Prescription Drug Useby

Daniel Dickerson, D.O., M.P.H.U.C.L.A.

Integrated Substance Abuse Programs (I.S.A.P.)

Objectives

• Definition of prescription use and misuse• Identify the main classes of prescription

and over the counter substance being abused

• Trends in use• Cultural considerations

Prescription & Over the Counter DrugsPrescription & Over the Counter Drugs

Use/Misuse/ Abuse/Addiction • Problematic Use = regularly using more pain pill

than prescribed• Prescription Drug Misuse (PDM) = Intentional

use of someone else’s prescription medication to alleviate symptoms related to a health problem

• Prescription Drug Abuse (PDA) = Use of schedule prescription medication to experiment, get high, or create an altered state

• Addiction = compulsive use withMultiple consequences

Boyd ppt, 2007

Problems With Pills• Examples can include:

- Using with alcohol or other illicit substances– Taking for psychoactive “high” effects– Taking in extreme doses– Mixing pills– Obtaining from non-medical sources– Stealing pills– Smoking or injecting oral pills– Pretending to be in pain fro pills– Doctor shopping for pills

Commonly Misused Rx Drugs

– Opiates: pain-killers• Ex) Vicodin, Oxycontin

– Depressants (Sedatives/Tranquilizers): treat anxiety and sleep disorders• Ex) Xanax, Valium

– Stimulants: treat ADHD• Ex) Aderall, Ritalin, Concerta

Prescription Drug Statistics

Stimulants

Sedatives

4.7 million

0.3 million

Narcotic Pain Relievers

Anti-Anxiety Medication

1.1 million

1.8 million

2005 NSDUH Survey

OTC Medicine Misuse•Dextromethorphan DXM (narcotic codeine) the active ingredient in over 100 cold/cough remedies.

•Found in tablets, capsules, gel caps, lozenges & syrups

•Teens discovered using mass quantities of DXM-containing products get them “high”.

Cough medicine

Inhalants

Vicodin

Generation“Pharming Culture”

A Pill For Every Ill• Patients who are addicted to medication

– Some are: aware, partially aware, no insight

• Users with comorbid psychiatric traits or conditions– Chemical copers– Depression, anxiety, personality disorders

• Physical and psychological pain – a complex relationship

• The challenge of lifestyle modifications

More than 6.3 Million Americans Reported Current Use of Prescription Drugs for Nonmedical Purposes

in 2004When used in ways other than they are prescribed, prescription drugs

have the potential for abuse and addiction

SAMHSA 2004

Epidemiology of Rx and OTC Drug Misuse Among Youth

GHBGHB

HeroinHeroin

KetamineKetamine

LSDLSD

MethMeth

EcstasyEcstasy

Cough MedicineCough Medicine

Crack/CocaineCrack/Cocaine

MarijuanaMarijuana 8.6 million8.6 million4.5 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

Drug Abuse among Youth

(or 1 in 5 teens)

(or 1 in 10 teens)

NSDUH, 2007

“Pharming Culture”

Today's teens are more likely to have abused Rx and OTC drugs than most illicit drugs

Every day 2,500 teens 12-17 try a painkiller for the 1st time

MTF, 2006

Examples of Popular OTC Products

Coricidin HBP Cough & Cold Robitussin Cough productsSudafed Cough medicinesDimetapp DM Tylenol Cold productsVicks NyQuil and DayquilAlka-Seltzer Plus Cold &

Cough Triaminic Cough syrups

Top 5 Drugs Used by 12th Graders

31.5%

9.7%4.3% 7.5% 6.9% 6.6%

0%

10%

20%

30%

40%M

ariju

ana

Vic

odin

Oxy

cont

in

Am

phet

amin

es

OT

C C

ough

/Col

dM

eds

Seda

tives

/Tra

nqsPerc

ent o

f Res

pond

ents

Past Year

SOURCE: MTF, 2006

3.8%

Rita

lin

OTC Medications Misused by Teens

38.6%

17.8%18.1%

30.5%

0%

10%

20%

30%

40%N

yQui

lPr

oduc

ts

Cor

icid

inPr

oduc

ts

Rob

otus

sin

Prod

ucts

Oth

er O

TC

Med

icat

ions

Perc

ent o

f Res

pond

ents

Past Year

SOURCE: MTF, 2006

Concerning Trends

–Adolescents 12-13

–Teen Females

–Young Adults 18-24

Extent of Rx & OTC Drug Misuse among Youth in California

12th Biennial California Student Survey: Drug, Alcohol & Tobacco Use

• Secondary students (7th, 9th, 11th graders)

• Representative State sample: random schools & classrooms– 13,930 students

– 48 middle and 68 high schools (including 10 continuation)

Misuse of opiate painkillers (no prescription) to get high 2006:

15% of 11th graders9% of 9th graders4% of 7th graders

California Student Survey 2006

Changes to Survey

• 2007: Expanded substances and made separate question on recreational use of pharmaceuticals (high school only)

