implementing effective prescription drug abuse prevention strategies jim middleton, pharmacist carol...
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Implementing Effective Prescription Drug Abuse
Prevention Strategies
Jim Middleton, Pharmacist
Carol Meyer-Niedzwiecki,
SAC Prevention Director
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Today's Goals!
1. Increase knowledge 2. Learn about interventions
3. Obtain tools and develop an action plan
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Topics to Get There
National issues with Local Significance
Background Education for the Layperson
The Misdirection of AssistanceResearch, News and Updates
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Some of the Challenges:
OVERALL PICTURE – Youth and adultPrescription drug abuse is rising
We live in a culture of “pain relief”
Youth Perception – Prescription drugs are safer than 'street drugs,' they are 'non-addictive,' and there is
less 'stigma' to their use
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Some of the problem
Highly publicized
From the CDC: Enough painkillers
were prescribed in
2010 to medicate
every American adult
around the clock
for a month.
(Nov, 2011 report)
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Some of the Problem
More than 40 people die
every day from ODs involving narcotic
pain relievers(CDC&P)
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Some of the Problem
National Data tells us:
14,800 people in the U.S. died from painkiller ODs in 2008. Greater than threefold increase
from 4,000 deaths in 1999. (CDC&P)
36,450 deaths from prescription and other illegal drugs in 2008 compared with 39,973 vehicle
crashes. (AP)
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Why is there abuse?
The “usual suspects” here:
get high, experimentation, cope, focus, peer pressure, lose weight, bulk up, self medicate, easy to get,
“It won't happen to me” and the proliferation of advertising
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Monitoring the Future Survey 2010
Annual prevalence of narcotics (other than heroin) amongst 12th Gr: 3.3% (1992) 9.5% (2004)
OXYCONTIN Gr 8 2.1%
Gr10 4.6%
Gr 12 5.1%
VICODIN Gr 8 2.7%
Gr 10 7.7%
Gr 12 8.0%
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NSDUHPDs #2 (marijuana #1) illicit drug used
Non-medical use of PDs by persons 12 yrs of age and older 2.5% (2008) 2.8% (2009)
Use rates overall higher in 2000's than 1990's
PAIN RELIEVERS 2002 2010
Youth 3.2% 2.5%
Young adults 4.1% 4.5%
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Michigan Data tells us:BRFSS 2009 (only ask about barbiturate use without a doctor's
prescription)
Ever In past 30 days
Gr 9 8% 4%
Gr 10 9% 5%
Gr 11 13% 8%
Gr 12 11% 5%
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And where are the drugs coming from?
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And where are the drugs coming from?
From a friend or relative – 55%By a direct prescription from a physician – 17.3%
Bought from a friend or relative – 11.4%Stolen from a friend or relative – 4.8%
From a dealer or stranger – 4.4%“Other” (ie, robbed a pharmacy, went to Mexico) – 7.1%
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And where are the drugs coming from?
Looking at it a different way:
By a direct prescription from a physician – 17.3%By an indirect prescription from a physician – 71.2%
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What We Look For
1. Patients who know more about prescription drugs than I do
2. Patients who know more about insurance coverage than I do, or insist they have no prescription coverage but like particular brands of drugs
3. Very thin, asymptomatic, agitated, toothless 20-somethings wanting Sudafed 24-hour capsules
4. And sadly, incoming patients who are perhaps a bit too friendly
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What We Look For
6. Elaborate Excuses, generally involving trips to Tennessee, an ex-spouse, neighbor's dog, a funeral, a bathroom sink, a kitchen sink, a neighbor's spouse, a neighbor's dog, a neighbor's ex-spouse from Tennessee with a dog....
7. A phone call that starts with “OK, it's like this....”
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Overall Causes of Death - US
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Compared to motor vehicle accidental death rates
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Accidental Drug Deaths since 1999
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Accidental Deaths by Drug
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Death by opioids vs sales
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Rates in US overall
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Consequences of overdoses
Death
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Death always reported as a drug reaction?
