Trends in Addiction Medicine and in Synthetic Drug Use Michel A Sucher MD FASAM Medical Director Community Bridges, Inc. Stephanie Siete Director of Community Education

Disclosures Greenberg & Sucher, PC Community Bridges, Inc. President and shareholder Community Bridges, Inc. Medical Director Community Medical Services Medical Staff Membership Scottsdale Healthcare, Banner Behavioral Health Hospital, Mission Hospital Pharmaceutical Companies-NONE Other Treatment Providers-NONE

Agenda Addiction Medicine 101 The PHP Model Medication Assisted Treatment-controversies and challenges Tools to Assist in evaluation and treatment Community Bridges, Inc. The Prescription Drug Epidemic-Problem and Solutions The New Era of Synthetic Drugs

Addiction Medicine 101 Addiction Defined-Addiction is a primary, chronic disease of brain circuitry. Addiction is characterized by inability to consistently abstain from drugs of abuse, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships.

Addiction Medicine 101 Addiction is a chronic medical illness Similar to diabetes, asthma and hypertension Progression to Addiction Social or As prescribed use-no issues or consequences Abuse-use begins to cause problems in life Addiction-life interferes with using (loss of control)

Addiction Treatment 101 Treatment Works Levels of Treatment Substance dependence treatment is effective Levels of Treatment Medical Detoxification-inpatient and outpatient Opioids, Benzodiazepines Other Outpatient Residential/Inpatient/Extended residential Medication Assisted Treatment

The PHP Model Physician Health Programs have the most objective data on treatment of substance use disorders Backed by objective data Drug test results Face to face relapse prevention therapy groups Regular case management interviews and reports Worksite monitoring No self treatment/medication

The PHP Model Actually this is disease management of substance dependence BMJ 11/08 904 physicians, 16 states, 7.2 year follow up, all specialties Most programs are fully abstinent based No alcohol, opiates, benzos, other drugs (unless medically required and Rx’d by knowledgeable physicians No self medication

The PHP Model Extraordinary Success Rates BMJ Outcomes 78% no positive drug tests Of remaining 22%, 2/3 had only 1 positive drug test Only 6-7% had long term consequences such as license loss, death, suicide, etc. Arizona State Board of Dental Examiners 92% success rate in most recent 5 year study 79% success rate in prior 10 years (before addition of relapse prevention groups, mandatory inpatient treatment and strict compliance measurement

Medication Assisted Treatment Opiate Dependence Methadone (agonist) Buprenorphine (Suboxone, Subutex, etc) (agonist/antagonist) Naltrexone (antagonist) Alcohol Dependence Antabuse Naltrexone (oral and injectible) Acamprosate Other

Opiate Dependence Issues Legitimate medical use-physical dependence Pain management Substance dependence Illegitimate/illegal drug use-physical dependence and addiction Abuse Addiction Pseudo addiction

Treatment of Opiate Dependence Medical Detoxification Inpatient Outpatient Maintenance Treatment Methadone Buprenorphine Opiate Antagonist Treatment-Naltrexone Abstinence Treatment

Controversies in Opiate Addiction Treatment Maintenance vs Abstinence Medical Disease Model Good news-It’s a disease Bad news-It’s a disease, in the US we treat diseases with medications (eg hypertension, diabetes, etc.) Abstinence much more rarely offered or attempted Often young heroin or Rx opiate addicts placed directly into medication assisted treatment without any opportunity to try abstinence or antagonist treatment

Treatment for Alcohol Dependence Medical Detoxification Medication Assisted Treatment-still rarely used Includes antabuse, naltrexone, acamprosate Levels of Treatment Alcoholics Anonymous Intensive Outpatient Treatment Inpatient/residential treatment More treatment is better

Challenges in Addiction Treatment Medical marijuana (18 states plus DC) Legal marijuana (WA, CO currently) Synthetic drugs (spice, bath salts, etc.) New synthetic drugs

Drug Testing A lab test for a medical condition to determine if the disease is in remission The most objective measure of abstinence Should be widely used in the treatment of addiction (like checking blood sugars and blood pressure) Extremely accurate when done properly “You won’t find a drug you don’t test for”

