1. Prescription and OTC Drug Abuse
Jennifer Swift
Lake Erie College of Osteopathic Medicine
Wegmans Pharmacist, Pharm D.
Stephen Tarbell
University of Buffalo
Pharmacy Candidate 2011

2. Quick Quiz 1 in 5 teenagers have tried this:
Prescription Pain Medications
B. Marijuana
C. Chewing Tobacco
Answer is prescription PAIN medications………In the retail pharmacy setting we are seeing more and more doctors writing medications for vicodin and tylenol with codeine for children years old. Many adults also get pain medications and thus kids can get into parents’ medicine cabinets if the medications are not kept out of reach or if parents don’t inform their children of the dangers of trying someone else’s medication.
Besides marijuana, teenagers most likely to abuse
prescription pain killers
Including: Vicodin, Oxycontin, Oxycodone

3. Prescription Pain Medications
Examples:
Vicodin
Oxycodone/ Oxycontin
Morphine
Tylenol with Codeine
What are some examples of PAIN medication? There are many different formulations on the markets today, but some of the most commonly prescribed are………………….PATS Teen Report 2005 source
Parents need to know this!!!!!!!!!!!!!!! When I was in high school my parents gave me the talk about making sure I stayed away from marijuana, alcohol, and “drugs” in general. However, I associated drugs with illegal drugs, never anything prescribed by a physician. Parents needs to be more specific in their talk about drug abuse making sure to talk about all drugs and make sure the students understand the broad spectrum. This even includes vitamins and herbal medication. Overdosing on Calcium even is very dangerous and especially in young women laxatives. A person could be extremely dehydrated which leads to severe damage.

4. Quick Quiz 14% of teenagers have been offered this: Acting Audition
B. Cocaine
C. Prescription Medication for Non-Medical Use
Answer C: Prescription medication for non-medical use……………Although cocaine is also a problem, most parents educate their children on the dangers of illegal drug abuse. However, so many parents forget to talk about the dangers of prescription and over-the-counter medications. Many parents have expired prescription medications in their cabinets at home they safe which potentially their child could try. A child could overdose on the medication, or experience have harmful effects if the medication is expired.
At this point ask the class if they can name any prescription or OTC meds to show the wide variety of medications that exist and how commonly known they are.

5. “Pharming” Parties New form of a party
people bring in medications, dump them all into a bowl, and then you take a handful of pills and take them all at once.
Even if you only do this once you may possibly cause permanent damage to your body if not death.
CBS 4 News: Hollywood FL
Explain how you would have no idea what medications you are taking
Certain medication combinations can be extremely harmful and possibly fatal, especially if alcohol in mixed with certain medications.
Try to locate boston legal clip on pharm parties…check year 2006 5

6. Are Medications Safe? Life saving remedies when used correctly
Very dangerous if used incorrectly
Many people think “medications”, doctor prescribed, healthcare recommended, seen on tv and automatically think SAFE. But this is definitely not true. On a daily basis we, as pharmacists, call doctors to change medications they’ve prescribed due to drug interactions, drug allergies, etc. So, people need to know that not all medications are safe, EVEN when prescribed by their doctor. There are many contraindications to medications and each medication taken needs to be carefully reviewed by doctors and pharmacist. This also includes over-the-counter medications. For instance, ibuprofen, if some is taking an antidepressant or has a stomach ulcer, they should not take ibuprofen. There are many warnings on the boxes of OTC meds that people ignore. They’re there for a reason. The more education people have about medications and the more questions asked the better of you’re going to be. Don’t doctor shop or pharmacy shop b/c you’re increasing your risk of danger.
As the title slide appears ask the group if they think that medications are safe….if they say yes ask why and if they say no ask why……..after this display the next portion of the slide and give specific examples of how medications can save lives and how they can also be very dangerous

7. Who abuses Medications?
Abusers of prescription products can range from school age children to celebrities.
Suspicion of medication abuse has been alleged in the death of
Michael Jackson
Anna Nicole Smith
Elvis Presley
When I created this presentation these were the people who came mind. In the last few months you can add: Brittany Murphy, and the daughter of the Jets owner

