Prescription Drug Abuse

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Prescription Drug Abuse
Walter Ling MD Integrated Substance Abuse
Programs Semel Institute for Neuroscience and
Human Behavior UCLA Western Conference on
Addiction Universal City, California Sunday
November 13, 2005 lwalter_at_ucla.edu www.uclaisap.o
rg
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Prescription Drug Abuse Scope of the Talk

• What and which drugs?
• Why now?
• Who abuse prescription drugs?
• What can we do?

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Definitions Whats abuse behavior to us?
Any non-prescribed use of a drug (NIDA, 2002
DEA, 1970)
Non-medical use of a substance for psychic
effect, dependence, or suicide attempt or gesture
(SAMHSA, 2002)
Any harmful use, irrespective of whether the
behavior constitutes a disorder in the DSM-IV
diagnostic nomenclature (IOM, 1996)
A maladaptive pattern of substance use, leading
to clinically significant impairment or distress,
as manifested by one or more behaviorally-based
criteria (APA, 1994)
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Drugs of Abuse Not Just Opioids

• Opioids and other pain killers
• Stimulants
• Anti-anxiety drugs
• Sedative/hypnotics
• Feel good drugs (antidepressants)
• Look good drugs (steroids)
• Feeling goofy drugs (psychedelics)

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Number of new non-medical users of therapeutics
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Pain Prescription Abuse

• In 2002, nearly 30 million people over 12 used
  prescribed pain relievers non-medically
• 1.5 million dependent/abused prescribed pain
  relievers 2nd. only to marijuana

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Under the CounterJuly 7, 2005 CASA

• More than 15 million American abuse Opioids,
  Depressants Stimulants in 2003
• Rx abuse among teens triple in 10 years
• From 1992 to 2003, abuse of controlled Rx drugs
  grew at the rate 2x that of marijuana 5x that of
  cocaine 60x that of heroin
• In 2003, 2.3 million teens 12-17 y.o. (1/10)
  abused a controlled Rx, 83 opioids
• ER visits related to opioid medication more than
  doubled between 1994 and 2001 (DAWN 2002)

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Commonly Abused Opioids

• Diacetylmorphine Heroin
• Hydromorphone Dilaudid
• Meperidine Demerol
• Hydrocodone Lortab, Vicodin
• Oxycodone OxyContin,
• Percodan,
• Percocet, Tylox

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Oxycodone and Oxycodone CR

• Oxycodone OxyIR, Roxycodone
• Acute pain
• 4-6 hrs duration of action
• Tabs, caps, liquid
• Oxycodone CR Oxycontin
• Chronic pain already tolerant to opioids
• 12 hrs duration of action
• Not for prn use
• Tablets only

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Emergency Dept. MentionsOf Single-Entity
Oxycodone
2002 National Survey on Drug Use and Health
(NSDUH), SAMHSA, Sept 5, 2003
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Increased Media Attention
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Oxycodone
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Easy Access Role of the Internet? Delivered
in the Privacy of your Home
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Prescription Abusing Populations

• Prescription drug abusers
• Youths, elderly, women, minorities
• Pain patients who abuse opiate medication
• Users with comorbid psychiatric conditions
• Substance abusers
• Prescription drugs only
• Prescription drugs plus other substances such as
  heroin (polydrug abusers)

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Youth Prescription Abuse

• Youth obtain prescription opioids from peers
  family and friends
• Fastest growing prescription abuse group
• Females users out number males
• Prevention programs dont work
• Not reached by treatment programs
• Largely unknown later consequences

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The Elderly Prescription Opioid Abuser

• Multiple medical problems
• Higher incidence of chronic pain
• Misunderstand directions misuse vs abuse
• Multiple prescribers
• Rationalization and denial among family members,
  peers or care providers
• Deficits presumed to be due to age
• Interaction with alcohol or other drugs
• Over representation of females

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Women and Prescription Drug Abuse

• Similar rates as men
• More likely to use abusable prescription drugs,
  especially opioids and anxiolytics
• 2-3 x more inclined to be diagnosed with
  depression and given more psychotherapeutics
• Twice more prone to be addicted to drugs
• Combine with alcohol more often
• More elderly women, more prescriptions

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Women and Prescription Drug Abuse

• 4 million women abuse prescription drugs
• Among 12-17 year olds female surpass males in use
  of cigarettes, cocaine, inhalants and
  prescription drugs
• Women account for 60 of ER visits for
  prescription drug abuse

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Prescription Drug Abuse in Pain Patients

• Complex relationship between drug abuse and use
  of opioids in pain management
• Overlapping vulnerability and psychopathology
• Somatoform pain disorders
• Consumption of other substances
• Iatrogenic factors
• Uncritical prescribing, inadequate monitoring,
• absence of functional improvement
• Inadequately treated pain
• J Jage Euro J Pain 2005 9157-162

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Is pain associated with opioid disorders? Opioid
Disorders According to Different Levels of Past
4 Week Interference Due to Pain
Nearly Linear Relationship of Pain and Opioid Use
Disorder
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As Prescriptions Increase, Emergency Room
Reports Have Increased at the Same or Faster rate
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Increased prescription of opioids has resulted
in increased opioid analgesic abuse 1997-2002
(Gilson et al., 2004)

• Medical use
  Abuse
• Oxycodone 402.90 346.87
• Fentanyl 226.68 641.87
• Hydromorphone 96.35 341.56
• Morphine 73.30 113.46
• Meperidine -6.13 -16.44

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The Fateful Triangle Opioids Pain and Addiction

• Under treatment of pain
• Increasing availability of opioid analgesics
• Increase in abuse of prescription opioids

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• OpiumLull all pain
  and anger, and bring forgetfulness of every
  sorrow. - Odyssey
• Among the remedies which it has pleased Almighty
  God to give to man to relieve his suffering, none
  is so universal and so efficacious as opium. -
  Thomas Syndenham, 1680

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Opium

• It banishes melancholy, begets confidence,
  converts fear into boldness, makes the silent
  eloquent and bastards brave

John Brown
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Opium

• Opiatean unlocked door in the prison of
  identity. It leads into the jail yard. -
  Ambrose Bierce, The Devils Dictionary
• The junk merchant does not sell his product to
  the consumer, he sells the consumer to the
  product. He does not improve and simplify his
  merchandise, he degrades and simplifies the
  client.
• -
  Burroughs

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From Pain Relief to Addiction Role of the
Opiates

• Relieve pain
• Relieve pain and suffering
• Relieve suffering and misery
• Make you feel better
• Make you feel good
• Make you high

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Characterizing Pain

• Pain An unpleasant sensory and emotional
  experience arising from the actual or potential
  tissue damage or described in terms of such
  damage.
• It is always subjective. Each individual
  learns the application of the word through
  experiences related to injury in early life.IASP

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Acute vs Chronic Pain

• Acute pain is for survival
• Chronic pain serves no purpose
• Sufferers of chronic pain suffer for nothing
• Concern in acute pain what pain does the patient
  have?
• Concern in chronic pain what patient does the
  pain have?
• .

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Pain More than a Feeling

• Feeling (sensory experience) Pain
• Meaning (emotional cognitive) Suffering
• --Historicalearly life
• Learnedexperience
• Privatesubjective
• Uniqueindividual
• Action Expression of the word Behavior
• Chronic pain is not having lots of pain its
  having
• pain and behaving like a chronic pain patient

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Chronic Pain and Addiction Common Features

• Chronic pain
• Early trauma
• Loss of mastery
• Loss of control
• Loss of sense of self
• Cognitive error
• personalization
• Over interpretation
• catastrophy

• Addiction
• Early trauma
• Loss of mastery
• Loss of control
• Loss of self efficacy
• Cognitive error
• nirvana
• Denial

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Addiction in Pain Patients

• Published rates of abuse and/or addiction in
  chronic pain populations are 10 (3-18)
• Known risk factors in the general population also
  predict prescription opioid abuse in pain
  patients
• Fishbain, 1986,
  1992 Kouyanou et al., 1997
• Adams et al., 2001
  Brown, 1996

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Whos at Risk and How to Tell?

• Four ways to identify patients at risk
• History personal history family history
• Screening instruments
• Behavioral check lists
• Therapeutic maneuver

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History

• What predicts addiction?
• Personal history of drug abuse
• Family history of drug abuse
• Current addiction to alcohol or cigarettes
• History of problems with prescriptions
• Co-morbid psychiatric disorders
• Same predictors as in non-pain patients

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Screening Instruments

• CAGE
• MAST
• DAST
• Nonspecific for pain patients

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Ongoing Warning Signs

• Altered/forged prescription
• Theft of prescription pads
• Frequent requests to move appointments up
• Keep pain appointments miss others
• Grossly disheveled/impaired
• Request early refills/frequent phone calls
• Lost/stolen prescriptions
• Frequent unauthorized dose escalations
• Positive urine tests for illicit drugs

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Is the pain patient addicted? (Drug-seeking ?
Addiction)
Drug-seeking or increased requests for pain
medication
? pathology/pain of new source
Detailed pain work-up
No new pain pathology
? opioid dose
Improved functioning Absence of toxicity
Unimproved functioning Presence of toxicity
therapeutic dependence
pseudoaddiction
Addictive disease
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Can Addicts be Treated with Opiates?

• Yes, but with caution
• Increase recovery activities
• Provide support systems
• Treat co-morbidity
• Remember Non-opioid analgesics
• Non-pharmacological treatments
• Cognitive behavior therapies

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Treating Pain with Opioids What Can We Expect
to Achieve?

• Reduction in pain and suffering
• Meaningful pain reduction
• Improved functionality
• Meaningful improvement in activities

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Meaningful Pain Reduction How Much?

• Using a VAS or Numeric scale of 0-10
• (4-6 mod pain 7-10 severe pain)
• For Moderate pain ( mean6)
• Meaningful reduction2.4 (40)
• Very much better3.5 (45)
• For Severe pain (mean8)
• Meaningful reduction4.0 (50)
• Very much better5.2 (56)
• M. Soledad Cepeda et al.
• Proc 10th world Cong on Pain vol 24 pp
  601-609

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Meaningful Functional Improvement My Favorites

• Patient perspective of improvement
• Used to do, cant do now, would like to do again
• Could be physical, social, recreational
• With friends, family, church
• Achievable, enjoyable and meaningful
• Hobbies
• Volunteer work

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Conclusion Prescription Drug Abuse

• Escalating problem
• Heterogeneous population
• Youth
• Elderly
• Women and minorities
• Chronic pain patients
• Pain and addiction complex disorder

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Acknowledgment and Thanks

• Conference organizers
• Friends and colleagues
• ISAP elsewhere
• NIDA
• You the audience