Presentation on theme: "Trends in Addiction Medicine and in Synthetic Drug Use"— Presentation transcript:
1 Trends in Addiction Medicine and in Synthetic Drug Use Michel A Sucher MD FASAMMedical DirectorCommunity Bridges, Inc.Stephanie SieteDirector of Community Education
2 Disclosures Greenberg & Sucher, PC Community Bridges, Inc. President and shareholderCommunity Bridges, Inc.Medical DirectorCommunity Medical ServicesMedical Staff MembershipScottsdale Healthcare, Banner Behavioral Health Hospital, Mission HospitalPharmaceutical Companies-NONEOther Treatment Providers-NONE
3 Agenda Addiction Medicine 101 The PHP Model Medication Assisted Treatment-controversies and challengesTools to Assist in evaluation and treatmentCommunity Bridges, Inc.The Prescription Drug Epidemic-Problem and SolutionsThe New Era of Synthetic Drugs
4 Addiction Medicine 101Addiction 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.
5 Addiction Medicine 101 Addiction is a chronic medical illness Similar to diabetes, asthma and hypertensionProgression to AddictionSocial or As prescribed use-no issues or consequencesAbuse-use begins to cause problems in lifeAddiction-life interferes with using (loss of control)
6 Addiction Treatment 101 Treatment Works Levels of Treatment Substance dependence treatment is effectiveLevels of TreatmentMedical Detoxification-inpatient and outpatientOpioids, BenzodiazepinesOtherOutpatientResidential/Inpatient/Extended residentialMedication Assisted Treatment
7 The PHP ModelPhysician Health Programs have the most objective data on treatment of substance use disordersBacked by objective dataDrug test resultsFace to face relapse prevention therapy groupsRegular case management interviews and reportsWorksite monitoringNo self treatment/medication
8 The PHP ModelActually this is disease management of substance dependenceBMJ 11/08904 physicians, 16 states, 7.2 year follow up, all specialtiesMost programs are fully abstinent basedNo alcohol, opiates, benzos, other drugs (unless medically required and Rx’d by knowledgeable physiciansNo self medication
9 The PHP Model Extraordinary Success Rates BMJ Outcomes 78% no positive drug testsOf remaining 22%, 2/3 had only 1 positive drug testOnly 6-7% had long term consequences such as license loss, death, suicide, etc.Arizona State Board of Dental Examiners92% success rate in most recent 5 year study79% success rate in prior 10 years (before addition of relapse prevention groups, mandatory inpatient treatment and strict compliance measurement
11 Opiate Dependence Issues Legitimate medical use-physical dependencePain managementSubstance dependenceIllegitimate/illegal drug use-physical dependence and addictionAbuseAddictionPseudo addiction
12 Treatment of Opiate Dependence Medical DetoxificationInpatientOutpatientMaintenance TreatmentMethadoneBuprenorphineOpiate Antagonist Treatment-NaltrexoneAbstinence Treatment
13 Controversies in Opiate Addiction Treatment Maintenance vs AbstinenceMedical Disease ModelGood news-It’s a diseaseBad news-It’s a disease, in the US we treat diseases with medications (eg hypertension, diabetes, etc.)Abstinence much more rarely offered or attemptedOften young heroin or Rx opiate addicts placed directly into medication assisted treatment without any opportunity to try abstinence or antagonist treatment
14 Treatment for Alcohol Dependence Medical DetoxificationMedication Assisted Treatment-still rarely usedIncludes antabuse, naltrexone, acamprosateLevels of TreatmentAlcoholics AnonymousIntensive Outpatient TreatmentInpatient/residential treatmentMore treatment is better
15 Challenges in Addiction Treatment Medical marijuana (18 states plus DC)Legal marijuana (WA, CO currently)Synthetic drugs (spice, bath salts, etc.)New synthetic drugs
16 Drug TestingA lab test for a medical condition to determine if the disease is in remissionThe most objective measure of abstinenceShould 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”
17 Drug Testing Urine-most common Hair/Nails-long look back period Blood-good for alcohol and therapeutic drug levelsBreath-alcoholOral Fluids-increasing useCan test for virtually anything except N2O
18 CSPMP Arizona State Board of Pharmacy Any prescriber can enroll Looks at all controlled Rx prescriptions since 2008Takes less than a minute once enrolledGives Rx details re: prescribers and pharmaciesShould be done on every patient, every visit
19 Research in Addiction Medicine Brain and Neurotransmitter ResearchNew MedicationsVaccinesProcess Addiction ResearchSex, Gambling, Food, High Risk Behaviors, etc.Outcome studies
20 Rx Medications-The Problem Pain is “5th” Vital SignDiscipline more likely for under prescribing than over prescribingWe have essentially become providers of “narcotics on demand”Pain management guidelines from the FSMB and AMB-good but often not followedWe trust our patients but do not verify their histories-drug testing and CSPMP checks are NOT used nearly often enough
21 Rx Medications-The Problem Hydrocodone most commonly prescribed Rx medication in the USAAccidental overdose deaths exceed MVA deaths every year since 2009Much addiction, overdoses, deaths the result of treatment for legitimate medical conditionsOpioids, Benzodiazepines, Sedative- Hypnotics now more common than illegal drugs as entry/gateway drug in teens; Most obtained from parents or friends parents medicine cabinets
22 Prevalent Drugs of Abuse: AlcoholCigarettesMarijuana* Prescription DrugsSource: Monitoring the Future Survey, Institute for Social Research, University of Michigan, 1999.