8. Medication Dangers
Between 1999 and 2004 nearly all POISON deaths were due to DRUGS, and the most coming from the abuse of PRESCRIPTION and ILLEGAL drugs.
In 1999  12,186 DEATHS
In 2004  20,950 DEATHS
These statistics are from the office of national drug control policy executive office of the President from February teens and prescription drugs
Emphasize that just because prescription medications/otc’s are legal does not mean that they are safer to use than products such as marijuana, heroic, or cocaine…source From office of national drug control policy executive office of the president..february teens and prescription drugs
Be cautious also about OTC meds:::::::::::::::Pain relievers include: ibuprofen, tylenol, naproxen (motrin, cold medications containing acetaminophen, etc)

9. Are prescription medications safer than illegal drugs?
41% of teens believe they are safer
Prescription medications can be just as dangerous if not MORE DANGEROUS than illegal drugs
Must be used only under supervision of a healthcare professional
Many people think the answer is YES. And it makes sense to believe that something legal is safer than something illegal. This is true to an extent and people (adults and children) need to understand why.
Don’t use family members or friends medications. It is Federal Law a person should only use a medication prescribed to themselves.
Explain that just because drugs are legal they can be just as dangerous if not deadlier than illegal drugs…source PATS Teens report 2008

10. On the label of a prescription:
“Caution:” Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed.”
Medications are NOT to be shared!!!
Drugs are very dangerous when taken in a manner other than that which was prescribed by a physician.
There are certain dosages which MDs must prescribe within.
Rx medications often interact with prescription medications.
Drugs can decrease a patient’s breathing, cause liver damage, kidney damage and death.
This even includes something as simple as penicillin. We commonly see parents stopping antibiotics halfway through therapy because they are feeling better and saving it for later. So now you’ve killed the bacteria that makes you feel bad but haven’t killed all of it. You’ve created resistance. BAD!!! This is causing people to need broader spectrum antibiotics that are more expensive and have more side effects. A parent might save those few remaining days of penicillin and give it to their child when they are feeling sick. That parent might not know what the child has – causing a worse illness, or perhaps the child is allergic to penicilllin, the parent doesn’t know that, and the child goes into anaphylactic shock.
Worse yet, the child tries the penicillin not knowing they are allergic and there you have a very dangerous situation.
It is so important to take your medications EXACTLY as prescribed, and not share them with anyone else.

11. What is the most commonly abused pain killer?
VICODIN
contains Hydrocodone/ APAP
most commonly abused pain killer at 18%
Vicodin is an oral semisynthetic (half-man made, half-natural) opiate agonist and APAP is acetaminophen, commonly known as tylenol.
An MSNBC article titled generation Rx? found Teens abusing prescriptions which cited a study by partnership for a DRUG FREE AMERICA
Hydrocodone: binds to the opiate receptor in the body and changes a person’s perception of pain at the spinal cord and in the central nervous system. Opiate analgesics also alter the emotional response to pain causing a patient’s brain to stop registering that the person has pain.
Acetaminophen: Acetaminophen acts primarily in the central nervous system and increases the pain threshold which allows a person to tolerate more pain than without APAP

12. Vicodin Hydrocodone causes Tylenol causes Dizziness Drowsiness
Slows breathing
Hallucinations
Tylenol causes
Liver toxicity if >4,000mg/ day
Besides pain relief what can vicodin due in the body?

13. Oxycodone/ Oxycontin Uses How it works Control pain after an operation
Dental pain
Moderate to severe pain
How it works
In brain and spinal cord to block perception of pain
What about oxycontin? A more potent pain reliever commonly used only in patients who experience no pain relief from tylenol with codeine or vicodin
Oral semisynthetic opiate agonist
Oxycontin is extended – release oxycodone. Lasts 12 hours in body veruses 4-6 hours that immediate release oxycodone lasts.

14. Oxycodone/ Oxycontin Adverse Reactions Slows heart rate
Increase or decrease blood pressure
Fainting
Dry mouth
Blurred vision
Cardiac arrest
(heart stops)
Agonist - A drug that combines with receptors to initiate drug actions
Analgesic - A compound that relieves pain by altering perception of pain-related stimuli without producing anesthesia or loss of consciousness
Narcotic - Any drug, synthetic or naturally occurring, with effects similar to those of opium and opium derivatives
Opioid - Any derivative of opium or any narcotic with effects similar to those of an opiate

15. Oxycodone/ Oxycontin Adverse Reactions continued Muscle twitching
Sweating
Hallucinations
Headaches
Circulatory depression
Slurred speech
Oxycodone 5mg tablet
Oxycodone 15mg tablet
These are potentially dangerous side effects that come with taking oxycontin. It might stop the pain, but it causes other problems. Many medications are prescribed only when the Benefits outweigh the Risks of the medication. Even prescription medications come with unwanted side effect but for patients with extreme pain, they are willing to risk this.

