Pharmacology Update 2008

Kevin ScheelMS, MAC, LADC

Kevin ScheelDirector of Educational Services, Distance Learning Center for Addiction Studieshttp://www.DLCAS.com kscheel@dlcllc.org866 431-4240

Pharmacology

The broad science concerned with drugs, their sources, their physical and chemical properties, their actions in the body, and their use in the treatment of disease.

Pharmacotherapeutics

The study of the use of drugs in the treatment of disease.

Agonists

These drugs can be substituted for the drug of abuse to provide a more controllable form of addiction. The properties and actions of these drugs are similar to those of particular abused drugs.

Antagonists

These drugs occupy the same receptor sites in the brain as specific drugs of abuse. However, they do not produce the same effects as the abused drugs, and they are non‑addicting.

Tolerance

Reduction in the effects of a drug with repeated use. This often leads the user to increase the dose if possible in order to regain the original effects.

The Most Dangerous Drug

Instructions: Following will be an alphabetical listing of various drugs of abuse. For the next 5 minutes, please think about each drug and it's "dangerous" potential. Then do the following:

First, list what criteria you use to determine a drugs dangerousness

Next, rank the drugs from the most dangerous (1) to the least dangerous(10)

Alcohol Cocaine Ecstasy Inhalants LSD

Marijuana Methamphetamine Oxycontin Salvia Xanax

THE FOLLOWING VARIABLES EFFECT THE ONSET AND CONTINUATION OF DRUG ABUSE AND ADDICTION

The User Heredity Innate Tolerance

genetically determined sensitivity (or lack of sensitivity) to a drug that is observed on first exposure before there is any experience with the drug.

Speed of developing Acquired TolerancePharmacokinetic (homeostasis)Pharmacodynamic (neurochemical)Behavioral

Cross-tolerance

Likelihood of experiencing Intoxication as Pleasure

Psychiatric Symptoms Prior Experiences/Expectations Propensity for Risk Taking

Behavior

The Environment Social Setting Community Attitudes Peer Influence; Role Models Availability (or Lack) of other

Reinforcers (sources of pleasure or recreation)

Employment or Educational Opportunities

Conditioned Stimuli: Environmental cues become associated with drugs after repeated use in the same environment

The Psychoactive Substance

Availability Cost Purity/Potency Pharmacokinetics

how the body absorbs, distributes, transforms or metabolizes, and excretes the drug.

The Psychoactive Substance, continued

Mode of Administration Chewing (absorption via oral mucous

membranes) Gastrointestinal Intranasal

Intravenous Sub-cutaneous Intra-muscular Inhalation

Today’s Schedule Review current statistics on drug

use/abuse Discuss drugs of abuse that are

creating new problems/concerns for addiction professionals

Identify resources for staying current

Current Use Statistics

2007 MONITORING THE FUTURE SURVEYhttp://www.monitoringthefuture.org/

2006 NATIONAL SURVEY ON DRUG USE AND HEALTHhttp://www.oas.samhsa.gov/nhsda.htm

2007 MTF Overview – The Good News Overall, the results are very positive -

From 2006 to 2007, the percentage of 8th graders reporting lifetime use of any illicit drug declined from 20.9% to 19.0%.

Reported past year use among 8th graders declined from 14.8% to 13.2%.

Past year prevalence has fallen by 44% among 8th graders since the peak year of 1996.

Past year prevalence has fallen 27% among 10th graders and 15% among 12th graders since the peak year of 1997.

Cigarette smoking continues to fall to the lowest rate in the survey's history. Between 2006 and 2007, declines were observed in lifetime, past month, and daily cigarette use among 8th graders. Although there were no 1-year declines for 10th and 12th graders, all grades have continued a longer term trend of declining cigarette use. 1

Past year use of marijuana by 8th graders declined from 11.7% in 2006 to 10.3% in 2007. Between 2001 and 2007, past month marijuana use declined by nearly 25% for 8th, 10th, and 12th graders combined.

