1. Prescription Drug Abuse
Thomas E. Freese, PhD
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs
UCLA David Geffen School of Medicine, Dept. of Psychiatry

2. Prescription (Rx) Drug Abuse: What’s the Problem?
phoenix may 2004
Prescription (Rx) Drug Abuse: What’s the Problem?
I’m very delighted to be here today. I will be talking about the nature and trends were seeing with respect to Rx and OTC drug misuse, nationally and locally.

3. phoenix may 2004
What is Misuse?
Misuse = “Non-medical use” or any use that is outside of a medically prescribed regimen
Examples can include:
Taking for psychoactive “high” effects
Taking in extreme doses
Mixing pills
Using with alcohol or other illicit substances
Obtaining from non-medical sources
I want to first start off by defining what is considered or meant by “misuse”?
-Virtually any Rx and OTC drug can be misused.
-Misuse is considered to be using Rx and OTC drugs for non-medical purposes – in other words - any use that is outside of a medically prescribed regimen. 3

4. Methods of Prescription Diversion: Four Major Pathways
Pharmaceuticals manufactured lawfully, but stolen during distribution
Medications obtained inappropriately from legitimate end-users
Fraudulent prescriptions written on stolen prescribing pads
“Doctor shopping” (e.g., a method where individuals see several doctors in an attempt to obtain multiple prescriptions without revealing what they are doing).
Bullet #2: friends share prescription drugs, family members leave medicine in easily accessible places, etc.
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.

5. The Prescription Drug Epidemic is Unique in Some Ways
Prescription drugs are not inherently bad
When used appropriately, they are safe and vitally needed
Threat comes from misuse, abuse, and diversion
Just because prescription drugs are legal and are prescribed by an MD, they are not necessarily safer than illicit substances.
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.

6. Factors Fueling the Epidemic
Increase in legitimate commercial production and distribution of pharmaceuticals
Increase in marketing to physicians and public re: pain medications
Physicians have become more willing to prescribe medications, esp. for pain management
150% increase in prescriptions written for controlled drugs
Last bullet: 12 times the rate of increase in the population and almost 3 times the increase in prescriptions written for all other drugs
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.

7. The Fateful Triangle: Pain and Prescription Opioid Abuse
Under treatment of pain
Increasing availability of opioid analgesics
Increased production and distribution
Increase in the number of prescriptions filled
Increased internet availability
Increase in abuse of prescription opioids

8. Twin Epidemics: Prescription Drug Abuse and Unrelieved Pain
50 million Americans live with chronic pain
An additional 25 million live with acute pain
Mismanagement of pain has far reaching societal consequences.
In fighting illicit misuse, must not hinder patients’ access to beneficial medical treatments.
Prescription drugs are potent and must be monitored and managed appropriately (N. Katz, Tufts University).
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.

9. Nature of the Link Between Increasing Opioid Prescribing for Non-cancer Pain and Abuse
Chronic use of prescription opioids for NCPC is much higher and growing faster in patients with MH and SUDs than in those without these diagnoses
Clinicians should monitor the use of prescription opioids in these vulnerable groups to determine whether opioids are substituting for or interfering with appropriate MH and substance abuse treatment
Edlund, Mark et al, Clinical Journal of Pain 2010

10. Diagnosing Addiction Opioid-maintained Pain Patients
No validated diagnostic criteria for addiction in pain patients; only “at risk” behaviors:
Control
Compulsive use
Continue use despite harm
Craving
Identifying “at risk” patients:
History
Screening instruments
Behavioral checklists
Therapeutic maneuver

11. Webster, et al. Pain Med. 2005;6:432.
Opioid Risk Tool (ORT)
Administration
On initial visit
Prior to opioid therapy
Scoring
0-3: low risk (6%)
4-7: moderate risk (28%)
> 8: high risk (> 90%)
Webster, et al. Pain Med. 2005;6:432.