16. Morphine MS Contin MSIR Avinza Kadian Oramorph Roxanol
Some brand name medications that contain morphine include:

17. Morphine Acts in the brain and spinal cord to relieve pain
High likelihood for
addiction
tolerance
physical and psychological dependence
How does morphine work?
However, it is highly addictive and if a patient is on it for a long time they must continue to increase their dose. It is a closely monitored medication with many legal restrictions. For instance, a person cannot fill a morphine rx (this goes with any controlled substance) more than 7 days early over the entire life of the rx, unless their dose changes. Only in very rare instances will a prescribed approve an early refill of a controlled substance.

18. Morphine Effects on the body Nausea/ Vomiting Dry mouth Blurred vision
Slows heart rate
Shortness of breath
Confusion
Drowsiness
Kidney failure
Muscle twitches
Nausea/ Vomiting
Dry mouth
Blurred vision
Unconsciousness
Death
These are dangerous effects!!!

19. Over-the-Counter (OTC) Medications
Cough and cold medications
Delsym/ Robitussin
Pain relievers
Tylenol
Ibuprofen
1 in 10 teens have abused OTC cough medicine to get a high
So we’ve discussed the effects of abusing some prescription drugs, but what about over-the-counter medications
Can products you buy OTC be dangerous? ABSOLUTELY!
Some of the common active ingredients in products that can cause bad effects are: tylenol (APAP), IBU, and dextromethorphan (Delsym, Robitussin)
Dxmstories.com is a good website to look at to show the dangers of dxm and stories… source PATS Teen Report 2005

20. Dextromethorphan What is it? Side effects morphine derivative
works in the cough center (medulla)
of the brain
Side effects
altered time perception
visual hallucinations
brain damage
seizure
loss of consciousness
irregular heart beat
When ingested at recommended dosage levels for intended purposes, dextromethorphan is generally regarded as a safe and effective cough suppressant.
Adolescents: 120 mg/day
Don’t take with MAOIs

21. Dextromethorphan Normal dosage: 120 mg/day, 60mg/dose Plateau
Dose (mg)
Behavioral Effects
1st 
100–200
Mild stimulation
2nd 
200–400
Euphoria and Hallucinations
3rd 
300– 600
Distorted visual perceptions and
Loss of motor coordination
4th 
Dissociative sedation
In addition: Approximately 5-10% of Caucasians are poor DXM metabolizers which increases their risk for overdoses and deaths. (Office of Diversion Control. September 2007:
Ketamine for Conscious Sedation in Pediatric Emergency Care: Pharmacology of Ketamine
Dissociative sedation: is defined as "a trancelike cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability."
Can lose your ability to breathe b/c your body relaxes so much

22. Tylenol

23. Tylenol Active ingredient What is it? Acetaminophen APAP Pain reliever
Fever reducer
Overdose
4,000mg
Liver toxicity
Common cause of
liver transplants
Be extremely cautious with Tylenol overdose b/c it is an active ingredient in many OTC cough and cold products.
Also, it is not recommended to combine with alcohol. Alcohol is metabolized by the liver and so it APAP. Therefore, the two products can cause liver damager if abused or overused.

24. Tylenol Acetaminophen is found in many over-the- counter products
Benadryl
Cepacol
Coricidin
Dayquil
Dimetapp
Excedrin
Midol
Nyquil
Theraflu
Triaminic
Vicks
Zicam
Take home lesson here: Watch the active ingredients in OTC products and watch the APAP levels
APAP/ Tylenol is not just a brand

25. Tylenol Acetaminophen is also found in many prescription products
Endocet
Vicodin
Lortab
Ultracet
Percocet
Darvocet
Fioricet
Tylenol with Codeine
Tylenol 3 (300 mg/30 mg)
Tylenol 4 (300 mg/60 mg)
*** One handful of medications could contain and OD of APAP
*** CET = means APAP 25

26. Liver
Just to quickly go over how important the liver is::::::::::::::::::
It produces and stores substances needed to make RBCs, eliminate poison, store and use fats.
Cirrhosis of the liver is when the liver begins to deteriorate and begins malfunction.
Scar tissue blocks healthy tissue and stops blood flow through the liver which impairs the liver’s ability to control infections and remove bacteria and toxins from the blood.
Symptoms of cirrhosis: weakness, fatigue, loss of appetite, N/V, abdominal pain and bloating
May be irreversible when caught.
Statins are tested for LFTs.