Since 2006, past year steroid use decreased in 8th, 10th, and 12th graders combined from 1.3% to 1.1%.

Methamphetamine abuse continues to decline - between 2006 and 2007, lifetime and past year use among 8th and 12th graders decreased.

A substantial long-term decline was observed in past year alcohol use among 8th graders, down to 31.8% from its peak of 46.8% in 1994. Additionally, past year use of flavored alcoholic beverages among 10th graders decreased from 48.8% in 2006 to 45.9% in 2007.

2007 MTF Overview – Areas of Concern In 2007, 15.4% of 12th graders reported using a

prescription drug nonmedically within the past year2. Vicodin continues to be abused at unacceptably high levels.

Attitudes toward substance abuse, often seen as harbingers of change in abuse rates, were mostly stable. However, among 8th graders, perceived risk of harm associated with MDMA decreased for the third year in a row. Attitudes towards using LSD also softened among 10th graders this year.

Between 2005 and 2007, past year abuse of MDMA increased among 12th graders from 3.0% to 4.5%; and between 2004 and 2007, past year abuse of MDMA increased among 10th graders from 2.4% to 3.5%.

2006 NATIONAL SURVEY ON DRUGS USE AND HEALTH – Illicit Drug UseIllicit Drug Use

In 2006, an estimated 20.4 million Americans aged 12 or older were current (past month) illicit drug users, meaning they had used an illicit drug during the month prior to the survey interview. This estimate represents 8.3 percent of the population aged 12 years old or older. Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.

The rate of current illicit drug use among persons aged 12 or older in 2006 (8.3 percent) was similar to the rate in 2005 (8.1 percent).

Marijuana was the most commonly used illicit drug (14.8 million past month users). Among persons aged 12 or older, the rate of past month marijuana use was the same in 2006 (6.0 percent) as in 2005.

In 2006, there were 2.4 million current cocaine users aged 12 or older, which was the same as in 2005 but greater than in 2002 when the number was 2.0 million. However, the rate of current cocaine use remained stable between 2002 and 2006.

Hallucinogens were used in the past month by 1.0 million persons (0.4 percent) aged 12 or older in 2006, including 528,000 (0.2 percent) who had used Ecstasy. These estimates are similar to the corresponding estimates for 2005.

There were 7.0 million (2.8 percent) persons aged 12 or older who used prescription-type psychotherapeutic drugs nonmedically in the past month. Of these, 5.2 million used pain relievers, an increase from 4.7 million in 2005.

In 2006, there were an estimated 731,000 current users of methamphetamine aged 12 or older (0.3 percent of the population).

Among youths aged 12 to 17, current illicit drug use rates remained stable from 2005 to 2006.

Among persons aged 12 or older who used pain relievers nonmedically in the past 12 months, 55.7 percent reported that the source of the drug the most recent time they used was from a friend or relative for free.

Alcohol Use Slightly more than half of Americans aged 12 or older

reported being current drinkers of alcohol in the 2006 survey (50.9 percent). This translates to an estimated 125 million people.

More than one fifth (23.0 percent) of persons aged 12 or older participated in binge drinking (having five or more drinks on the same occasion on at least 1 day in the 30 days prior to the survey) in 2006. This translates to about 57 million people.

Tobacco Use In 2006, an estimated 72.9 million Americans aged 12 or

older were current (past month) users of a tobacco product. This represents 29.6 percent of the population in that age range. In addition, 61.6 million persons (25.0 percent of the population) were current cigarette smokers; 13.7 million (5.6 percent) smoked cigars; 8.2 million (3.3 percent) used smokeless tobacco; and 2.3 million (0.9 percent) smoked tobacco in pipes.

Initiation of Substance Use (Incidence, or First-Time Use)

The illicit drug use categories with the largest number of recent initiates among persons aged 12 or older were nonmedical use of pain relievers (2.2 million) and marijuana use (2.1 million). These estimates are not significantly different from the numbers in 2005.