– Added cold/cough medicines, diet pills, and Ritalin/Adderal

Lifetime PrevalenceGrade 9 Grade 11

(%) (%)

Street Drugs Marijuana 25 42 Methamphetamines 5 7 Ecstasy 6 10Prescription/Medicinal Drugs* Painkillers 12 18 Barbiturates 2 3 Sedatives/tranquilizers 4 6 Diet pills 9 8 Ritalin/Adderal 4 6OTC Cold/Cough Medicines 26 25

*to get high – not for medicinal reasons

Top Reasons for Rx & OTC Drug Misuse

Social with friends

Legal - Widely Available

Easily Accessible

Affordable: Low Cost/Free

Safe - Prescribed

Non-addictive: Medicine

Partnership Attitude Tracking Survey (PAT): Released in April 2006 by The Partnership for a Drug-Free America

Recent Research: Why Teens Use?

• Teens admit to misusing Rx drugs for reasons other than getting high, including to relieve pain or anxiety, to sleep better, just to experiment, to help with concentration or to increase alertness. (Boyd, McCabe, Cranford & young, 2006).

• More than 1/3 of teens say they feel pressure to abuse Rx drugs and say using these drugs is an important part of fitting in with their friends. (Seventeen, 2006).

• When teens abuse Rx drugs, they often characterize their use as “safe” (Friedman, 2006).

Access & Availability

• Family & Friends Homes

• Retail Pharmacies

The Internet

Social Networking Web Sites

Venues for penetrating the Medicine Abuse

SubcultureYouTubeMySpaceFacebook

LiveJournal

Footage of teens “high”User Guides: Rx & OTC abuse instructions (recipes)Blogs & videos of experiences

Social Rx & OTC Slang

Xbrs or xanabars: anti-anxiety Xanax

Vic: Vicodin Skittles, Dex, Robo, Tussin, (any

OTC cold pill containing DXM)Triple Cs or CCC: Coricidin Cough

& Cold medSIZ’zurp: cough syrup & ETOHTrail Mix: Pharm Party

Keeping Parents Clueless

Side Effects can be Lethal if…• Combining Rx & OTC medications.• Taking Rx and OTC meds with alcohol.• Using Rx and OTC with other illicit drugs.• Interactions: Rx & OTC meds with other

physical medications

Rx & OTC Drug Over Doses

• This year: Michael Jackson?? (oxycotin)• Last 6 months: Rapper Pimp C (Chad Butler): cough syrup

& Hennessey– “sizerp”• Last Year: Heath Ledger: lethal cocktail of Rx drugs - pain,

sleeping, anti-anxiety• Last 2 Year: Anna Nicole Smith & Son (Daniel) both died

due to Rx drugs • Last 3 Years: Rapper ODB: fatal mixture of Rx drugs &

cocaine

• Unrecognized

• Under-screened

• Under-treated

People Don’t Understand the Risks & Effects of Abusing Rx and OTC

Medicines

Over 50% believe that abusing these medicines to get high is NOT risky…

Join Together, 2006

Parents Don’t Recognize Problem

• Only 8% of parents are aware of Rx & OTC abuse.

• 75% don’t talk to their kids about the problem.

• Unaware that the drug supply can come from their own home.

Other Key Stakeholders

• Lack of screening and awareness about Rx and OTC problem among:

– Medical professionals (MDs, Nurses)

– Social workers, juvenile delinquent counselors, probation officers

– School teachers, nurses, & counselors

McCabe, S.E., Teter, C.J., & Boyd, C.J. (2004)

Prescription Drug Trends

Under treatment of pain

Increasing availability of opioid analgesics

Increase in abuse of prescription opioids

Ling ppt, 2005

Pressure to Prescribe

• Friday at 4 pm• I am going to have a seizure if you don’t

refill my medication• My doctor told me to call you• I left my pills on the bus• It takes 5 minutes to say yes and 45

minutes to say no• You don’t know how bad my pain is

Big Issue• Purdue Pharma, the

maker of OxyContin, helped fuel widespread abuse of the drug by aggressively promoting it to general practitioners.

• Sales grew from $48 million in 1996 to over $1 billion in 2000

• Became leading drug of abuse in 2004…

• Increased marketing and sales of narcotics

Number of new non-medical users of therapeutics

Pharm Sales Grew

Development of …Medicine Subculture

Endorsements the Drug Makers

Increasing trend to use Psychiatric Drugsto Treat Youth Behavioral Problems…

Problem: Massive Marketing from Pharma

Modern Culture

Direct-to-Consumer Advertising• “Amazon.com pushing Rx drug “ADHD” with front-

page, youth celebrity endorsing it”• Free Ambien Rx drug Trial offers for “depression” at

youth concert

Legislation

• 1906 – Food & Drug Act.– Banned interstate commerce in misbranded &

adulterated drugs.

