse and diversion of scheduled controlled prescription medications by college students. In H.R. White, D. Rabiner (Eds.), College Substance Use: Etiology, Consequences and Prevention. Thousand Oaks, CA: Sage.
5. McCabe, S.E., West, B.T., Teter, C.J., Ross-Durow, P., Young, A., Boyd, C.J. (2011). Characteristics associated with the diversion of controlled medications among adolescents. Drug and Alcohol Dependence, 118(2-3):452-458.
6. McCabe, S.E., West, B.T., Boyd, C.J. (2013). Leftover prescription opioids and nonmedical use among high school seniors: A multi-cohort national study. J Adolescent Health, 52(4):480-485.
7. McCabe, S.E., West, B.T., Teter, C.J., Boyd, C.J. (2014). Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 2003 to 2013: Connecting the dots. Addictive Behaviors 39(7):1176-1182.
8. Sepúlveda, D.R., Thomas, L.M., McCabe, S.E., Cranford, J.A., Boyd, C.J., Teter, C.J. (2011). Misuse of prescribed stimulant medication for ADHD and associated patterns of substance use. Journal of Pharmacy Practice, 24(6):551-560.
9. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
34
Assessment Questions
QUESTION #1: Which of the following characteristics is consistently associated with individuals who divert their prescription medications?a. Genderb. Medication misusec. Polypharmacyd. Race/Ethnicity
35
Assessment Questions
QUESTION #2: The most common source for obtaining prescription drugs to use nonmedically is which of the following:a. Friends/Relativesb. Altered prescriptionsc. Drug Dealersd. Internet Websites
36
Assessment Questions
QUESTION #3: Which of the following methods is the most common pathway for obtaining prescription drugs to use nonmedically? a. Doctor shoppingb. Theft/take without askingc. Purchase from someoned. Obtain for free
QUESTIONS (?)
top related