23 Rx Drug Use – An Epidemic “Prescription drug abuse is the nation's fastest-growing drug problem”White House Office on National Drug Policy1.3 million emergency room visits in 2010, a 115% increase since 2004Overdose deaths on opioid pain relievers surpassed deaths from heroin and cocaine for the first time in 2008
25 The Rx NationEvery day 2,700 teens try a prescription drug to get high for the first time Partnership for Drug Free America, 2010Drug 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.
26 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 lifetime18 percent in 200824 percent in 2012Translates to about 5 million teens. This is a 33 percent increase over a five-year periodOf those kids who said they abused Rx medications, one in five (20 percent) has done so before age 14More than a quarter of teens (27 percent) mistakenly believe that misusing and abusing prescription drugs is safer than using street drugs
27 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 drugsMore 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.
28 Over-prescription of Rx drugs In Arizona, 476 million pills were prescribed in Pain Relievers accounted for over 50% of these scriptsNearly 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 painkillersIn AZ, 1,176 Rx deaths were attributed to drug overdoses in 2010
30 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 SafetyBy Jim Walsh The Republic | azcentral.com Tue Jan 15, :55 AM
31 Oxycodone OxyContin most recognized and abused form Prescribed to relieve painTwice as strong as morphineTime released (8-12 hours)Pills crushed and snorted or cooked down and injected to break down time release componentStrong, heroin-like, euphoric effectsExpensiveDollars to milligrams: 10, 20, 40, 80, 120 (ex)Other variations: Percocet and Percodan
32 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– 19 young people die of heroin overdoses in Plano, TexasPurity levels ranged up to 75%
33 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.
34 What’s happening? Change a few molecules Methamphetamine Heroin Marijuana“Bath Salts” “Krokodil” “Spice”Change a few molecules
35 Unknown: chemicals, effects, outcomes Chemicals… not drugsWhat chemicals?What does a ban mean?How long does it last?Who enforces these legal efforts?Who has authority?Community collaboration neededEast Valley Synthetic Drugs Task Force
36 “Krokodil” Desomorphine Dirty cousin to morphineRoughly same effect as heroin but at least three times cheaper and extremely easy to makeActive 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 phosphorousIn 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 GermanyThe "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 diesGangrene 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
39 End Results For UsersInitially the injection site turns a yellow/green and the surrounding flesh begins to grow lesionsLesions break open into gaping wounds.These areas are then highly susceptible to gangreneContinued use the flesh begins to eat away, sometimes to the boneVital organs of the user’s body began to decay and failLongest know life span of an addict is 2-3yrsOne year is the typical lengthOfc. L.Gill ASUPolice
40 Kratom Opiate-like leaf from Southeast Asia Chewed as a leaf or in a teaLegal and unregulated in USStreet names:Thang, Kakuam, Thom, Ketum, BiakSmall doses acts as energy boostIs in the coffee familyLarger doses creates mellow, sedating effectActing on opiate receptors
41 Kratom Kratom Use on the Rise Kratom Sales “appealing to bath salt crowd”Kratom On the RisePOSTED: 05:00 PM MST Mar 07, 2013Kratom Sales“It’s not that bad”KING 5 NewsPosted on January 15, 2013 at 12:13 AM
43 More Kratom info Similar heroin withdrawal effects Effects occur within 5-10 minutes. Lasting 2-5 hoursAdded to DEA “drugs and chemicals of concern” listIn 2005, only 2 incidents nationwide… in 2011, Banner Good Samaritan Poison Control in Phoenix saw 6 casesUntraceable in drug tests
44 2C-I or “Smiles” First surfaced in 2003 European club scene Closely related to 2C-ELimited research2 deaths in 2012 (ND and MN)
45 2C-I or “Smiles” MDMA and LSD combo – more potent Speedy charge, intense hallucinationsLiquid, powder or pill form commonCan be mixed in food/drinksEffects can occur within 40 minutes, last 2-3 hoursSchedule 1 substance – possession and distribution illegalUntraceable in drug tests
46 Benzo Fury Stimulant and hallucinogenic effects The drug is a synthetic, laboratory- designed substanceSimilar effects to amphetamine and cocaine
47 25I-NBOMe “25-I” or “N Bomb” New synthetic version of LSD Use with a blotter and/or put it on your tonguePowerful hallucinationsDeaths in Louisiana, California and North Dakota“25I” is an analog, or derivative of “2CI”25I-NBOMe in Utah
48 ‘N-bomb’ drug stirs fear in Phoenix area By JJ Hensley The Republic | azcentral.com Fri May 3, :24 PMA 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.
49 25i-NBOMeThe 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
52 Synthetic Cannabinoids and Substituted Cathinones
53 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 brainSold in headshops or on internet as incense or potpourri for $5 - $60 per gramRolled up in joints or inhaled from pipesUndetectable in many drug testsFebruary 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 chemicalsApril 3, 2013 – ALL chemicals illegal in AZ
54 Previously banned cannabinoids in Arizona HB 2167 (2011)JWH-250JWH-015HU-201CP 47,497and its C8 homologueJWH-018JWH-073JWH-019JWH-398JWH-200Previously banned cannabinoids in Arizona
55 JWHProfessor 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.
56 HB 2327Key provision: Expands the state's definition of dangerous drugs to include chemical configurations that typically compose synthetic cannabinoids and bath saltsAll chemical compounds illegalIllegal in sales, possession, manufacturing and transferringClass 4 felonyup to two and a half years of incarceration CBS News - HB 2327
57 Where does it come from now? Southeast AsiaPurchased chemicalsResearch ChemicalsPersonal productionInternetSales“How to”
60 Ingenuity of Designer Chemists IllegalLegalJWH-018AM-2201Change 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
61 Possible Health RisksHallucinations, delusions, severe agitation, elevated heart rate and blood pressure, vomiting, tremors, and seizuresIn the most severe cases users have blacked out for several hours, had feelings of cardiac arrest, and/or recorded feelings of psychosisSome of symptoms such as increased agitation, elevated blood pressure, and heart rates severely increase in “Spice”Marijuana label is mislabeling!Spice is NOT pot61
62 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 survivedEffects: deaf, blind, curved spines, born without arms or legs, shortened limbs, heart and brain damage
63 Who is using synthetic drugs? Arizona Teens1 in 10 AZ teens using synthetic drugs8th graders – 6.9%10th graders – 11.1%12th graders – 13.9%This is first time capturing synthetic drug data on teens in AYSArizona Youth Survey, 2012
64 DAWN Report – Synthetic Drugs December 4, 2012 (Drug Abuse Warning Network) 11,406 ER visits for synthetic cannabinoids¾ or 75% of patients were ages years of ageThe majority (76%) did not receive follow up care after discharge from ER59% of year old patients only presented with spice – no other substance found
65 In 2011…According to the U.S. Drug Abuse Warning Network, some 28,000 emergency room visits in were caused by known synthetic cannabinoids, more than double the 2010 number.
66 Sold As… “Code Words” not tobacco… PotpourriHerbal incenseGlass cleanerPlant fertilizerInsect repellentSouvenirBath salts
67 What are Substituted Cathinones? “Bath Salts” Derivatives of cathinone, a psychoactive substance with stimulant properties occurring naturally in the khat planteffects are similar to amphetamines like ecstasy and cocaineStreet namesAbyssinian Tea, African Salad, Catha, Chat, Kat, OatPowder and crystal form that crumbles easilyWhite to light brown in colorSold in 50 mg to 500 mg packets/containersLabeled “not for human consumption”Sold for $5 to $75Easily available onlineLaw enforcement and open news sources, Officer Donald Reid, 2012
68 Bath Salts BansAt least 42 states have outlawed substituted cathinonesPoison 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 20103 federally banned chemicals: mephedrone, methylone, methylenedioxypyrovalerone (MDPV)
69 EffectsHigh similar to cocaine, methamphetamine, MDMA (Ecstasy) or LSDInitial euphoria last 3-4 hoursPsychosis, hallucinations, suicidal thoughts can last 3-4 daysUnknown long term effects3-4 months after last initial useCited as “imminent threat to public safety” by DEALaw enforcement and open news sources, Officer Donald Reid, 2012
70 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)DeathHarm to selfHarm to othersHypertensionPermanently alter brains chemistryPsychiatric conditions
75 Bath Salts in the NewsPD: Man on bath salts runs naked through Tempe neighborhoodABC 15 – July 18, 2012PD: Man ingests bath salts, swims naked in Tempe Town LakeAZFamily – July 24, 2012Flesh-Eating Disease Blamed on ‘Bath Salts’Jan 13, :19pm'Bath Salts' Drug Suspected In Miami Face-Eating AttackMay 30, 2012Man high on bath salts thought he was being chased by electricity during burglary, police sayFriday, March 25, 2011, 7:56 AM Updated: Friday, March 25, 2011, 10:56 AM
76 Can you still purchase? http://bath-salts-direct.com/ direct.com/acatalog/stimulating-bath-salts- powder-blends.htmlSpice Gold Direct shared a link.
77 Synthetics in the News… ABC 20/20 Synthetic Drugs - 9 minutesBath Salt Use - Good Morning AmericaSynthetic Drugs - shorter version 2 minutes
78 How do we respond? Community awareness Treatment Law Enforcement Product recognitionSymptom recognitionTreatmentMedical careLaw EnforcementRespond and ProtectLegislationEliminate itBe Safe and do NOT attempt to reason with someone under the influence. Call for help.
79 Resources http://www.tascaz.org/ Banner Good Samaritan Poison and Drug Information Center 24-hour phone:
81 Where can you find more information? Call your local poison center at 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.
82 Prerequisites for Solutions Acknowledge the ProblemUnderstand the risks of inappropriate prescribingLearn that the common belief that chronic use of controlled substances is safe and non impairing may not be trueGet everyone (public, patients, insurers, prescribers, etc) out of denialEducate, Educate, Educate
83 Possible Solutions Education for Providers Proper prescribing courses (possibly required CE)Proper procedure and rules re: dispensingAddiction Medicine 101 and realistic information about true risk of addiction to controlled substancesTaking complete histories, obtaining prior medical records, use of CSPMP and similar programsRole of physicians and pharmacists and how they can work together to identify and prevent abuse
84 Possible Solutions Education for Providers, cont’d Effects of controlled substances on cognition and performanceTreatment options for patients who become addicted and how to access appropriate treatment optionsMonitoring/disease managementOutcomes data
85 Possible Solutions Who to Educate Educate physicians Educate patients Educate parentsEducate teenagers and childrenEducate societyEducate insurersEducate all stakeholdersLike we are doing here today
86 Possible Solutions Increased regulation Increased enforcement and disciplineHolding patients, family members responsible in addition to the medical professionExpansion/enhancement/improved funding for CSPMP and similar providers of key informationBetter coordination of care between providers for every patient
87 Essentials for ChangeUnderstanding addiction treatment options and efficacySeparate treatment models for the substance dependent individual vs the accidental “addict” with legitimate medical issuesPrompt Identification of patients in crisis from misuse/abuse of prescription medicationsInsistence upon detoxification and treatment when indicated
88 Community Bridges, Inc.Started as medical detoxification in Mesa, AZ for the indigentNow full service crisis and treatment agency for mental health and substance abuse30 facilities statewide, all connected by EMR and TelemedicineHighly qualified staff of psychiatrists, addiction physicians, psychiatric and family nurse practitionersLevel IV Stabilization and Recovery Unit (SRU) in Payson
89 Where We Serve Maricopa County Phoenix Mesa Winslow Level IV Holbrook Level IVWV Triage Level IIIPayson Level IVPhoenixGlendale OPCentral City Level ICtr for Excellence OPProbation OPGlobe Level IVDRC/CASS OPDrug Court OPSteele Commons OPMesaEast Valley Level IADMINEast Valley Triage Level IIICenter for Hope Level IIPreventionPartnershipCasa Grande Level IVJourney/OPClinical Ops Admin.Az Bridge to RecoveryAspire OP for WomenSupportive HousingBenson Level IIYuma Level IIIBenson Level IV
90 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 criticalTreatment is effectiveUse drug testing and CSPMP queries
91 Thanks for your attention Questions? Greenberg & Sucher, PC Michel A Sucher MD FASAM PO 1420 Scottsdale, AZ ; Cell
92 Thanks for your attention Questions?Stephanie Siete24/7 Access to Care