1. Prescription Drug Abuse
Steve Hanson
Director, Bureau of Treatment
NYS OASAS

2. Why Prescription Drugs
They work
They are fairly easily available
The culture of Prescription Drugs
Advertising
Patient Expectations
Pharmaceutical Company Promotion
The Internet
The Mail

3. Basic Facts
48 million (age 12 and over) used Rx meds for non-medical purpose - 20% of U.S. population
2007 – 1.9 million ED visits related to Drug misuse/abuse (DAWN report)
31% - 582,000 – Rx drugs alone
8% - 144,000 – Rx drug + illicit drugs
10% - 189,000 – Rx + alcohol
52% - 611,000 – involved Rx drugs

4. Non Medical Use of Rx ED Visits Per 100,000 (2007)

5. ED Visits Non-Med use of Rx Drugs 2004-2005

6. Past Month Illicit Drug Use among Persons Aged 12 or Older: 2009

7. Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2009

8. Past Month Use of Selected Illicit Drugs among Young Adults Aged 18 to 25: 2002-2009

9. Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2009

10. Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older:

11. ED visits non-med use of Rx drugs

12. Source Where Psychotherapeutics Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2005
Percent of Past Year Users
Other
Bought on Internet
Drug Dealer/ Stranger
1 or More Doctors
Bought/Took from Friend/ Relative
Free from Friend/Relative 8

13. Two “Types” of Rx Drug Abusers
The Drug Abuser who likes Rx drugs.
Frequently use other drugs (cocaine, alcohol, heroin, other non-Rx drugs)
Fits the “model” of a drug abuser.
“addicted” to high
The Patient who becomes dependent on their medication
Infrequent use of other substances – unless can’t get Rx.
Don’t fit “model” of drug user – age, other behaviors.
“dependent” on the drug

14. Addiction vs. Dependency
Addiction – use the drug for the high, euphoria
Dependent – use the drug to avoid withdrawal effects
Can be both

15. Commonly Abused Rx Drugs
Opiates/pain killers
Depressant/anti-anxieties
Stimulants

16. Nonmedical Use of Pain Relievers in Past Year among Persons Aged 12 or Older, by Substate Region: Percentages, Annual Averages Based on

17. The Action of Opiates

18. Natural Pain Suppression
Slide 4–6 Illustration of natural pain suppression caused by endorphin action at the synaptic gap.
This diagram of a synapse shows that when pain signals are being transmitted through the nervous system, a secondary terminal releases endorphins that then slot into receptor sites on the primary terminal and limit the release of the pain neurotransmitter, substance “P.” (p. 148)
Natural Pain Suppression

19. Artificial Pain Suppression
Slide Illustration of artificial pain suppression caused by the use of heroin or other opioids.
Heroin or any opioid slots into the secondary endorphin receptor sites limiting the release of substance “P” that gets through by slotting into the primary substance “P” receptor sites on the receiving dendrite of the next neuron. (p. 148)
Artificial Pain Suppression

20. Opiate Effects Analgesia - change in pain perception
Euphoria - whole body orgasm
Sedation - “on the nod”
Respiratory Depression - OD
Cough Suppression
Nausea/vomiting
Constipation

21. Tolerance Rapid tolerance with continued use
Cell sensitivity thought to be the tolerance mechanism.
User now needs to find additional amounts
Multiple doctors
Asking friends/relatives

22. Addiction/Dependency
Opioids trigger reward system – euphoria – leads to continued use – addiction
Withdrawal symptoms are significant – regular use to avoid withdrawal - dependence

23. Withdrawal Pain Depression Alert Rapid Breathing Coughing
Nausea/Vomiting
Diarrhea
3-5 days

24. Oxycontin Oxycodone – synthesized from thebaine (part of opium)
Crush the tablet for quicker high
Oral, snort, inject
Percocet – oxycodone & acetominophen
Percodan – oxycodone & aspirin

25. Vicodin Hydrocodone and acetominophen Lorcet, Lortab
Schedule III – high psychological/medium physical
Pain and post-surgical use (pain)

26. Issues with Rx Opiate Dependence
Presence of real pain
“I’m addicted to vicodin, not alcohol, why do I have to quit that too?”
Drug Testing – make sure you test for drug of choice as well as alternatives.

27. Anti-anxietals/Anxiolytics
Panic Disorder
Phobias / social phobia
Obsessive Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Generalized Anxiety Disorder
The neuroses – treated by Freud

28. Benzodiazepines Share a chemical structure Librium – 1960
Valium - #1 Rx drug , 3x #2
Xanax
Ativan
Very profitable

29. Benzodiazepines Very Long Acting Short Acting
Halazepam (Paxipam) Alprazolam (Xanax )
Prazepam (Centrax ) Temazepam (Restoril ) Flurazepam (Dalmane ) Oxazepam (Serax )
Lorazepam (Ativan )
Intermediate Acting Very Short Acting
Clonazepam (Klonipin ) Triazolam (Halcion )
Chlordiazepoxide (Librium )
Diazepam (Valium )
Slide 4–15 List of various kinds of benzodiazepines over a background of Valium.
For years, while the patents remained in effect, drug companies had exclusive markets for the benzodiazepines they developed. As the patents ran out, generic forms of the drug came on the market, encouraging the companies to develop new drugs. (p. 165)

30. Effects of Benzodiazepines
Anxiety control (e.g., panic attack)
Relaxation
Drowsiness & sleep
Control seizures
Reduced muscular coordination
Dulled physical sensations
Tolerance to effects develops
Slide 4–16 List of the effects of benzodiazepines over a background of Xanax.
Benzodiazepines were developed as safe substitutes for barbiturates to promote anxiety relief, sedation, and muscular relaxation. In general they were safer but tolerance could still develop and withdrawal symptoms still occurred even with low-level prolonged use. (pp. 165–168)

31. Benzodiazepines (cont.)
Action – most increase GABA
Safe – Ld very high
Anticipation/placebo effect
Problems – work so well, people don’t want to stop.
Side effects – dose related – cognitive impairment, amnesia, slurred speech
Long Withdrawal

32. Drug Court/Treatment Issues
People with true anxiety disorder
Anxiety can be a major relapse trigger
Stressful situations in early recovery
Strong craving for relief
To medicate or not to medicate…

33. Why Prescription Drug Users May Believe That They Are “Different”
“I had/have real pain, I wasn’t using these to get high like those drug addicts”
“My doctor prescribed these for me. It wasn’t my idea”
“I never robbed anyone or did those things that addicts do.”
“I have to take something for this pain!”

34. What the Rx Drug User Might Have Trouble Relating To
“Hitting Bottom”
Changing People, Places & Things
Change your “Lifestyle”
You must be completely abstinent from everything else – alcohol included
Going to meetings all of the time.

35. Drug Court/Treatment Issues
Urine testing – ensuring that the panel used includes the drugs that the participants take
Medication needs – people suffering from a medical/psychiatric condition that needs to be medicated – which medications are “okay”
Withdrawal risks

36. COMMUNITY SUPERVISION
Difficult population to supervise
Unique strategies of supervison
Training needs of the supervision officer.

37. Supervision
Must be unrelenting in the monitoring of prescription drug use
All prescriptions must be reported
Must work with physician to determine need for medication.
Connect with addictionologist to monitor withdrawal, medication assisted treatment, and on-going pain treatment.

38. Letter for Physician To Medical Treatment Provider/Doctor:
Your patient, ___________________________ is a participant in the Drug Court Program, a court ordered substance abuse treatment program. He/She has been assigned to this program due to ongoing and significant substance dependence.
Your patient has provided documentation indicating that you have prescribed medication with addictive properties as part of his/her treatment. Please verify your knowledge and approval of this patient’s prescribed medication and that you feel the current course of treatment is necessary and no other alternative form of treatment exists.
To ensure that this is a valid prescription and you have received this letter, the participant must return this letter with the information below completed.
Physicians Name_________________________________ (Please print and/or type)
Address ___________________________________
Phone Number___________________________________
DEA# _________________________________________
Signature_______________________________________
Sincerely,

39. Supervision Monitoring prescription pills.
Random searches of person and property.
Monitor DEA database to determine multiple prescriptions.
Obtain release of information from each physician to facilitate communication between Dr. and team.

40. Supervision
On-going communication between supervision officer and treatment
Monitoring of drug use through random, frequent drug testing
Not only testing for illegal drug use, but for MAT drugs.

41. Skills for Supervision Officer
Must understand the disease model of addiction.
Be aware of relapse signs and/or triggers.
Motivational Interviewing- to engage clients buy in, by developing discrepancies and gauging client’s readiness to change.

42. Skills of Supervision Officer
Clear communication with treatment provider.
Provide immediate sanction/incentive for each drug test.

43. Opiate Addicts in Drug Court
Decision must be made by entire team that the person will be allowed in the program.
Understanding that some clients will be on pain medication for the rest of their lives, and our job is to monitor that client is taking medicine as prescribed.

44. Opiate Addicts in Drug Court
This population is a growing threat to the safety of our community. The availability of prescription drugs and the on-going abuse must be addressed.
Drug Courts are here to change the lives of addicts, while offering protection to the community through accountability and on-going collaboration of the courts and treatment.

45. While the opioid client is difficult to monitor, choosing to not deal with them is not the answer.
Drug Courts must continue to develop methods to monitor these clients and not allow them to go unsupervised just because they are hard to monitor.