Drug Testing Urine-most common Hair/Nails-long look back period Blood-good for alcohol and therapeutic drug levels Breath-alcohol Oral Fluids-increasing use Can test for virtually anything except N2O

CSPMP Arizona State Board of Pharmacy Any prescriber can enroll Looks at all controlled Rx prescriptions since 2008 Takes less than a minute once enrolled Gives Rx details re: prescribers and pharmacies Should be done on every patient, every visit

Research in Addiction Medicine Brain and Neurotransmitter Research New Medications Vaccines Process Addiction Research Sex, Gambling, Food, High Risk Behaviors, etc. Outcome studies

Rx Medications-The Problem Pain is “5th” Vital Sign Discipline more likely for under prescribing than over prescribing We have essentially become providers of “narcotics on demand” Pain management guidelines from the FSMB and AMB-good but often not followed We trust our patients but do not verify their histories-drug testing and CSPMP checks are NOT used nearly often enough

Rx Medications-The Problem Hydrocodone most commonly prescribed Rx medication in the USA Accidental overdose deaths exceed MVA deaths every year since 2009 Much addiction, overdoses, deaths the result of treatment for legitimate medical conditions Opioids, Benzodiazepines, Sedative- Hypnotics now more common than illegal drugs as entry/gateway drug in teens; Most obtained from parents or friends parents medicine cabinets

Prevalent Drugs of Abuse: Alcohol Cigarettes Marijuana * Prescription Drugs Source: Monitoring the Future Survey, Institute for Social Research, University of Michigan, 1999.

Rx Drug Use – An Epidemic “Prescription drug abuse is the nation's fastest-growing drug problem” White House Office on National Drug Policy 1.3 million emergency room visits in 2010, a 115% increase since 2004 Overdose deaths on opioid pain relievers surpassed deaths from heroin and cocaine for the first time in 2008

Accidental Rx Overdoses

The Rx Nation Every day 2,700 teens try a prescription drug to get high for the first time. Partnership for Drug Free America, 2010 Drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs.

Teen Prescription Drug Abuse According to the New PATS Data (2008-2012) One in four teens (24 percent) reports having misused or abused a prescription drug at least once in their lifetime 18 percent in 2008 24 percent in 2012 Translates to about 5 million teens. This is a 33 percent increase over a five-year period Of those kids who said they abused Rx medications, one in five (20 percent) has done so before age 14 More than a quarter of teens (27 percent) mistakenly believe that misusing and abusing prescription drugs is safer than using street drugs

Parental Lax attitude about Teen Rx Use According to the New PATS Data (2008-2012) One in six parents (16 percent) believes that using prescription drugs to get high is safer than using street drugs More than half of teens (56 percent) indicate that it’s easy to get prescription drugs from their parent’s medicine cabinet. About half of parents (49 percent) say anyone can access their medicine cabinet. One in five parents (20 percent) report that they have given their teen a prescription drug that was not prescribed for them. Survey also found that 17 percent of parents do not throw away expired medications, and 14 percent of parents say they themselves have misused or abuse prescription drugs within the past year.

Over-prescription of Rx drugs In Arizona, 476 million pills were prescribed in 2011. Pain Relievers accounted for over 50% of these scripts Nearly three out of four prescription drug overdoses are caused by prescription painkillers. Opiate overdoses (once almost always due to heroin use), are now increasingly due to abuse of prescription painkillers In AZ, 1,176 Rx deaths were attributed to drug overdoses in 2010

Arizona drug-related DUIs rising “Prescription painkillers and synthetic drugs such as ‘spice’ are common culprits” Alberto Gutier, director of the Governor’s Office of Highway Safety By Jim Walsh The Republic | azcentral.com Tue Jan 15, 2013 10:55 AM

Oxycodone OxyContin most recognized and abused form Prescribed to relieve pain Twice as strong as morphine Time released (8-12 hours) Pills crushed and snorted or cooked down and injected to break down time release component Strong, heroin-like, euphoric effects Expensive Dollars to milligrams: 10, 20, 40, 80, 120 (ex) Other variations: Percocet and Percodan