In 2006, there were 783,000 persons aged 12 or older who had used inhalants for the first time within the past 12 months; 77.2 percent were under age 18 when they first used.

Substance Dependence, Abuse, and Treatment In 2006, an estimated 22.6 million persons (9.2 percent

of the population aged 12 or older) were classified with substance dependence or abuse in the past year based on criteria specified in the Diagnostic and Statistical Manual. 3.2 million were classified with dependence on or abuse of both

alcohol and illicit drugs 3.8 million were dependent on or abused illicit drugs but not

alcohol 15.6 million were dependent on or abused alcohol but not illicit

drugs.

There were 4.0 million persons aged 12 or older (1.6 percent of the population) who received some kind of treatment for a problem related to the use of alcohol or illicit drugs in 2006. More than half (2.2 million) received treatment

at a self-help group.

Discuss drugs of abuse that are creating new problems/concerns for addiction professionals

Alcohol - Absinthe

Absinthe is an anise-flavored liqueur distilled with oil of wormwood, a leafy herb

Absinthe also contains flavorful herbs such as hyssop, lemon balm, and angelica

Active ingredient is thujone, a neurotoxin

Popular in underground circles in Europe and the United States

Linked to convulsions, madness, and death

History

Wormwood used medicinally since the Middle Ages to exterminate tapeworms while leaving the human host uninjured and even rejuvenated by the experience

At the end of the 18th century, the herb became recreational as people discovered they could get high

Unacceptably bitterdark green colormixed with water and sugarelaborate spoons and glasses

Side-Effects

Renal failure Convulsions Involuntary evacuations Abnormal respiration Foaming at the mouth

Alcohol - AWOL

Alcohol without liquid (AWOL) – process introduced first in Asia and Europe that allows people to take in liquor (distilled spirits) without actually consuming liquidmachine vaporizes alcohol and mixes it

with oxygen, allowing the consumer to breathe in the mixture

AWOL machine produces a very fine alcohol mist

continual intake of this mist over a twenty-minute period is the equivalent of taking one shot of distilled spirits

introduced to the United States in August of 2004

health and safety risks of inhaling alcohol vapors are unknown and many legislators are promoting legislation to ban alcohol inhalation machines

Michigan has made it illegal to possess, sell or use an AWOL machine, and at this time, sixteen other states have banned the device

Effects

Largely unknown at this timemarketed as low-carb, no

hangover, no worry for DWIrapid delivery to brain a concern

for physical effects

Oxycontin

Known as the 'hillbilly heroin,' OxyContin is the brand name for a semisynthetic opioid analgesic prescribed for chronic moderate to severe pain.

Its active ingredient is oxycodone, which is also found in drugs like Percodan and Tylox.

OxyContin contains between 10 and 160 milligrams of oxycodone in a timed-release tablet, which provides continuous relief for up to 12 hours

It is more potent than hydrocodone (Lortab, Vicodin) and has a greater potential for abuse

Oxycodone is also found in at least 45 other drugs on the market, including Percocet

Painkillers such as Tylox contain 5 milligrams of oxycodone and often require repeated doses to bring about pain relief because they lack the timed-release formulation

Since hitting the U.S. market in 1996, OxyContin has become one of the most popular -- and most abused -- medical painkillers

More than 7.2 million prescriptions have been dispensed annually since 2001

Two primary factors set OxyContin abuse apart from other prescription drug abuse.

1. OxyContin contains a much larger amount of oxycodone than other prescription pain relievers

2. Large profits are to be made in the illegal sale of OxyContin – 40mg tablet costs approximately $4 by prescription, yet it may sell for $20 to $40 on the street

Treatment Considerations

Two types of treatment have been documented as effective for opioid addictionlong-term, residential, therapeutic

community type of treatment long-term, medication-assisted

outpatient treatment

antagonist maintenance with naltrexone

agonist with methadone and levo alpha acetyl-methadol (LAAM)

FDA has also approved the partial agonist buprenorphine (Suboxone) , which holds great promise for treatment

Methamphetamine

Discovered in 1919 in Japan from its parent drug, amphetaminenasal decongestants and bronchial

inhalers. More pronounced effects on the

central nervous system.

Popular use in World War II resulted in more than 20 years of popularity as prescription medication.

Today – one of the most popular illicit drugs – easily made in clandestine laboratories with inexpensive OTC ingredients.

Methamphetamine is commonly known as "speed," "meth," and "chalk."

In its smokable form, it is often referred to as "ice," "crystal," "crank," and "glass."

White, odorless, bitter-tasting crystalline powder. 

Causes increased activity, decreased appetite, and a general sense of well-being.

The effects of methamphetamine can last 6 to 8 hours.

Pattern of Use

Can be smoked, snorted, orally ingested, or injected.

Immediately after smoking the drug or injecting it intravenously, the user experiences an intense rush or "flash" that lasts only a few minutes and is described as extremely pleasurable.

Snorting or oral ingestion produces euphoria – a high but not an intense rush.

Snorting produces effects within 3 to 5 minutes, and oral ingestion produces effects within 15 to 20 minutes.

Most often is used in a "binge and crash" pattern.

Tolerance occurs within minutes –pleasurable effects disappear even before the drug concentration in the blood falls significantly – “binge” use is the result.

Long-term effects

Long-term methamphetamine abuse results in many damaging effects, including violent behavioranxietyconfusioninsomnia

psychotic features, including paranoia, auditory hallucinations, mood disturbances, and delusions (for example, the sensation of insects creeping on the skin, which is called "formication").

Medical Complications

Rapid heart rate, irregular heartbeat, increased blood pressure, and irreversible, stroke-producing damage to small blood vessels in the brain.

Hyperthermia (elevated body temperature) and convulsions.

Inflammation of the heart lining Damaged blood vessels and skin

abscesses (IV use) Violent behavior, paranoia, anxiety,

confusion, and insomnia Calcium loss and resultant problems

Treatment options

The most effective treatments for methamphetamine addiction are cognitive behavioral interventions

Recovery support groups also appear to be effective adjuncts to behavioral interventions

Currently there are no particular pharmacological treatments for dependence on amphetamine or amphetamine-like drugs such as methamphetamine

Antidepressant medications are helpful in combating the depressive symptoms frequently seen in methamphetamine users who recently have become abstinent

Hallucinogens - SALVIA

Salvia divinorum – a powerful psychoactive plant, member of the sage genus and the Lamiaceae (mint) family.Diviner's Sage, Magic Mint, ska María

Pastora, Sally D, Sage of the Seers, or simply Salvia (although the genus name is shared among many plants),

Used by the indigenous Mazatec shamans for healing during spirit journeys

The plant is found in isolated, shaded and moist plots in Oaxaca, Mexico

Traditional methods of usechewing & swallowing fresh leavescrush the leaves to extract juices, then

drink (usually mixed with water)dosages vary from as few as 6 leaves to

as many as 120 when using these methods.

Modern methods of usesmokingchewingtinctures made with grain alcohol

Duration of effect

If smoked the main effects are experienced quickly – intense 'peak' reached within a minute or so and lasts for about 1-5 minutes

5-10 minutes, less intense with return to normal after about 15 to 20 minutes.

Chewing – 10 to 15 minutes for effects lasting 40 to 50 minutes but producing much milder and lighter effects than other methods of dosing

Bitter taste is usually so objectionable that most individuals will not chew the leaf long enough to obtain any kind of psychedelic effect

Effects

Low doses – spontaneous laughter, mild closed-eye visuals, stuttering or strobing visual effects, enhanced or distorted depth perception, and a heightened sense of color and texture may be experienced

Moderate doses – trance-like state, time distortion and open-eye visuals become increasingly apparent; sensations of falling, similar to, but more pronounced than what is occasionally felt at the onset of sleep

High doses – dimensional distortion, vertigo, feelings of intense exhilaration and/or panic, hearing voices, loss of speech, dissociation, reports of experiencing alternate realities, out-of-body experiences

Marijuana – Pot 2.0 University of Mississippi’s

Marijuana Potency Project reports the average levels of THC rose from 3.5 percent in 1988 to 7 percent in 2003 to 8.5 percent in 2006

highest concentration of (THC) found in a cannabis (marijuana) sample is 33.12

Inhalants

WHY INHALANT USE IS INCREASING

1. Potentially abused products, when used as designed, are legal, useful and serve many appropriate needs in society

2. Almost inexhaustible supply -- over 1,000 products can be abused

3. Products are universally available -- at home, school and convenience, grocery and auto supply stores

4. Products are free or generally inexpensive

5. Laws prohibiting sale of products to minors are difficult to enforce; legal consequences of use are minimal

6. No complex paraphernalia are necessary to abuse products

7. Youth do not have to go to a "dealer" to obtain products (they can be bought and/or are available in the home and at school)

8. Use can occur anywhere9. Products are easy to conceal

10. Use is difficult to detect

11. Targeted education and awareness programs are not available in many schools and communities

12. Adults are generally not aware of the problem and tend to deny that their children may be sniffing or huffing

13. Young people are generally unaware of the consequences of use

Glossary of Terms

Bolt, Bullet, Climax, Locker Room, Rush. Street names for butyl nitrite, which is packaged in small bottles.

Poppers and Snappers. Street names for ampoules of amyl nitrite.

Whippets. Balloons or plastic bags filled with nitrous oxide.

Sudden Sniffing Deaths. Death, usually due to heart failure, within minutes of using an inhalant.

Texas Shoe Shine. Spray paint containing toluene.

Torch or Fire Breathing. Igniting exhaled volatile gas, such as propane or butane.

“Sniffing," "Snorting," "Bagging" (fumes inhaled from a plastic bag), "Huffing" (inhalant-soaked rag in the mouth). Terms for inhaling substances.

Types of Inhalants

Volatile solventsgases such as butane gas fumes, or liquids,

such as gasoline or paint thinnerinclude spray paint, paint and wax

removers, hair spray, odorants, air fresheners, cigarette lighter fuels, analgesic sprays, and propellant gases used in aerosols such as whipped cream dispensers

Nitrites "poppers' or "rush," some nitrite

products are sold as room odorizers. use of nitrites has fallen off dramatically

in recent years

Anestheticsprincipal substance of abuse is nitrous

oxidecolorless, sweet-tasting gas used by

doctors and dentists for general anesthesia

"laughing gas”

The National Inhalant Prevention Coalition - community education and awareness on the dangers of inhalant use. http://www.inhalants.com

OTC – Dextromethorphan

"DXM," "robo," "skittles," "Vitamin D," "dex", "tussin," "syrup heads." 

Non-prescription cough suppressant dextromethorphan is an emerging problem among school-aged youth and young adults in the United States

Intoxication comes from swallowing large doses of cough syrup, known as "robodosing" or "robo-tripping" or taking handful of cough suppressant pills, sometimes called "skittles" (an appearance similar to the popular

fruit candy – includes such OTC’s as Coricidin®)

The drug creates a depressant effect, as well as a mild hallucinogenic effect, when taken in large doses, and is often used as an alternative to ecstasy

Adverse Effects

decreased ability to regulate body temperature, resulting in reduced sweating and increased body temperatures - "rave-related heat stroke."

dry mouth and loss of body fluid, from the anti-cholinergic effect of the drug

dry itchy skin and occasional patches of flaky skin

blurred vision, hallucinations, cognitive alterations, delusions, and a dissassociative state

nausea, abdominal pain, vomiting, vomiting of blood

irregular heartbeat, high blood pressure, numbness of fingers or toes, redness of face, headache

loss of consciousnessdeath (rarely)

Principles of Drug Addiction Treatment

1.No single treatment is appropriate for all individuals.

2.Treatment needs to be readily available.

