1. Prescription Opioid Abuse Historical Aspects 1990 - Current  Through the efforts of pain control advocates, organized medicine, scientific journals, & malpractice suits, prescribing opiates for pain became more common during the last decade of the 20 th Century  Opioid therapy became accepted (although often inadequately) for treating acute pain, pain due to cancer, & pain caused by a terminal disease  Still disputed is the use of opioids for chronic pain not associated with terminal disease

2. 2 Evolving Landscape of Drugs of Abuse FarmingPharming

3. Prescription Opioids  Fastest growing drug abuse  Usually used orally but may be crushed & snorted or injected  Injection more likely with Oxycontin  More frequent source: medicine cabinets & prescriptions  Believed to be safer than illicit street drugs

4. Epidemiology  In 2001, 8 million persons abused prescription pain relievers at least once during previous 12 months  In 2004, this had jumped to 11.4 million  2005 NSDUH, 5% non-medical use of rx pain meds in those 12 and older  Prescription meds second only to marijuana as most commonly abused drugs (no etoh)

6. 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

7. Why Has the Abuse of Prescription Drugs Been Increasing? Increasing numbers of prescriptions (greater availability) Increasing numbers of prescriptions (greater availability) Attention by the media & advertising (television and newspaper) Attention by the media & advertising (television and newspaper) Easier access (e.g. internet availability) Easier access (e.g. internet availability) Improper knowledge & monitoring (adverse effects go unrecognized) Improper knowledge & monitoring (adverse effects go unrecognized) Others? Others? Increasing numbers of prescriptions (greater availability) Increasing numbers of prescriptions (greater availability) Attention by the media & advertising (television and newspaper) Attention by the media & advertising (television and newspaper) Easier access (e.g. internet availability) Easier access (e.g. internet availability) Improper knowledge & monitoring (adverse effects go unrecognized) Improper knowledge & monitoring (adverse effects go unrecognized) Others? Others?

8. As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster Rate Number of Prescriptions (in 1000s) Source: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department Mentions Hydrocodone Oxycodone prescriptions emergency 0 0 10000 20000 30000 40000 50000 60000 70000 80000 1994 1995 1996 1997 1998 1999 2000 2001 0 0 6000 12000 18000 24000 ED Mentions.

9. Increased Media Attention

10. 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

11. 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!

12. Changing Methods of Distribution Hand commerceE commerce

13. Less 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

14. 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

15.  Types of Painkillers (synthetics typically give better highs)  Short acting: Lortab (very common), percocet, vicodin  oxycontin lasts 12 hours; ms contin – morphine sulphate; lasts 12 hrs.  24-hr ms contin now available(kadian?)  duragesic fentanyl patch lasts 3 days; check used patches for tampering (can get patches on the internet)  ultram (not an opiate)  some may combine soma (a muscle relaxer) and lortab gives good pop ISSUES IN OPIOID ASSESSMENT

16.  realize very few chronic pain clients are “addicts”  assess for prior and current alcohol/drug problems  assess for self-medicating of psych disorders  do drug screen; do they already have drug in them? Are they diverting their meds to the street? (oxycontin going for about $1 per milligram)  check pharmacies for multiple rx  assess pain level on and off meds – are they helping functioning? Assessing Need for Narcotics (opioids)

17.  check compliance with medical tx – if client only wants narcotics, be suspicious…are they willing to sign a “medication use” agreement/contract?  are there secondary gain issues involved? (e.g., workmens comp.) poorer pain tx outcomes are associated with those in litigation.  type and dosage of drug currently taking; in some, tolerance is so high that withdrawal symptoms (increased pain) may occur when taking a typical dose  rural vs. urban setting: rx drug abuse worse in rural areas Assessing Need for Narcotics (opioids)

18. Treatment Issues  Age  Adolescent  Adult  Elderly  Drug History  New onset of drug abuse  Relapser  Chronic poly substance abuser  Route  Oral  Intranasal  Injector  Comorbidity  Psychiatric  Chronic pain Who is the Patient

19. Assessing Need for Narcotics  chronic opioid tx not appropriate for:  those with active addictions  those who use etoh (liability)  those who refuse other types of tx  when QOL not improved after use of meds  for those with previous narcotics problems  opioids not given for lengthy amounts of time  need to be in tx / NA  client may underestimate risk of relapse

20. Treatment Options  Detoxification  To antagonist maintenance (naltrexone, nelmefene, depot naltrexone)  To residential therapeutic community  To abstinence–oriented programs (counseling, 12 step programs)  Maintenance  Methadone, LAAM  Buprenorphine

21. Opiate Addiction Pharmacotherapy  AgonistsMethadone, LAAM  Partial AgonistsBuprenorphine  AntagonistsNaltrexone  Anti-WithdrawalMethadone; Buprenorphine Clonidine: rapid detox using Buprenorphine, Naltrexone, & Clonidine  Anti-CravingClonidine or Lofexidine

22. Advantages of Buprenorphine  Buprenorphine binds more tightly to the receptor than any other opiate  It is a partial mu agonist, occupying that receptor only 70%- also kappa antagonist  Ceiling effect protects against overdose–but also limits degree of agonist effect–ceiling effect approximately 32 mg  Withdrawal easier than from methadone or heroin  Maintained patients describe;  “Clear headedness”  Increased energy  Improved sleep & mood stability  Easier to engage in therapy

23. Other Forms of Pain Management  epidural nerve blocks  radio frequencies; zap nerve and deadens for up to 6 months  electrical stimulation: blocks pain signals  relaxation techniques  Biofeedback  physical therapy / chiropractic  Acupuncture  morphine pump in body  other medications  Antidepressants  Neurontin  Flexoril