Heroin Purity In 1980s = 3.6% pure 1990 = 18% pure 1998 = 41% pure Today = 60-90% ??? No longer have to inject heroin to feel the effect. Purity so high effects felt by snorting or smoking 1996-1998 – 19 young people die of heroin overdoses in Plano, Texas Purity levels ranged up to 75%

Rx Drug – Take Back Day www.DEA.gov 742,497 pounds of Rx drugs were collected from almost 6,000 sites around the country on April 27. More than 2.8 million pounds of prescription medications have been removed from circulation during the 6 national take-back days the DEA has sponsored. www.DEA.gov

What’s happening? Change a few molecules Methamphetamine Heroin Marijuana “Bath Salts” “Krokodil” “Spice” Change a few molecules

Unknown: chemicals, effects, outcomes Chemicals… not drugs What chemicals? What does a ban mean? How long does it last? Who enforces these legal efforts? Who has authority? Community collaboration needed East Valley Synthetic Drugs Task Force

“Krokodil” Desomorphine Dirty cousin to morphine Roughly same effect as heroin but at least three times cheaper and extremely easy to make Active component is codeine, a widely sold over-the-counter painkiller (non toxic on its own). Mixed w gasoline, paint thinner, hydrochloric acid, iodine and red phosphorous In 2010, between a few hundred thousand and a million people, according to various official estimates, were injecting the resulting substance into their veins in Russia and now Germany The "rotting" explains the drug's nickname. At the injection site, which can be anywhere from the feet to the forehead, the addict's skin becomes greenish and scaly, like a crocodile's. Blood vessels burst and the surrounding tissue dies Gangrene and amputations are a common result, while porous bone tissue, especially in the lower jaw, often starts to dissipate, eaten up by the drug's acidity

Krokodil Drug - Desomorphine

Ofc. L.Gill ASUPolice

End Results For Users Initially the injection site turns a yellow/green and the surrounding flesh begins to grow lesions Lesions break open into gaping wounds. These areas are then highly susceptible to gangrene Continued use the flesh begins to eat away, sometimes to the bone Vital organs of the user’s body began to decay and fail Longest know life span of an addict is 2-3yrs One year is the typical length Ofc. L.Gill ASUPolice

Kratom Opiate-like leaf from Southeast Asia Chewed as a leaf or in a tea Legal and unregulated in US Street names: Thang, Kakuam, Thom, Ketum, Biak Small doses acts as energy boost Is in the coffee family Larger doses creates mellow, sedating effect Acting on opiate receptors

Kratom Kratom Use on the Rise Kratom Sales “appealing to bath salt crowd” Kratom On the Rise POSTED: 05:00 PM MST Mar 07, 2013 Kratom Sales “It’s not that bad” KING 5 News Posted on January 15, 2013 at 12:13 AM

Kratom Overdoses Hallucinations Delusions Listlessness Tremors Aggression Constipation Nausea

More Kratom info Similar heroin withdrawal effects Effects occur within 5-10 minutes. Lasting 2-5 hours Added to DEA “drugs and chemicals of concern” list In 2005, only 2 incidents nationwide… in 2011, Banner Good Samaritan Poison Control in Phoenix saw 6 cases Untraceable in drug tests

2C-I or “Smiles” First surfaced in 2003 European club scene Closely related to 2C-E Limited research 2 deaths in 2012 (ND and MN)

2C-I or “Smiles” MDMA and LSD combo – more potent Speedy charge, intense hallucinations Liquid, powder or pill form common Can be mixed in food/drinks Effects can occur within 40 minutes, last 2-3 hours Schedule 1 substance – possession and distribution illegal Untraceable in drug tests

Benzo Fury Stimulant and hallucinogenic effects The drug is a synthetic, laboratory- designed substance Similar effects to amphetamine and cocaine

25I-NBOMe “25-I” or “N Bomb” New synthetic version of LSD Use with a blotter and/or put it on your tongue Powerful hallucinations Deaths in Louisiana, California and North Dakota “25I” is an analog, or derivative of “2CI” 25I-NBOMe in Utah

‘N-bomb’ drug stirs fear in Phoenix area By JJ Hensley The Republic | azcentral.com Fri May 3, 2013 10:24 PM A drug marketed as an alternative to LSD or mescaline could be among the most powerful and potentially deadly of the synthetic drugs that have inundated the market in recent years, police and physicians believe. A 19-year-old from the West Valley was in a medically induced coma for four days after taking the drug, a synthetic hallucinogen known as “n-bomb,” and would have died if he had not received treatment when he did, according to a physician. Scottsdale police are investigating whether the deaths this year of two 18-year-olds are linked to the drug.