• 1938 – Food, Drug, & Cosmetic Act (FDC Act).– Drugs must be proven safe before distribution.

• 1962 – Kefauver-Harris amendments to FDC Act.– Drugs must be proven effective before distribution.

Legislation

• 1972 – start of FDA program to ensure all OTCs are effective and safe.

• 1988 – program completed, except for new OTCs.

Recent Public Health Efforts to Address Rx & OTC Misuse

Prevention Activities

• ONDCP– 12 week national public awareness campaign – Began with 2 Ads aired during Super Bowl– 1st paid TV advertising targeting parents in 2

years.

Policy Change:New Rx Drug Regulations

• Action has taken place throughout U.S. federal and state levels.– Federal: address issues with Rx practices

among MDs:• F.D.A. will increase oversight and be placing

new limits on prescriptions of 24 popular narcotics (like OxyContin) for increasing MD responsibility

– State: establishing prescription monitoring programs to identify doctor shoppers

NY Times, 2009; McLellan, 2009

Prescription pain medication and Hispanic youth

• Pain-medication and stimulant medication abuse has been recognized as a significant issue among Hispanic youth.

• In 2005, one in five (21%) of 581,000 Hispanic teens in one study admitted to trying prescription medications to get high.

• Almost half (45%) of Hispanic teens believe that prescription medications, are much safer to use than illicit drugs, even if not prescribed by a physician.

• “Keeping your teens drug free: A guide for Hispanic families” with a two-disc DVD can be obtained for free from: http://www.TheAntiDrug.com or http:www.LaAntiDroga.com, or calling toll-free 1877-SIN-DROGAS.

(Hispanic PR Wire, 2005)

Prescription pain medication abuse and African Americans and American Indians/Alaska Natives

• Although research is limited, reports indicate widespread illicit use of prescription pain medication in the inner city (Vivian et al., 2005).

• A rising concern exist with regards to pain medication abuse among American Indians/Alaska Natives.

• Further culturally-relevant prevention and education programs are needed in minority communities with regards to prescription pain medication abuse.

Cultural Competence“A set of attitudes, skills, behaviors, and policies

that enable organizations and staff to work effectively in cross-cultural situations.” Cross et al

“The ability of individuals and systems to respond respectfully and effectively to people of all cultures, in a manner that affirms the worth and preserves the dignity of individuals, families, and communities.”

University of Minnesota

Questions poised by Felipe Castro, Ph.D. with regards to Latino populations

• What are cultural factors and processes that can affect the development of drug use and abuse among Latino populations?

• What are important aspects of drug abuse treatment that are relevant to Latino populations?

• What are some specific issues in culturally-relevant relapse prevention?

Elements of Culture

• Culture” is Conceptualized as:* Objective- music, art, literature, artifacts* Subjective- beliefs, attitudes, values,expectations, norms

* Content- knowledge and information* Process- ways of perceiving and distilling meaning; ways of organizing knowledge and of coping with life situations

(Castro,Felipe)

Elements of culture• Themes: Culture as :

*Ways of life, adaptations to the environment; coping skills*Shared symbols and meanings; community of actors*Beliefs, values, attitudes, norms, perceptions, traditions*Transmitted across generations; a social heritage*A process that evolves across time*Constructed by people who generate meaning from experience*Consists of life patterns

Dimensions of culture• What are certain domains by which we can

organize our conceptions of “culture” and its variability?

• * Cohorts- hippies, yuppies, generation X• * Religious groups- Catholicism, Islam• * Racial/ethnic- Chicano, Puerto Rican, Asian• * Political associations- radical, liberal,

conservative• * Ecological- urban, rural, tropical, polar• * A person can have multiple cultural

identities a cultural mosaic (Chao & Moon, 2005).

The cultural mosaic

• A framework to identify demographic, geographic and associated features underlying culture* A cultural mosaic describes an individual’s collage of multiple cultural identities* “The cultural mosaic is described as a complex system with localized structures, linking cultural tiles in ordered and chaotic ways”

(Chan, G. T. & Moon, H., 2005)

Treatment considerations for treating clients with cultural competence

• Obtain family migration history.

• Assess degree of loss of cultural milieu and traumatic experiences

• Current cultural support systems

• Individual’s concept of illness

• Level of acculturation • Assess potential areas of

cultural strengths and supports

• Identify areas of cultural conflict

Utilizing cultural competent skills• Building rapport is critical.• Don’t assume anything about your client’s

cultural identity. • Be curious and sensitive. • Cultural competency is a dynamic, ongoing

endeavour.• Be aware that significant stigma may exist with

regards to substance abuse in various cultures.• Clinical Manual of Cultural Psychiatry by Russell

Lim, M.D. recommended for further reading on cultural competency.

Contact Information

• Daniel Dickerson, D.O., M.P.H.• E-mail: daniel.dickerson@ucla.edu• Phone: 562-277-0310