12. Aberrant Drug-Taking Behaviors
Probably more predictive
Selling prescription drugs
Prescription forgery
Stealing or borrowing another patient’s drugs
Injecting oral formulation
Obtaining prescription drugs from non-medical sources
Concurrent abuse of related illicit drugs
Multiple unsanctioned dose ↑ s
Recurrent prescription losses
Probably less predictive
Aggressive complaining about need for higher dose
Drug hoarding during periods of reduced symptoms
Requesting specific drugs
Acquisition of similar drugs from other medical sources
Unsanctioned dose escalation 1 – 2 times
Unapproved use of the drug to treat another symptom
Reporting psychic effects not intended by the clinician
Passik and Portenoy, 1998

13. Hyperalgesia (Increased sensitivity to pain) can be opioid induced
Opioid-induced hyperalgesia
Pain tolerance
Solomon 1980
Hyperalgesic processes brought into play to counteract analgesic forces
Bring pain tolerance back to normal level
Opioid-induced analgesia

14. Commonly Misused Rx Drugs
phoenix may 2004
Commonly Misused Rx Drugs
Classified in 3 classes
Opiates: pain-killers
Ex) Vicodin, OxyContin, Tylenol Codeine
CNS Depressants (Sedatives/Tranquilizers): treat anxiety and sleep disorders
Ex) Xanax, Ativan, Valium, Soma
Stimulants: ADHD, weight loss
Ex) Aderall, Ritalin, Concerta, Dexedrine, Fastin
The categories of prescription drugs most widely used as illicit intoxicants and broadly recorded in many of the pertinent databases are: opiates, sedatives/ tranquilizers, and stimulants
Commonly misused prescription drugs can be classified into the following 3 classes:
Opioids used to treat pain – some examples include Vicodin, Tylenol with Codeine, OxyContin, and Percocet
CNS Depressants used to treat sleep disorders and anxiety disorders – some examples include: barbiturates, benzodiazepines, and brands such as Klonopin, Nembutal, Soma, Valium, and Xanax
3) Stimulants: mainly prescribed to treat ADHD, including amphetamines, methylphenidate, and brands such as Adderall, Concerta, Dexedrine, and Ritalin. weight loss also abuse prescription stimulants such as Dexedrine and fastin.

15. A Global Look at Drug Abuse: World Drug Report, 2010
Updated 5/21/12
SOURCE: UNODC, World Drug Report, 2010.

16. Drug Prevalence in the United States
Marijuana = most commonly abused illicit drug
Non-medical use of prescription drugs = 2nd most commonly abused drug category
Prescription drug abuse is 3x more prevalent than illicit use of cocaine, crack, and hallucinogens
LEAVE AS IS
SOURCE: CA ADP, PDM Summary Report, 2009.

17. Past Year Non-Medical Psychotherapeutic Use: 2007 vs. 2010
Updated 5/21/12
SOURCE: SAMHSA, NSDUH, 2010 Results.

18. Percentage of US Population with Past Month Drug Use
phoenix may 2004
Percentage of US Population with Past Month Drug Use
Updated 5/21/12
The number and percentage of persons aged 12 or older who were current nonmedical users of psychotherapeutic drugs in 2010 (7.0 million or 2.7 percent) were similar to those in 2009 (7.0 million or 2.8 percent) and to those in 2002 (6.3 million or 2.7 percent)
SOURCE: SAMHSA, NSDUH, 2010 Results. 18

19. Past Year Rx Drug Misuse in the U.S.
16 million aged 12+ used a Rx drug (non-medically) in the past year
Updated 5/21/12
SOURCE: SAMHSA, NSDUH, 2010 Results.

20. Specific Drug Used When Initiating Drug Use: NSDUH, 2010
phoenix may 2004
Specific Drug Used When Initiating Drug Use: NSDUH, 2010
Updated 5/21/12
SOURCE: SAMHSA, NSDUH, 2010 Results. 20

21. New Users of Psychotherapeutics
2.4 million persons aged 12 or older used psychotherapeutics non-medically for the first time within the past year
2.0 million for pain relievers
1.2 million for tranquilizers
624,000 for stimulants
252,000 for sedatives
Average of 6,600 initiates per day.
2010 estimate was similar to 2009 rate, but significantly lower than 2004 rate (2.8 million).
In 2010, the average age at first nonmedical use of any psychotherapeutics was 22.3 years
21.0 years for pain relievers, 24.6 years for tranquilizers, 21.2 years for stimulants, and 23.5 years for sedatives.
Updated 5/21/12
SOURCE: SAMHSA, NSDUH, 2010 Results.

22. Treatment Admissions for Primary Prescription Drug Abuse: U.S.
(Percent of All Admissions)
Updated 5/21/12
SOURCE: SAMHSA, Treatment Episode Data Set, 2009 results.

23. Californians in Treatment
34%
20%
Updated 5/21/12
SOURCE: CA ADP, Fact Sheet: Californians in Treatment, FY 23

24. Prescription Drug-Related Emergency Department Visits
phoenix may 2004
Prescription Drug-Related Emergency Department Visits
Out of 4.5 million drug-related ED visits in 2009:
1.1 million associated with non-medical use of prescription drugs (24.6% of all drug-related visits)
Pain relievers (47.8%) were the most common type of medications involved in medical emergencies associated with nonmedical use of pharmaceuticals.
Pain relievers seen more commonly were oxycodone (13.7%), hydrocodone (8.0%), and methadone (5.8%).
Updated 5/21/12
Non-narcotic pain relievers, such as acetaminophen and nonsteroidal anti-inflammatory agents (e.g., ibuprofen, naproxen), were seen at lower levels of between 3 and 5 percent. Anxiolytics, sedatives, and hypnotics (drugs to treat anxiety and insomnia) were found in 33.6 percent of visits related to nonmedical use of pharmaceuticals. Benzodiazepines (anti-anxiety drugs) were involved in 29.0 percent of ED visits, with alprazolam (e.g., Xanax) indicated in 10.4 percent of such visits. Among other major categories of drugs, psychotherapeutic agents (antidepressants and antipsychotics) were involved in 12.3 percent of ED visits related to nonmedical use of pharmaceuticals, with respiratory agents and cardiovascular agents each involved in about 3 to 5 percent of these ED visits. Also appearing in the range of 3 to 5 percent were muscle relaxants and anticonvulsants. When population size and sampling error are taken into account, visits for nonmedical use of pharmaceuticals did not differ between males and females (349.2 and visits per 100,000 population, respectively). The rate of ED visits for patients in age categories between 18 and 34 were all over 500 visits per 100,000 population, with lower levels observed for younger and older patients.
SOURCE: SAMHSA, Drug Abuse Warning Network, 2009 Results. 24

27. Prescription Drug Use Among Teens

28. Young Brains Are Different from Older Brains
Alcohol and drugs affect the brains of adolescents and young adults differently than they do adult brains
Adolescent rats are more sensitive to the memory and learning problems than adults*
Conversely, they are less susceptible to intoxication (motor impairment and sedation) from alcohol*
These factors may lead to higher rates of dependence in these groups
*Hiller-Sturmhöfel., and Swartzwelder (NIAAA Publication 213) 28

29. Prescription Drug Abuse among U.S. High School Seniors
More than 12% of high school seniors said they had used opioid-based prescription drugs for non-medical purposes at least once in their lifetime.
Eight percent did so within the past year.
Reasons for use included: to relax, relieve tension, get high, experiment, relieve pain, or have a good time with their friends.
Those who used the drugs for reasons other than pain relief were more likely to use other addictive drugs and have signs of addictive disorders.
Heavy drinkers = 2 or more drinks per day every day.
SOURCE: Join Together Online, August 6, 2009; NIDA, MTF Survey, 2008.

30. Age Distribution of Prescription Drug Misuse in the Past Year
COULDN’T FIND UPDATED FIGURE; MIGHT WANT TO LEAVE IN FOR SAKE OF ILLUSTRATION IN AGE BREAKDOWN, SINCE STATS HAVEN’T CHANGED MUCH RECENTLY…
SOURCE: SAMHSA, NSDUH, 2006 Results.

31. SOURCE: SAMHSA, NSDUH, 2010 results.
Sources Where Pain Relievers were Obtained: Past Year Non-Medical Users Aged 12 or Older: 2010
Updated 5/21/12
The majority of individuals who use prescription drugs non-medically, for unintended purposes, obtain the drugs from friends or family members.
SOURCE: SAMHSA, NSDUH, 2010 results. 31

33. Over-the-Counter Drug Misuse among Young Adults
3.1 million year olds reported lifetime use of OTC cough and cold medications to get high
1 million reported past year use
Even gender distribution
Female year olds more likely to misuse OTC drugs than male counterparts
82% of lifetime OTC drug users also reported lifetime use of marijuana
Lower rates of lifetime use of hallucinogens, ecstasy, or inhalants
REMAINS THE SAME
SOURCE: CA ADP, Rx Drug Summary Report, 2009.

34. Prescription Drug Use Among Older Adults

35. Potential Issues for Older Adults
phoenix may 2004
Potential Issues for Older Adults
Prescription drug abuse begins with misuse due to inappropriate prescribing or lack of compliance
Age-related physiological changes (metabolism and response)
Greater likelihood of undiagnosed psychiatric and medical comorbidities
Difficulties with complying with complex drug regimens
Drug interactions
Read slide
SOURCE: CA ADP, Rx Drug Summary Report, 2009.

36. Rx Drug Abuse among Older Adults
phoenix may 2004
Rx Drug Abuse among Older Adults
Older Adults account for 13% of US population but use 1/3 of all medications prescribed.
7.2 million (21.7%) receive at least 1 Rx annually.
Older adults use Rx drugs 3 times more than the general population.
On average, older persons take 4.5 medications per day.
Nationally, 9.2 million (4.9%) of older adults abused Rx drugs in the last year while in California, 812,000 (3.7%).
Read slide
SOURCES: SAMHSA, 2006; NIDA, 2005 36

38. What are opioids? Opiate: derivative of opium poppy
Morphine
Codeine
Opioid: any compound that binds to opiate receptors
Semisynthetic (including heroin)
Synthetic
Oral, transdermal and intravenous formulations
Narcotic: legal designation
Heroin: semisynthetic derived from morphine
Semisynthetic: derived by altering chemicals contained in opium

39. Opioids
Instructions
Introduce opioids by reading the slide to your audience.
Point to the different pictures showing the different forms of opioids, including prescription drugs.

40. Opioids: Acute Effects
Euphoria
Pain relief
Suppresses cough reflex
Histamine release
Warm flushing of the skin
Dry mouth
Drowsiness and lethargy
Sense of well-being
Depression of the central nervous system (mental functioning clouded)
Instructions
Read the slide to your audience.

41. Effects of Opioids Sedation Pupil constriction Slurred speech
Impaired attention/memory
Constipation, urinary retention
Nausea
Confusion, delirium
Seizures
Slowed heart rate
Respiratory depression
1st 4: DSM criteria for opioid intoxication
Also: itchiness, myoclonus

42. Long-Term Effects of Opioids
Fatal overdose
Collapsed veins
Infectious diseases
Higher risk of HIV/AIDS and hepatitis
Infection of the heart lining and valves
Pulmonary complications & pneumonia
Respiratory problems
Abscesses
Liver disease
Low birth weight and developmental delay
Spontaneous abortion
Cellulitis
Instructions
Read the long-term effects of stimulant use to your audience
Point to the areas of the body that are affected by the use of these drugs.
Additional Information for Trainers
Chronic users of opioids may develop collapsed veins, infection of the heart lining and valves, abscesses, cellulitis, and liver disease. Pulmonary complications, including various types of pneumonia, may result from the poor health condition of the abuser, as well as from heroin’s depressing effects on respiration.
Heroin abuse during pregnancy and its many associated environmental factors (e.g., lack of prenatal care) have been associated with adverse consequences including low birth weight, an important risk factor for later developmental delay. In addition to the effects of the drug itself, street heroin may have additives that do not readily dissolve and result in clogging of the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in vital organs.
(Source: NIDA InfoFacts.)

43. Pain: The Fifth Vital Sign
JACHO Guidelines 2000:
Mandated pain assessment and treatment
Nurse and physician education required
When opioids prescribed properly for pain, addiction rare in patients without underlying risk factors
Vulnerabilities same as for other addictions: genetic, peer and social influences, trauma and abuse history
Temperature, blood pressure, heart rate, respiration

44. Pain Control and Addiction
“Pseudoaddiction”:
Presence of drug-seeking behavior in context of inadequate pain control
Behavior stops with adequate pain relief
Description of a clinical interaction (not a true diagnosis)
Physical dependence
with continued use, withdrawal syndrome produced by rapid dose reduction; occurs via neuroadaptation
Not synonymous with addiction
Also may see “hyperalgesia”: increased pain with increasing opioid doses

45. Opioid Withdrawal Dysphoric mood Nausea or vomiting Diarrhea
Tearing or runny nose
Dilated pupils
Muscle aches
Goosebumps
Sweating
Yawning
Fever
Insomnia
Also see protracted withdrawal – low energy, anhedonia, sleep disturbance, dysphoria, anxiety, craving for up to months

46. Opiates and Reward
Opiates bind to opiate receptors in the nucleus accumbens: increased dopamine release

48. Sedative-Hypnotics Used to treat anxiety and sleep disorders
Mechanism: enhances GABA
acts to slow normal brain function
Barbiturates
Phenobarbital®
Pentobarbital®
Fioricet® (butalbital/acetaminophen/caffeine)

49. Sedative-Hypnotics Cont’d
Benzodiazepines
Librium® (chlordiazepoxide HCL)
Valium® (diazepam)
Restoril® (tempazepam)
Klonopin® (clonazepam)
Ativan® (lorazepam)
Xanax® (alprazolam)
Non-benzo hypnotics
Ambien® (zolpidem)
Sonata® (zaleplon)
Lunesta® (eszopiclone)
Soma® (carisoprodol)
Cross-tolerance with alcohol (GABA related)
Soma: muscle relaxant, metabolized to mebprobamate (Miltown)
Non-benzo hypnotics bind to alpha 1 subunit of GABA-A receptor; thus sedating without anxiolytic or anticonvulsant properties

50. Sedative-Hypnotic Effects
Sedation
Slurred speech
Incoordination
Unsteady gait
Impaired attention or memory
Stupor or coma
Overdose risk increased with opioids or in combination with other sedatives, including alcohol
Toxicity: unsteady gait, impaired gag reflex, and blurry vision, obtundation

51. Sedative-Hypnotic Withdrawal
Increased pulse, blood pressure, or sweating
Hand tremor
Nausea or vomiting
Transient hallucinations or illusions
Agitation
Anxiety
Seizures

53. Prescription Stimulants
Stimulants (i.e., amphetamines) are often prescribed to treat individuals diagnosed with attention-deficit hyperactivity disorder (ADHD).
Substantial amounts of pharmaceutical amphetamines are diverted from medical use to non-prescription use.
Amphetamines increase wakefulness and alertness and have been used by:
The military, by pilots, truck drivers, and other workers to keep functioning past their normal limits
Common amphetamines include Dexedrine (d-amphetamine), methamphetamine, Ritalin, and Adderall (dl-amphetamine).
SOURCE: Erowid.org

54. Short-Term Effects Euphoria Increased energy/productivity
Increased concentration
Decreased appetite
Increased libido
Decreased sleep
*increased risk HIV/Hepatitis B&C transmission with increased libido/impulsivity
*Short-term effects plus ease of manufacture and less stigma are what makes meth appealing to use among different groups. Also used to self-medicate depression/AHDH

55. Medical Risks
Norepinephrine release causes constriction of blood vessels, elevated blood pressure and rapid heart rate
Increased activity levels
Dangerously high body temperatures
Increased risk of seizures
Potentially fatal arrhythmias, heart attack, or stroke

56. Stimulants: Withdrawal Symptoms
Dysphoric mood (sadness, anhedonia)
Fatigue
Insomnia or hypersomnia
Psychomotor agitation or retardation
Craving
Increased appetite
Vivid, unpleasant dreams
Instructions
Read the slide to your audience.

57. Over-the-Counter Drugs
Available without a doctor’s prescription
Increasingly used among adolescents and young adults
Cough and cold medications containing Dextromethorphan (DXM)
Coricidin®, Robitussin®, Nyquil®
Sleep aids
Unisom®
Antihistimines
Benadryl ®
Anti-nausea agents
Gravol®, Dramamine®

58. Dextromethorphan Over-the-counter cough suppressant
Structurally related to morphine
Mechanism: NMDA antagonist
Dissociative psychedelic properties in excess doses (like ketamine, PCP)
can produce distortions of the visual field, feelings of dissociation, distortions of bodily perception, excitement, as well as a loss of comprehension of time.

59. Fitting Pharmacotherapies into Treatment59

60. Four Legs of Addiction
Think of this concept as a chair, with each leg representing a component of a patient’s treatment plan.
Psychological
Spiritual
Biological
Social
All four legs are required to “support” the patient, and if one leg is missing, the chair will be unstable and unable to accomplish its goal. 60

61. Medical Treatments for Opioid Addiction

62. Partial vs. Full Opioid Agonist
death
Full Agonist
(e.g., methadone)
Opiate
Effect
Partial Agonist
(e.g. buprenorphine) .
(e.g. Naloxone)
Antagonist
Dose of Opiate

63. Medications to Treat Addiction
Addiction is a chronic, relapsing brain disease characterized by compulsive use despite harmful consequences
Medications as part of comprehensive treatment plan
Treatment approaches:
Medications (Bio)
Therapy, lifestyle changes (Psycho-Social)
Thorough evaluation and diagnosis essential
Meds help but not a cure
Screening/assessment covered in Module I
FDA-approved vs. off-label meds…use in adolescents vs. adults.

64. Pharmacotherapy in Substance Use Disorders
Treatment of withdrawal (“detox”)
Treatment of psychiatric symptoms or co-occurring disorders
Reduction of cravings and urges
Substitution therapy
Other forms of relapse prevention/harm reduction: aversive conditions if use, restore impulse control,
Prevention: use of psych med that may delay or prevent onset of SUD: ex: evidence of tx of ADHD may delay onset of SUD in adolescence, tx of ADHD with bupropion may reduce rates of initiation of tobacco use.
Replacement therapy: NRT, methadone, buprenorphine

65. Naltrexone

66. Naltrexone General Facts
Generic Name:
naltrexone hydrochloride
Marketed As:
ReVia (oral), Depade(oral), Vivvitrol (long acting injectable)
Purpose:
To discourage opioid use by reducing or eliminating the euphoric effects experienced by consuming exogenous administered opioids.
Indication:
In the treatment of alcohol dependence and for the blockade of the effects of exogenous administered opioids.
Year of FDA-Approval: 1984

67. Appropriate Populations
Age Range:
18 to 65 years old
Adolescents:
Has not been tested or FDA-approved.
Elderly:
Pregnancy:
Has not been adequately tested on pregnant or nursing women; Pregnancy Category C designation, used only if the potential benefit justifies the potential risk to the fetus.
Polysubstance Abusers:
Has not been adequately tested with this population. 67

68. Opioid Replacement Goals
Reduce symptoms & signs of withdrawal
Reduce or eliminate craving
Block effects of illicit opioids
Restore normal physiology
Promote psychosocial rehabilitation and non-drug lifestyle
Basis of replacement therapy: replace w/ longer duration of action, less abuse potential, and better safety profile to prevent WD and craving.

69. Methadone

70. Methadone General Facts
(information from medication package insert)
Generic Name:
methadone hydrochloride
Marketed As:
Methadose and Dolophine
(among others)
Purpose:
To discourage illicit opioid use due to cravings or the desire to alleviate opioid withdrawal symptoms.
Indication:
For the treatment of moderate to severe pain not responsive to non-narcotic analgesics; for detoxification treatment of opioid addiction; for maintenance treatment of opioid addiction, in conjunction with appropriate social and medical services.
Year of FDA-Approval: 1964

71. Methadone General Facts
(information from medication package insert)
Amount: maintenance dose of 80 to 120mg
Method: mouth
Frequency: once a day
The effect of consuming food with methadone has not been evaluated and therefore, is not recommended.
Abstinence requirements: must be abstinent from opioids long enough to experience mild to moderate opioid withdrawal symptoms.
Initial dose will vary depending upon the client’s usage pattern, but should not exceed 40mg.
Risk of Overdose: Just like with any opioid, overdose is possible. In the event of an overdose, appropriate medical treatment should be sought.

72. Methadone General Facts
(information from medication package insert)
Pregnancy:
Methadone is the preferred method of treatment for medication-assisted treatment for opioid dependence in pregnant women. An expert review of published data on experiences with methadone use during pregnancy concludes that it is unlikely to pose a substantial risk. But, there is insufficient data to state that there is no risk.
Methadone has not been adequately tested on pregnant women. Therefore, methadone has a Pregnancy Category C designation, meaning that it should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Caution should be exercised when using methadone with this population.

73. Methadone General Facts
(information from medication package insert)
Pregnancy:
Detoxification is relatively contraindicated unless done in hospital with monitoring.
Babies born to mothers who have been taking opioids regularly prior to delivery may be physically dependent and may experience opioid withdrawal symptoms. It is known that methadone is excreted through breast milk, and a decision should be made whether to discontinue nursing or to discontinue the medication, taking into account the importance of the medication to the mother and continued illicit opioid use.

74. Methadone is the most studied medication for opioid addiction.
What does the research say?
Methadone is the most studied
medication for opioid addiction.
8-10 fold reduction in death rate
Reduces opioid use
Reduces crime
Improves family and social functioning
Increases likelihood of employment
Improves physical and mental health
Reduces spread of HIV
Low drop-out rate compared to other treatments
References:
-A Medical Treatment for Diacetylmorphine (Heroin) Addiction A Clinical Trial With Methadone Hydrochloride
Vincent P. Dole, MD; Marie Nyswander, MD . JAMA. 1965;193(8):
-A clinical trial of buprenorphine: Comparison with methadone in the detoxification of heroin addicts
Warren K Bickel PhD, Maxine L Stitzer PhD, George E Bigelow PhD, Ira A Liebson MD, Donald R Jasinski MD and Rolley E Johnson PharmD Baltimore, Md.; Clinical Pharmacology and Therapeutics (1988) 43, 72–78; doi: /clpt
-Reducing the Risk of AIDS Through Methadone Maintenance Treatment
John C. Ball, W. Robert Lange, C. Patrick Myers and Samuel R. Friedman; Journal of Health and Social Behavior Vol. 29, No. 3 (Sep., 1988), pp Published by: American Sociological Association.

75. Crime before and during Methadone Treatment at 6 programs
Crime Days Per Year
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991.
(More recent supporting studies include:
Bell, Mattick, Hay, Chan, & Hall – Methadone maintenance and drug-related crime, Journal of Substance Abuse, Volume 9, 1997, Pages
Explaining the Effectiveness of Heroin-assisted Treatment on Crime Reductions. Rebecca Lobmann & Uwe Verthein. Law and Human Behavior Vol 33, Number 1,

76. Treatment Months Since Stopping Treatment
High Rate of Relapse to IV drug use after drop-out from Methadone Treatment
Percent IV Users
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Treatment Months Since Stopping Treatment

77. Buprenorphine

78. Development of Tablet Formulations of Buprnorphine
Buprenorphine is marketed for opioid treatment under the trade names of Subutex® (buprenorphine) and Suboxone® (buprenorphine/naloxone)
Over 25 years of research
Over 5,000 patients exposed during clinical trials
Proven safe and effective for the treatment of opioid addiction

79. Buprenorphine: A Science-Based Treatment
Clinical trials have established the effectiveness of buprenorphine for the treatment of heroin addiction. Effectiveness of buprenorphine has been compared to:
Placebo (Johnson et al. 1995; Ling et al. 1998; Kakko et al. 2003)
Methadone (Johnson et al. 1992; Strain et al. 1994a, 1994b; Ling et al. 1996; Schottenfield et al. 1997; Fischer et al. 1999)
Methadone and LAAM (Johnson et al. 2000)

80. The Role of Buprenorphine in Opioid Treatment
Partial Opioid Agonist
Produces a ceiling effect at higher doses
Has effects of typical opioid agonists—these effects are dose dependent up to a limit
Binds strongly to opiate receptor and is long-acting
Safe and effective therapy for opioid maintenance and detoxification

81. Advantages of Buprenorphine in the Treatment of Opioid Addiction
Patient can participate fully in treatment activities and other activities of daily living easing their transition into the treatment environment
Limited potential for overdose
Minimal subjective effects (e.g., sedation) following a dose
Available for use in an office setting
Lower level of physical dependence

82. Advantages of Buprenorphine/Naloxone in the Treatment of Opioid Addiction
Combination tablet is being marketed for U.S. use
Discourages IV use
Diminishes diversion
Allows for take-home dosing

83. Why Combining Buprenorphine and Naloxone Sublingually Works
Buprenorphine and naloxone have different sublingual (SL) to injection potency profiles that are optimal for use in a combination product.
SL Bioavailability Injection to Sublingual
Potency
Buprenorphine 40-60% Buprenorphine ≈ 2:1
Naloxone 10% or less Naloxone ≈ 15:1
SOURCE: Amass et al., 2004.

84. Role of Medical Community
An estimated 70 percent of Americans (approx 191million) visit their primary care physician at least once every two years.
Care for patients by prescribing needed medications
Identify prescription drug abuse when it exists
Help patients recognize abuse problems
Support patients in seeking appropriate treatment.