25i-NBOMe The first case in Scottsdale involved an 18-year-old Saguaro High School student who died in late January after taking what he assumed was LSD. Scottsdale police are also investigating the death of an 18-year-old Arizona State University student who authorities believe died after taking the drug last weekend. In the January case, Noah Carrasco lost consciousness shortly after taking the dose, administered through nose drops. An onlooker thought Carrasco simply needed to get some fresh air and sleep it off, said Carrasco’s mother, Susan Wadsworth. A friend drove Carrasco around for a while but later became more concerned and took Carrasco to the hospital about 1:40 a.m. on Jan. 25. “He’d been dead already at least for a couple of hours,” Wadsworth said. “They didn’t know that that’s what they were taking. My son was not a reckless person. He decided to try what he thought was acid, and obviously I didn’t know this at the time. But he would never have tried something he knew was that dangerous.” Sold as “Smiles” Treated with Milk in one case… cocaine and meth in the other

Who is Molly?

Molly is… Molecule MDMA

Synthetic Cannabinoids and Substituted Cathinones

Synthetic Cannabinoids "Spice" or "K2" Often referred to as: "Spice," Genie" “Blaze” and "Zohai" K2 contains synthetic chemicals that act on the cannabinoid receptors in the brain Sold in headshops or on internet as incense or potpourri for $5 - $60 per gram Rolled up in joints or inhaled from pipes Undetectable in many drug tests February 2011 – AZ bans Spice (10 chemicals) March 2011 – Federal ban of substance (5 chemicals) July 2012 – Federal ban of 20 more chemicals (25) January 2013 – 31 Federally banned chemicals April 3, 2013 – ALL chemicals illegal in AZ

Previously banned cannabinoids in Arizona HB 2167 (2011) JWH-250 JWH-015 HU-201 CP 47,497 and its C8 homologue JWH-018 JWH-073 JWH-019 JWH-398 JWH-200 Previously banned cannabinoids in Arizona

JWH 1995 - Professor John W. Huffman at Clemson University received a federal research grant to study marijuana effects of marijuana on the brain. JWH was told he needed to create substitute chemicals to study… the secret chemical substitutes were ripped off and now are frequently abused.

HB 2327 Key provision: Expands the state's definition of dangerous drugs to include chemical configurations that typically compose synthetic cannabinoids and bath salts All chemical compounds illegal Illegal in sales, possession, manufacturing and transferring Class 4 felony up to two and a half years of incarceration  CBS News - HB 2327

Where does it come from now? Southeast Asia Purchased chemicals Research Chemicals Personal production Internet Sales “How to”

Prevalence-2010 Ofc. L.Gill ASUPolice

Prevalence-2012 Ofc. L.Gill ASUPolice

Ingenuity of Designer Chemists Illegal Legal JWH-018 AM-2201 Change one strand of the molecule and you have a new, legal substance. This makes the exponential growth of these drugs a reality. Ofc. L.Gill ASUPolice

Possible Health Risks Hallucinations, delusions, severe agitation, elevated heart rate and blood pressure, vomiting, tremors, and seizures In the most severe cases users have blacked out for several hours, had feelings of cardiac arrest, and/or recorded feelings of psychosis Some of symptoms such as increased agitation, elevated blood pressure, and heart rates severely increase in “Spice” Marijuana label is mislabeling! Spice is NOT pot 61

Thalidomide OTC tranquilizer released in the late 1950s Marketed in 46 countries as sleep aid, alleviating nausea “given with complete safety to pregnant women and nursing mothers without any adverse effect on mother and child.” During 4 years it was on market, doctors prescribed it as a nontoxic antidote to morning sickness and sleeplessness—sold to millions. Affected 100,000 pregnant women, causing over 90,000 miscarriages and thousands of deformities to the babies who survived Effects: deaf, blind, curved spines, born without arms or legs, shortened limbs, heart and brain damage