– not in Battle Creek
– homicides labeled “result of a gunshot wound”, not “individual, while on meth, attempted to rob a crack house and was shot in the process”
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Analysis of one (of 57) toxicology reports (2010)
– 41 year old Caucasian male, Battle Creek
– accidental death, toxicology revealed in blood:
7-Amino Clonazepam
Benzoylecgonine
Acetone
Methadone
Phenylpropanolamine
Amphetamine
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“Let's DO something!”Legislative Updates:
The majority of states now have Prescription Drug Monitoring Programs (PDMPs)
P.A. 84 (was SB 333): electronic reporting (NPLEx), effective 1/1/12
P.A. 85: product placement, ID buyer, record saleH.B. 4564: misdemeanor if purchaser uses fake ID to buy
ephedrine productH.B. 5089: establish an unused PD repository program.
Participating pharmacies would have to offer disposal programs for turned in meds
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Legislation Can Have Unintended Consequences
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My personal gateway drug...
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Rising to the Challenge
The need to balance access for therapeutic use vs easy access for abuse
The body does not know the difference between a 'legal' and an 'illegal' use of a drug
The body regards all drugs, foods, environmental chemicals with the same level of priority – it behaves unconsciously
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The body uses chemicals to maintain
a healthy balanceSerotoninDopamine
EpinephrineAcetylcholine
InsulinGABA
Electrolytes
In very tiny quantities
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Drugs Affect These Same Chemicals
SerotoninDopamine
EpinephrineAcetylcholine
InsulinGABA
Electrolytes
In very LARGE quantities
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How the brain sees drugs:
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So, treat those conditions! (well...)
Add Dopamine to control Parkinsonism, you can develop signs of mental illness
Block Dopamine to control Schizophrenia, you can develop symptoms that look like Parkinsonism
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The primitive brain is very compact (the Limbic system)
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Dopamine is a pleasure transmitter
– Increased levels result from chocolate, CNS stimulants
– Increasing the levels artificially leads to mania(Parkinson's patients developing gambling obsession)
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At what age do we introduceour children to drugs?
Define “drugs”
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Children aren't stupid! Really!!!
– Survey of parents thought their children on Ritalin or Adderall were at least 97% compliant with treatment
– reality was 75%
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The Drugged Society and Its Consequences
– “Oh, I take my husband's Xanax all the time. That doesn't interact with my Ambien, does it?”
– (call received Saturday, 19 Feb 2011)
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So we try to rise to the challenge,but maintain a proper balance
For example, in the 1880s, morphine abuse was nearly epidemic
We needed a heroic replacement to treat pain but not cause the addiction
The best chemists of the day worked on the problem – lo and behold, they created.......
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Heroin!
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Unregulated Marketing 1905
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Unregulated Marketing 1905
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Regulated Marketing - 1919
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In the 1930s
Scientists were searching for a drug that would
work to control seizure disorders (epilepsy)
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Sometimes you just have to wonder...
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Narcotic Analgesia
– Opiates have a natural product base – opium
poppy
– Opioids are the product of the chemist's bench – ie meperidine (Demerol)
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Consider these effects on
– Migraine
– GI disorders
– Bone pain (calcitonin breaks down bone)
– Estrogen-receptor type breast cancer
– Ability to control pain – the same 'benefit' will require larger and larger doses
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Relaxation in a tablet...
– The “Benzos” - benzodiazepines
– It all began with chlordiazepoxide (Librium), then diazepam (Valium), then lorazepam (Ativan), then chlorazepate dipotassium (Tranxene)... then alprazolzam (Xanax) …. a 50 year legacy of pharmacotherapeutic alternatives to facing stressors in our lives...
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GABA – gamma amino butyric acid
- “butyric” for “butter” (butter is 3-4% butyrate)
- hmmm.... dairy products to relax us.....