27. Advil/ Motrin Active ingredient Ibuprofen What is it?
Anti-inflammatory
Pain reliever
Fever reducer
What is causes
GI bleeding
GI: gastrointestinal bleeding

28. Common Street Names OxyContin Dextromethorphan
Ocs, oxy, 40 (a 40mg tablets), 80 (an 80mg tablet), Blue, Hillbilly heroin, Kicker
Dextromethorphan
Dex, DXM, Skittles, Robo, Syrup, Triple-C, Tussin, Vitamin D

29. Effects of Drug Abuse Short term drug abuse
feels “good”
seems harmless
Medication abuse may include
trouble sleeping
dependence
social withdrawal
trouble breathing
organ damage
death
Fine line between benefit and harm when it comes to medications.
should only be tested when you are taking medications under the care and supervision of a medical professional

30. Fact from Fiction
Easy to look at medications as the cure-all, especially watching TV commercials, but they are far from it.
Medications should only be used when necessary.
Media should be looked at cautiously
Important to listen to the quick talking at the end
side effects, precautions
If you ever have a question or wonder if a medication may be right for you, speak to your doctor or pharmacist.

31. How do you know if someone is abusing medications?
Change in sleep patterns
Change in attitude
Social withdrawal
Easily agitated
Sudden weight loss/gain
Out of the ordinary spending of money
This is not a cheap addiction. Some medications such as oxycontin can sell for at least 6 dollars a tablet or $1/ 1mg

32. Help is Available!!!
- allows teens to gauge their dependence and provides outlets of help
- discusses abuse of the OTC cough syrup Dextromethorphan
HELP(4357) - hotline that provides you with treatment programs in your area
Stress that there are a variety of outlets for help…..also stress that any questions they have about medications no matter how personal may be asked to a pharmacist or physician in complete confidentiality

33. Real Life Stories
Eddie was a 22 year old young man who began abusing a prescription medication called Xanax. At times Eddie would take 15 pills at once. One time while waiting for friends he fell asleep on a street corner. Eddie was found and decided to go to rehab.
After completing a 28 day rehab program Eddie relapsed and overdosed on 67 pills of Xanax.
Eddie died at the age of 22, leaving his parents, girlfriend, and two young children.
USA today article entitled prescription drugs find place in teen culture
Xanax (alprazolam) works in the body to slow the central nervous system. Used in patients with severe anxiety and who have panic disorders.
Can be addicting and cause you to be dependent. Will cause withdrawal when stopped (feel nauseous, sweat, increased heartbeat, hallucinations, seizures)
Benzo overdose – slurred speech, trouble walking, unable to focus, uncontrolled eye movements,
Can cause – irritability, aggression, hostility, impulsiveness if used in the wrong population.

34. Real Life Stories
Mark Daniel Bauer was an avid weightlifter. He took prescription drugs, that were not prescribed to him to relieve his chronic back pain.
Mark overdosed on morphine, oxycodone, and acetaminophen. Mark died on May 24, 2004.
He was 18 years old.
USA today article prescription drugs find place in teen culture

35. Real Life Stories
Nathaniel Bell was charged with committing first degree murder after stabbing Jose Felix-Martinez. The motive—Nathaniel had ingested large amounts of an OTC medication that contains dextromethorphan (Delsym) as well as cocaine and alcohol.
Source A Bad trip that Kills..LA times

36. Real Life Stories
Savannah Kissick was celebrating New Years Eve using painkillers and sedatives. She was rushed to the hospital that night and died soon after. Savannah was 22 years old.
Savannah’s friend Sarah Shay also overdosed on prescription drugs while partying with friends. Her friends dropped her body off at a local hospital and fled the area. She had already passed away. She was 19 years old.
Source Prescription drug abuse ravages state’s youth msnbc.com
Don’t ever leave a friend unconcious or who has overdosed on alcohol or a medication. GET HELP IMMEDIATELY!!!

37. Don't Become Part of the Statistic!!!
Take Home Point
Don't Become Part of the Statistic!!!
If you don’t take anything else out of this presentation, take this point home with you, don’t become just another number among those who abuse medications . Become part of the number who avoid this very dangerous practice and lead by example.
March 23, 2008: