prescription opioid abuse historical aspects 1990 - current through the efforts of pain control...
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Prescription Opioid Abuse Historical AspectsPrescription Opioid Abuse Historical Aspects1990 - Current1990 - Current
Prescription Opioid Abuse Historical AspectsPrescription Opioid Abuse Historical Aspects1990 - Current1990 - Current
Through the efforts of pain control advocates, organized Through the efforts of pain control advocates, organized medicine, scientific journals, & malpractice suits, prescribing medicine, scientific journals, & malpractice suits, prescribing opiates for pain became more common during the last opiates for pain became more common during the last decade of the 20decade of the 20thth Century Century
Opioid therapy became accepted (although often Opioid therapy became accepted (although often inadequately) for treating acute pain, pain due to cancer, & inadequately) for treating acute pain, pain due to cancer, & pain caused by a terminal diseasepain caused by a terminal disease
Still disputed is the use of opioids for chronic pain not Still disputed is the use of opioids for chronic pain not associated with terminal diseaseassociated with terminal disease
2
Evolving Landscape of Drugs of Evolving Landscape of Drugs of AbuseAbuse
Evolving Landscape of Drugs of Evolving Landscape of Drugs of AbuseAbuse
Farming Pharming
Prescription OpioidsPrescription Opioids
Fastest growing drug abuseFastest growing drug abuseUsually used orally but may be crushed & Usually used orally but may be crushed &
snorted or injectedsnorted or injected Injection more likely with OxycontinInjection more likely with OxycontinMore frequent source: medicine cabinets & More frequent source: medicine cabinets &
prescriptionsprescriptionsBelieved to be safer than illicit street drugsBelieved to be safer than illicit street drugs
EpidemiologyEpidemiology
In 2001, 8 million persons abused In 2001, 8 million persons abused prescription pain relievers at least once prescription pain relievers at least once during previous 12 monthsduring previous 12 months
In 2004, this had jumped to 11.4 millionIn 2004, this had jumped to 11.4 million2005 NSDUH, 5% non-medical use of rx pain 2005 NSDUH, 5% non-medical use of rx pain
meds in those 12 and oldermeds in those 12 and olderPrescription meds second only to marijuana Prescription meds second only to marijuana
as most commonly abused drugs (no etoh)as most commonly abused drugs (no etoh)
Potential subpopulations of prescription Opioid Abusers
Potential subpopulations of prescription Opioid Abusers
Persons who abuse or are dependent on only prescription opioids
Abusers of other opioids, e.g., heroin, when they cannot get their drug of choice
Polydrug abusers
Pain patients who develop abuse or dependence problems on these drugs in the course of legitimate medical treatment
Persons who abuse or are dependent on only prescription opioids
Abusers of other opioids, e.g., heroin, when they cannot get their drug of choice
Polydrug abusers
Pain patients who develop abuse or dependence problems on these drugs in the course of legitimate medical treatment
Why Has the Abuse of Prescription Why Has the Abuse of Prescription Drugs Been Increasing?Drugs Been Increasing?
Why Has the Abuse of Prescription Why Has the Abuse of Prescription Drugs Been Increasing?Drugs Been Increasing?
• Increasing numbers of prescriptions (greater Increasing numbers of prescriptions (greater availability)availability)
• Attention by the media & advertising (television Attention by the media & advertising (television and newspaper)and newspaper)
• Easier access (e.g. internet availability)Easier access (e.g. internet availability)• Improper knowledge & monitoring (adverse effects Improper knowledge & monitoring (adverse effects
go unrecognized)go unrecognized)• Others?Others?
• Increasing numbers of prescriptions (greater Increasing numbers of prescriptions (greater availability)availability)
• Attention by the media & advertising (television Attention by the media & advertising (television and newspaper)and newspaper)
• Easier access (e.g. internet availability)Easier access (e.g. internet availability)• Improper knowledge & monitoring (adverse effects Improper knowledge & monitoring (adverse effects
go unrecognized)go unrecognized)• Others?Others?