Who is using synthetic drugs? Arizona Teens 1 in 10 AZ teens using synthetic drugs 8th graders – 6.9% 10th graders – 11.1% 12th graders – 13.9% This is first time capturing synthetic drug data on teens in AYS Arizona Youth Survey, 2012 http://www.kpho.com/story/20272748/survey-1-in-10-az-teens

DAWN Report – Synthetic Drugs December 4, 2012 (Drug Abuse Warning Network) 11,406 ER visits for synthetic cannabinoids ¾ or 75% of patients were ages 12-29 years of age The majority (76%) did not receive follow up care after discharge from ER 59% of 12-29 year old patients only presented with spice – no other substance found

In 2011… According to the U.S. Drug Abuse Warning Network, some 28,000 emergency room visits in 2011 were caused by known synthetic cannabinoids, more than double the 2010 number.

Sold As… “Code Words” not tobacco… Potpourri Herbal incense Glass cleaner Plant fertilizer Insect repellent Souvenir Bath salts

What are Substituted Cathinones? “Bath Salts” Derivatives of cathinone, a psychoactive substance with stimulant properties occurring naturally in the khat plant effects are similar to amphetamines like ecstasy and cocaine Street names Abyssinian Tea, African Salad, Catha, Chat, Kat, Oat Powder and crystal form that crumbles easily White to light brown in color Sold in 50 mg to 500 mg packets/containers Labeled “not for human consumption” Sold for $5 to $75 Easily available online Law enforcement and open news sources, Officer Donald Reid, 2012

Bath Salts Bans At least 42 states have outlawed substituted cathinones Poison control centers around the country received 6,138 calls about bath salts in 2011, according to the American Association of Poison Control Centers, up from 304 in all of 2010 3 federally banned chemicals: mephedrone, methylone, methylenedioxypyrovalerone (MDPV)

Effects High similar to cocaine, methamphetamine, MDMA (Ecstasy) or LSD Initial euphoria last 3-4 hours Psychosis, hallucinations, suicidal thoughts can last 3-4 days Unknown long term effects 3-4 months after last initial use Cited as “imminent threat to public safety” by DEA Law enforcement and open news sources, Officer Donald Reid, 2012

More Effects Sweating Agitation Hallucinations Tremors Coma Excited Delirium (bizarre and/or aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength and hyperthermia) Death Harm to self Harm to others Hypertension Permanently alter brains chemistry Psychiatric conditions

Signs and Symptoms Extreme paranoia Psychotic features (reporting seeing demons, monsters, foreign soldiers, aliens) Violent behavior Tachycardia (rapid heartbeat) Chest pain Confusion High blood pressure Sweating Hyper-alertness

Signs and Symptoms Sleep depravation Agitation Extreme anxiety Hallucinations Teeth grinding Excessive water drinking Tremors Seizures

Bath Salts Common Names Ivory Wave Cloud 9 Ocean Bliss Eight Ballz White Lightning Hurricane Charlie Charge Plus Scarface Red or White Dove White Water Rapid Amped Ladybug Attractant Snowman Glass Cleaner

Synthetic Cathinones “Bath Salts” Flesh eating bacteria

Bath Salts in the News PD: Man on bath salts runs naked through Tempe neighborhood ABC 15 – July 18, 2012 PD: Man ingests bath salts, swims naked in Tempe Town Lake AZFamily – July 24, 2012 Flesh-Eating Disease Blamed on ‘Bath Salts’ Jan 13, 2012 6:19pm 'Bath Salts' Drug Suspected In Miami Face-Eating Attack May 30, 2012 Man high on bath salts thought he was being chased by electricity during burglary, police say Friday, March 25, 2011, 7:56 AM     Updated: Friday, March 25, 2011, 10:56 AM

Can you still purchase? http://bath-salts-direct.com/ http://spice-gold- direct.com/acatalog/stimulating-bath-salts- powder-blends.html Spice Gold Direct shared a link.