3.Effective treatment attends to multiple needs of the individual, not just his or her drug use.

4.At different times during treatment, a patient may develop a need for medical services, family therapy, vocational rehabilitation, and social and legal services.

5.Remaining in treatment for an adequate period of time is critical for treatment effectiveness.

6. Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction.

7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

8.Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.

9.Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.

10. Treatment does not need to be voluntary

to be effective.

11. Possible drug use during treatment must

be monitored continuously.

12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place them or others at risk of infection.

13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.

WEBSITES FOR STAYING CURRENT ON DRUGS OF ABUSE

NIDA Homepage Excellent resource with a great deal of research information and many downloadable articles. Be sure to check out the NIDA Notes link, and be sure to sign-up for the monthly publication. NIDA also has a Resource/Link page with multiple links with NIDA constituent organizations, grantees and Government sites of interest

http://www.nida.nih.gov/

Rx List

Reference to prescription medications. This directory of drugs has medical information about their use and side effects, as well as the ingredients found in each drug. This site can be searched by using either the brand or generic name of the drug.

http://www.rxlist.com

The LycaeumAn organization that is definitely dedicated to the promotion of “controlled substance use.” A valuable resource, none-the-less, to gain insight into the mind set of the user thinking and to stay current with information that is on the street regarding the use and “benefit” of specific drugs. Check out the graphics link – an excellent resource with pictures, drawings, etc., of various natural and synthetic drugs.

http://www.lycaeum.org/

The Texas Commission on Alcohol and Drug Abuse, Research PublicationsScroll down to “A Dictionary of Slang Drug Terms, Their Generic and Trade Names, and Pharmacological Effects and Uses” (October 1997). Click and download – an excellent resource for counselors.

http://www.dshs.state.tx.us/sa/research/SlangTermsProfiles.shtm

The Indiana Prevention Resource Center at Indiana UniversityArticles, information, and links for prevention efforts across the United States. Also has an excellent graphics section for pictures and slides of various drugs of abuse.

http://www.drugs.indiana.edu

The National Addiction Technology Transfer Center Website

Homepage for the ATTC project – valuable links to all of the online resources that are participating in this national project which is geared toward expanding the knowledge base of the professional addiction counselor.

http://www.nattc.org/

Center for Substance Abuse Research (CESAR)The Center for Substance Abuse Research (CESAR) is a research center within the College of Behavioral and Social Sciences, University of Maryland College Park. A primary mission of CESAR is to collect, analyze, and disseminate information on the nature and extent of substance abuse and related problems in Maryland and nationally.

http://www.bsos.umd.edu/cesar/cesar.html

The Wisconsin ClearinghouseOffers up-to-date information on substance abuse policy issues, legislation, prevention materials, resource information, news and links.

http://wch.uhs.wisc.edu/

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) The National Institute on Alcohol Abuse and Alcoholism (NIAAA) supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. NIAAA also provides leadership in the national effort to reduce the severe and often fatal consequences of these problems.

http://www.niaaa.nih.gov/

Substance Abuse and Mental Health Services Administration (SAMHSA) SAMHSA's mission is to assure that quality substance abuse and mental health services are available to the people who need them, and to ensure that prevention and treatment knowledge is used more effectively in the general health care system. (Managed care is among the topics covered on this site.)

http://www.samhsa.gov/

The Office of National Drug Control Policy

ONDCP is authorized to develop and coordinate the policies, goals, and objectives of the Nation's drug control program for reducing the use of illicit drugs.

http://www.whitehousedrugpolicy.gov/

American Society of Addiction Medicine

The nation's medical specialty society dedicated to educating physicians and improving the treatment of individuals suffering from alcoholism or other addictions.

http://www.asam.org/

The Distance Learning Center for Addiction StudiesStaying current with addiction and treatment information is necessary to insure quality of care and service to the field. The DLCAS provides distance training via the internet in a variety of topic areas. A joint venture of DLCAS and Hazelden.

http://www.dlcas.com/