As Prescriptions Increase, Emergency Room As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster Reports Have Increased at the Same or Faster
RateRate
As Prescriptions Increase, Emergency Room As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster Reports Have Increased at the Same or Faster
RateRate
Num
ber o
f Pre
scrip
tions
(in
1000
s)Nu
mbe
r of P
resc
riptio
ns (i
n 10
00s)
Source: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department MentionsSource: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department Mentions
HydrocodoneHydrocodone
OxycodoneOxycodone
prescriptionsprescriptions
prescriptionsprescriptions
emergencyemergency
emergencyemergency
00
1000010000
2000020000
3000030000
4000040000
5000050000
6000060000
7000070000
8000080000
19941994 19951995 19961996 19971997 19981998 19991999 20002000 2001200100
60006000
1200012000
1800018000
2400024000
ED Men tions
ED Men tions
.
Increased Media AttentionIncreased Media AttentionIncreased Media AttentionIncreased Media Attention
Commonly known Mechanisms of Diversion
Commonly known Mechanisms of Diversion
• Illegal sale of prescriptions by physicians;• Illegal sale of prescriptions by pharmacists;• “Doctor Shopping” by individuals who visit numerous
physicians to obtain multiple prescriptions; • Illegal substitutions or “shorting” by pharmacists; • Theft, forgery, or alteration of prescriptions
Robberies & thefts from pharmacies & thefts of institutional drug supplies
• Internet sales
• Illegal sale of prescriptions by physicians;• Illegal sale of prescriptions by pharmacists;• “Doctor Shopping” by individuals who visit numerous
physicians to obtain multiple prescriptions; • Illegal substitutions or “shorting” by pharmacists; • Theft, forgery, or alteration of prescriptions
Robberies & thefts from pharmacies & thefts of institutional drug supplies
• Internet sales
Easy Access: Role of the Internet?“Delivered in the Privacy of your Home”
Easy Access: Role of the Internet?“Delivered in the Privacy of your Home”
“Some reasons why you should consider using this pharmacy”
No prescription required!
“Some reasons why you should consider using this pharmacy”
No prescription required!
Less Often Discussed MechanismsLess Often Discussed Mechanisms
• Residential Burglaries• “Obituary Shopping”• Hotel & residential “sneak thefts”• Supply-chain theft– In-production losses– In-transit losses– Returns/reverse distributors– Employee pilferage
• Residential Burglaries• “Obituary Shopping”• Hotel & residential “sneak thefts”• Supply-chain theft– In-production losses– In-transit losses– Returns/reverse distributors– Employee pilferage
Mechanisms of Diversion by Middle& High School Students
Mechanisms of Diversion by Middle& High School Students
• Thefts from family medicine cabinets• Drug “switching” at home• Drug trading at school• Thefts & robberies of medications
from classmates
• Thefts from family medicine cabinets• Drug “switching” at home• Drug trading at school• Thefts & robberies of medications
from classmates
Types of Painkillers (synthetics typically give better highs)Types of Painkillers (synthetics typically give better highs)
Short acting: Lortab (very common), percocet, vicodinShort acting: Lortab (very common), percocet, vicodin
oxycontin lasts 12 hours; ms contin – morphine sulphate; oxycontin lasts 12 hours; ms contin – morphine sulphate; lasts 12 hrs.lasts 12 hrs.
24-hr ms contin now available(kadian?)24-hr ms contin now available(kadian?)
duragesic fentanyl patch lasts 3 days; check used patches duragesic fentanyl patch lasts 3 days; check used patches for tampering (can get patches on the internet)for tampering (can get patches on the internet)
ultram (not an opiate)ultram (not an opiate)
some may combine soma (a muscle relaxer) and lortab some may combine soma (a muscle relaxer) and lortab gives good popgives good pop
ISSUES IN OPIOID ASSESSMENTISSUES IN OPIOID ASSESSMENT
realize very few chronic pain clients are “addicts”realize very few chronic pain clients are “addicts”
assess for prior and current alcohol/drug problemsassess for prior and current alcohol/drug problems
assess for self-medicating of psych disordersassess for self-medicating of psych disorders
do drug screen; do they already have drug in them? Are do drug screen; do they already have drug in them? Are they diverting their meds to the street? (oxycontin going for they diverting their meds to the street? (oxycontin going for about $1 per milligram)about $1 per milligram)
check pharmacies for multiple rxcheck pharmacies for multiple rx
assess pain level on and off meds – are they helping assess pain level on and off meds – are they helping functioning?functioning?
Assessing Need for Narcotics (opioids)Assessing Need for Narcotics (opioids)
check compliance with medical tx – if client only wants check compliance with medical tx – if client only wants narcotics, be suspicious…are they willing to sign a narcotics, be suspicious…are they willing to sign a “medication use” agreement/contract?“medication use” agreement/contract?
are there secondary gain issues involved? (e.g., workmens are there secondary gain issues involved? (e.g., workmens comp.) poorer pain tx outcomes are associated with those comp.) poorer pain tx outcomes are associated with those in litigation.in litigation.
type and dosage of drug currently taking; in some, type and dosage of drug currently taking; in some, tolerance is so high that withdrawal symptoms (increased tolerance is so high that withdrawal symptoms (increased pain) may occur when taking a typical dosepain) may occur when taking a typical dose
rural vs. urban setting: rx drug abuse worse in rural areasrural vs. urban setting: rx drug abuse worse in rural areas
Assessing Need for Narcotics (opioids)Assessing Need for Narcotics (opioids)
Treatment IssuesTreatment Issues
AgeAge AdolescentAdolescent AdultAdult ElderlyElderly
Drug HistoryDrug History New onset of drug abuseNew onset of drug abuse RelapserRelapser Chronic poly substance Chronic poly substance
abuserabuser
RouteRoute OralOral IntranasalIntranasal InjectorInjector
ComorbidityComorbidity PsychiatricPsychiatric Chronic painChronic pain
Who is the Patient
Assessing Need for NarcoticsAssessing Need for Narcotics
chronic opioid tx not appropriate for:chronic opioid tx not appropriate for: those with active addictions those with active addictions those who use etoh (liability)those who use etoh (liability) those who refuse other types of txthose who refuse other types of tx when QOL not improved after use of medswhen QOL not improved after use of meds
for those with previous narcotics problemsfor those with previous narcotics problems opioids not given for lengthy amounts of timeopioids not given for lengthy amounts of time need to be in tx / NAneed to be in tx / NA client may underestimate risk of relapseclient may underestimate risk of relapse
Treatment OptionsTreatment Options DetoxificationDetoxification
To antagonist maintenance (naltrexone, nelmefene, To antagonist maintenance (naltrexone, nelmefene, depot naltrexone)depot naltrexone)
To residential therapeutic communityTo residential therapeutic community
To abstinence–oriented programs (counseling, 12 step To abstinence–oriented programs (counseling, 12 step programs)programs)
MaintenanceMaintenance
Methadone, LAAMMethadone, LAAM
BuprenorphineBuprenorphine
Opiate AddictionOpiate AddictionPharmacotherapyPharmacotherapy
AgonistsAgonists Methadone, LAAMMethadone, LAAM Partial AgonistsPartial Agonists BuprenorphineBuprenorphine AntagonistsAntagonists NaltrexoneNaltrexone Anti-WithdrawalAnti-Withdrawal Methadone; BuprenorphineMethadone; Buprenorphine
Clonidine: rapid detox Clonidine: rapid detox using using Buprenorphine, Naltrexone, Buprenorphine, Naltrexone,
& Clonidine& Clonidine Anti-CravingAnti-Craving Clonidine or LofexidineClonidine or Lofexidine
Advantages of BuprenorphineAdvantages of Buprenorphine Buprenorphine binds more tightly to the receptor than any Buprenorphine binds more tightly to the receptor than any
other opiateother opiate It is a partial mu agonist, occupying that receptor only 70%- It is a partial mu agonist, occupying that receptor only 70%-
also kappa antagonistalso kappa antagonist Ceiling effect protects against overdose–but also limits Ceiling effect protects against overdose–but also limits
degree of agonist effect–ceiling effect approximately 32 mgdegree of agonist effect–ceiling effect approximately 32 mg Withdrawal easier than from methadone or heroinWithdrawal easier than from methadone or heroin Maintained patients describe;Maintained patients describe;
““Clear headedness”Clear headedness” Increased energyIncreased energy Improved sleep & mood stabilityImproved sleep & mood stability Easier to engage in therapyEasier to engage in therapy
Other Forms of Pain ManagementOther Forms of Pain Management
epidural nerve blocksepidural nerve blocks
radio frequencies; zap radio frequencies; zap nerve and deadens for nerve and deadens for up to 6 monthsup to 6 months
electrical stimulation: electrical stimulation: blocks pain signalsblocks pain signals
relaxation techniquesrelaxation techniques
BiofeedbackBiofeedback
physical therapy / physical therapy / chiropracticchiropractic
AcupunctureAcupuncture
morphine pump in bodymorphine pump in body
other medicationsother medications AntidepressantsAntidepressants NeurontinNeurontin FlexorilFlexoril