85. Role of Prescription Drug Monitoring Program Community
Collection and analysis of controlled substance data
Identification and investigation of illegal prescribing, dispensing and procurement
Physician access can help decrease extent of doctor shopping
Operational in 37 states

86. CURES: CA’s Prescription Drug Monitoring Program
Name: Controlled Substance Utilization Review and Evaluation System (CURES)
Overseen by: CA Dept. of Justice, Bureau of Narcotic Enforcement
Schedules Monitored: II, III, and IV
Number of Prescriptions Collected Annually: 21 million (100 million entries to date)
Number of Controlled Substance Dispensers: 155,000
Website:

87. Safe Drug Disposal Medicine Take-Back Programs
phoenix may 2004
Medicine Take-Back Programs
Contact household trash and recycling service or pharmacist
Disposal in Household Trash
Mix medicines with an unpalatable substance such as kitty litter or used coffee grounds
Place the mixture in a container or sealed plastic bag
Throw the container in your household trash
Flushing of Certain Medicines
A small number of medicines that are especially harmful if misused
Includes Opioid Medications
FDA has a list of Medications that should be flushed
Studies now showing that does not significantly impact water
The categories of prescription drugs most widely used as illicit intoxicants and broadly recorded in many of the pertinent databases are: opiates, sedatives/ tranquilizers, and stimulants
Commonly misused prescription drugs can be classified into the following 3 classes:
Opioids used to treat pain – some examples include Vicodin, Tylenol with Codeine, OxyContin, and Percocet
CNS Depressants used to treat sleep disorders and anxiety disorders – some examples include: barbiturates, benzodiazepines, and brands such as Klonopin, Nembutal, Soma, Valium, and Xanax
3) Stimulants: mainly prescribed to treat ADHD, including amphetamines, methylphenidate, and brands such as Adderall, Concerta, Dexedrine, and Ritalin. weight loss also abuse prescription stimulants such as Dexedrine and fastin.

88. Safe Drug Disposal
phoenix may 2004
Throwing unused prescription drugs in trash may be best for environment: A new study
Throwing away unused prescription drugs in the trash may be the most environmentally friendly option.
The researchers compared the environmental impact of flushing medication, throwing it in the trash, and burning it.
The study took into account how much of the drugs would enter the environment, as well as emission impacts from water treatment, transportation and burning of waste materials.
The categories of prescription drugs most widely used as illicit intoxicants and broadly recorded in many of the pertinent databases are: opiates, sedatives/ tranquilizers, and stimulants
Commonly misused prescription drugs can be classified into the following 3 classes:
Opioids used to treat pain – some examples include Vicodin, Tylenol with Codeine, OxyContin, and Percocet
CNS Depressants used to treat sleep disorders and anxiety disorders – some examples include: barbiturates, benzodiazepines, and brands such as Klonopin, Nembutal, Soma, Valium, and Xanax
3) Stimulants: mainly prescribed to treat ADHD, including amphetamines, methylphenidate, and brands such as Adderall, Concerta, Dexedrine, and Ritalin. weight loss also abuse prescription stimulants such as Dexedrine and fastin.

89. Safe Drug Disposal
phoenix may 2004
Throwing unused prescription drugs in trash may be best for environment: A new study
Flushing allows the highest levels of drugs to enter the environment, and creates more air pollution.
Drug collecting and burning produce far greater emissions of greenhouse gases and other pollutants, largely due to the travel required for people to come to drop-off points, and to ship drugs for incineration.
Throwing drugs out at home, uses an infrastructure that already exists for collecting household trash.
The categories of prescription drugs most widely used as illicit intoxicants and broadly recorded in many of the pertinent databases are: opiates, sedatives/ tranquilizers, and stimulants
Commonly misused prescription drugs can be classified into the following 3 classes:
Opioids used to treat pain – some examples include Vicodin, Tylenol with Codeine, OxyContin, and Percocet
CNS Depressants used to treat sleep disorders and anxiety disorders – some examples include: barbiturates, benzodiazepines, and brands such as Klonopin, Nembutal, Soma, Valium, and Xanax
3) Stimulants: mainly prescribed to treat ADHD, including amphetamines, methylphenidate, and brands such as Adderall, Concerta, Dexedrine, and Ritalin. weight loss also abuse prescription stimulants such as Dexedrine and fastin.

90. For more information, contact:
Thomas E. Freese, PhD