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)

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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.

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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!

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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

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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

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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.

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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%).

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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

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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!

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“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

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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

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PROBLEMATIC BEHAVIORS

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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 (?)