Synthetics in the News… ABC 20/20 Synthetic Drugs - 9 minutes Bath Salt Use - Good Morning America Synthetic Drugs - shorter version 2 minutes

How do we respond? Community awareness Treatment Law Enforcement Product recognition Symptom recognition Treatment Medical care Law Enforcement Respond and Protect Legislation Eliminate it Be Safe and do NOT attempt to reason with someone under the influence. Call for help.

Resources http://www.tascaz.org/ Banner Good Samaritan Poison and Drug Information Center 24-hour phone: 1-800-222-1222 www.dea.gov

Helpful Websites www.communitybridgesaz.org www.partnerupaz.org www.health.org www.drugfreeaz.org http://www.timetotalk.org www.theantidrug.com www.jointogether.org

Where can you find more information? Call your local poison center at 1-800-222-1222. Poison centers are open 24 hours a day, seven days a week, every day of the year for poisoning emergencies and for informational calls, too. www.aapcc.org

Prerequisites for Solutions Acknowledge the Problem Understand the risks of inappropriate prescribing Learn that the common belief that chronic use of controlled substances is safe and non impairing may not be true Get everyone (public, patients, insurers, prescribers, etc) out of denial Educate, Educate, Educate

Possible Solutions Education for Providers Proper prescribing courses (possibly required CE) Proper procedure and rules re: dispensing Addiction Medicine 101 and realistic information about true risk of addiction to controlled substances Taking complete histories, obtaining prior medical records, use of CSPMP and similar programs Role of physicians and pharmacists and how they can work together to identify and prevent abuse

Possible Solutions Education for Providers, cont’d Effects of controlled substances on cognition and performance Treatment options for patients who become addicted and how to access appropriate treatment options Monitoring/disease management Outcomes data

Possible Solutions Who to Educate Educate physicians Educate patients Educate parents Educate teenagers and children Educate society Educate insurers Educate all stakeholders Like we are doing here today

Possible Solutions Increased regulation Increased enforcement and discipline Holding patients, family members responsible in addition to the medical profession Expansion/enhancement/improved funding for CSPMP and similar providers of key information Better coordination of care between providers for every patient

Essentials for Change Understanding addiction treatment options and efficacy Separate treatment models for the substance dependent individual vs the accidental “addict” with legitimate medical issues Prompt Identification of patients in crisis from misuse/abuse of prescription medications Insistence upon detoxification and treatment when indicated

Community Bridges, Inc. Started as medical detoxification in Mesa, AZ for the indigent Now full service crisis and treatment agency for mental health and substance abuse 30 facilities statewide, all connected by EMR and Telemedicine Highly qualified staff of psychiatrists, addiction physicians, psychiatric and family nurse practitioners Level IV Stabilization and Recovery Unit (SRU) in Payson

Where We Serve Maricopa County Phoenix Mesa Winslow Level IV Holbrook Level IV WV Triage Level III Payson Level IV Phoenix Glendale OP Central City Level I Ctr for Excellence OP Probation OP Globe Level IV DRC/CASS OP Drug Court OP Steele Commons OP Mesa East Valley Level I ADMIN East Valley Triage Level III Center for Hope Level II Prevention Partnership Casa Grande Level IV Journey/OP Clinical Ops Admin. Az Bridge to Recovery Aspire OP for Women Supportive Housing Benson Level II Yuma Level III Benson Level IV

Summary These are real issues Education is a key component Improved communication between providers and all involved professionals is essential (physicians, pharmacists, other) Prevention and early identification are critical Treatment is effective Use drug testing and CSPMP queries

Thanks for your attention Questions? Greenberg & Sucher, PC Michel A Sucher MD FASAM PO 1420 Scottsdale, AZ 85252 877-457-3111; Cell 480-213-7674 Email: drsucher@greenbergandsucher.com www.greenbergandsucher.com www.posttreatmentsupervision.com

Thanks for your attention Questions? Stephanie Siete ssiete@cbridges.com 602.377.4591 24/7 Access to Care 877.931.9142 www.CommunityBridgesAZ.org

News videos, articles, upcoming presentations Community Bridges AZ News videos, articles, upcoming presentations www.CommunityBridgesAZ.org