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What Parents and Educators Should Look for
– Sedation or erratic behavior of sudden onset
– Constipation and stomach complaints
– Loss of weight, loss of teeth, bleeding or infected gums
– Sudden interest in who in the family is ill, perhaps with cancer
– A need to refill your prescription meds early, especially if they have a sticker that reads “May Cause Drowsiness or Sedation”
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The Duty to Warn
Ancillary labels
– The wrong education provided? HIPAA challenges
– The hearing impaired in a
public arena
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The Right to be Pain Free
A JCAHO mandate A State of Michigan mandate Question: What is the definition of pain?
– Whatever the patient says it is! Sources for pain management
– Where did the notion originate?
– Is a dental office an appropriate starting point?• OxyContin as a first-line pain treatment for 14 year
olds?
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Diversion Flags
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What is observed....
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Free Speech and Marketing
Free Speech and Marketing
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Drug Take-Back Programs
– Collects unused drugs
– Offers a method of removing controlled substances from easy access
– Drugs do not enter the water supply, but are incinerated as medical waste (at 3000 degrees)
– Typical day of take back brings in 200,000 – 300,000 tablets
– Drug companies are VERY supportive of this
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Misdirected SolutionsAnd
Why We Are Here
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Control of Pseudoephedrine (Sudafed)
The Problem:
– no requirement for general oversight
– county-by-county monitoring of logs and usage varies wildly
– monitoring often gets cut with budget challenges (Kalamazoo county)
– user can hop from one pharmacy to the next
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The Challenged Response to the Challenge
- The Problem:
Narcotic Prescriptions are being prescribed at an overwhelming volume and are becoming harder to track....
- The Solution:
Cut the triplicate-script program, extend the amount of time to fill powerful narcotics and stimulants, and allow for multiple prescriptions – to make access more convenient
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The Challenged Response to the Challenge
- The Problem:
Abuse of Vicodin/Norco/Lortab type narcotics is leading to liver damage due to the amount of acetaminophen in each tablet
- The Solution:
Don't control the hydrocodone use – restrict the amount of acetaminophen in each tablet
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The Challenged Response to the Challenge
- The Problem:
Sudafed sales are directly related to the number of meth labs being created. Making Sudafed/pseudo- ephedrine a prescription seems to be the only real solution
- The Solution (in Michigan):
Keep Sudafed as an OTC but subscribe to a 'signature log' database without useful oversight – and cut police
![Page 67: Implementing Effective Prescription Drug Abuse Prevention Strategies Jim Middleton, Pharmacist Carol Meyer-Niedzwiecki, SAC Prevention Director](https://reader035.vdocument.in/reader035/viewer/2022062322/56649e985503460f94b9ae43/html5/thumbnails/67.jpg)
The Challenged Response to the Challenge
In other words, you may see a reduction in meth labs, because there's nobody to go after them!
![Page 68: Implementing Effective Prescription Drug Abuse Prevention Strategies Jim Middleton, Pharmacist Carol Meyer-Niedzwiecki, SAC Prevention Director](https://reader035.vdocument.in/reader035/viewer/2022062322/56649e985503460f94b9ae43/html5/thumbnails/68.jpg)
The Challenged Response to the Challenge
- The Problem:
Overmarketing prescription drugs directly to the consumer and mail-order distribution has escalated the amount of drugs available for misuse or abuse
- The Solution
Encourage take-back programs coordinated by volunteers
![Page 69: Implementing Effective Prescription Drug Abuse Prevention Strategies Jim Middleton, Pharmacist Carol Meyer-Niedzwiecki, SAC Prevention Director](https://reader035.vdocument.in/reader035/viewer/2022062322/56649e985503460f94b9ae43/html5/thumbnails/69.jpg)
The Challenged Response to the Challenge
- The Problem:
A 'top-down' solution runs into the danger of becoming manipulated, diverted, or politicized
- The Solution:
You. Here. Today.
“Bottom's up!”