Transcript Prescription drug abuse - Dayton Children's Hospital

 The views and opinions expressed in this presentation
are those of the author and do not reflect official
policy or position of the United States Air Force,
Department of Defense, or US Government
Case 1
• S: Sarah is a 15 y/o girl you are seeing for the first time. Mother brought her to
the clinic because she has had a 20 pound weight loss over the last 3 months.
Patient states she does not know what the worry is, she is still overweight. “I am
just eating less” She denies binging or purging.
• PMH – healthy 15 y/o girl
• FH: Brother with ADHD- Mother has depression in remission
• O: BMI 31. HR 110. Remainder non contributory
• A/P: Weight loss. You discuss with patient that she is losing weight a bit too
rapidly and refer her to a nutritionist for more healthy weight loss tips.
• On the way out mom asks if she can schedule her 17 y/o son. His ADHD
symptoms are not under good control this year.
Case 1
• 2 weeks later she presents to the ER via ambulance 30
•
•
•
•
•
•
•
•
•
minutes after sustaining a 5 minute grand mal seizure
She is now awake and extremely irritable and paranoid
She is picking at her skin and making strange facial
grimaces
Her vitals are T of 102, HR of 150, BP of 154/94, RR of 28
On exam she is sweating and his pupils are dilated
She has a tremor and 3-4 (+) reflexes
all of a sudden she states she is having crushing chest pain
You stabilize her and admit her for overnight observation.
10 minutes later urine drug screen is positive for
amphetamines
Her brother is there and he looks like he is holding back
tears. He says he was only trying to help.
Case 2
• 17 y/o presents with her mother after she found her lying
•
•
•
•
•
•
•
on the ground in a stupor. Some of her other friends were
there and they seemed intoxicated according to the mother
She is barely awake and cannot answer your questions
Review of systems (answered by mother) significant for
decreasing grades
Vitals show temp of 96, blood pressure of 92/50, HR of 52
and respiratory rate of 8
Her eyes show pinpoint pupils
Neurological exam shows hypotonia and 1+ DTRs
Urine drug screen broken that day
10 minutes later the mother tells you that her husband can’t
find his back pain meds
Case 3
• 14 y/o patient presents with his mother because he is acting
•
•
•
•
•
strange
Symptoms include loss of time sense, depersonalization
(feeling out of body), visual and auditory hallucinations
He also has abdominal pain, severe nausea and emesis
On exam he is drowsy, fearful, ataxic and tachycardic. At
times he is unresponsive
Urine drug screen is negative
You ask him if he is on LSD. He says “come on, no one does
that any more. I’m robo-tripping!”
Overview
• Epidemiology- Contrast prescription drug use trends with illicit
drug use since the 90s
• Discuss the symptoms and signs of use and overdose of
•
•
•
•
stimulants
narcotics
sedative –hypnotics
dextrometorphan
• Gathering the history
• Discuss motivational interviewing and other interventions and
how they can be used to help adolescents stop using and abusing
these drugs
• Prevention strategies
• Discuss how to avoid inadvertently contributing to the misuse of
prescription drugs
Epidemiology- The good news
(Monitoring the Future data)
Annual use of illicit drug use other than marijuana
25.00%
20.00%
15.00%
8th grade
10th grade
10.00%
12th grade
5.00%
0.00%
1996
2010
Large decreases in:
-LSD, ecstasy, inhalants, cocaine and other illicit stimulants
Epidemiology- the bad news
Annual prevalence of 12th graders using Narcotics other than heroin
12 graders
10.00%
8.00%
6.00%
12 graders
4.00%
2.00%
0.00%
1996
-Oxycontin
2004
2010
5.1% in 2010 (peak of 5.5% 2005)
-Vicodin 8.0 % in 2010
Epidemiology
 Teens abuse prescription drugs more than any illicit
drug except marijuana
 More than cocaine, heroin or methamphetamine
combined
 Life time use of prescription drug use without medical
supervision has ranged from 24% in 2005 to 21.6 % in
2010
 Question first asked in 2005
 Annual use has ranged from 17.1% (2005) to 14.4%
(2009); 15.0% in 2010
Epidemiology
 Ritalin first monitored in 2001-annual use
10.00%
8th grade
5.00%
10th grade
0.00%
2001
2010
12th grade
 However- Adderal not monitored until 2009
10.00%
8th grade
5.00%
10th grade
0.00%
2009
2010
12th grade
Epidemiology
 OTC cough and cold medications first
monitored in 2006
 Annual prevalence is around 5-7%

10th and 12th graders
 3-4%

8th graders
Epidemiology
 Barbiturates- annual use
12th graders
10.00%
5.00%
12th graders
0.00%
1996
2005
2010
 Tranquilizers (Xanax, etc)- annual use
12th graders
10.00%
5.00%
12th graders
0.00%
1996
2004
2010
Where do they get the drugs-2010
(Monitoring the Future data)
Narcotics- told to mark all that apply
bought on internet
0.00%
19.50% 18.80%
Stole from friend or
relative
32.50%
59.10%
37.80%
Given by friend or
relative
Bought from friend or
relative
Former Rx
Bought from drug dealer
Where do they get the drugs-2010
Tranquilizers- told to mark all that apply
bought on internet
5.90%
13.50%
50.30%
19.40%
18.60%
Stole from friend or
relative
63.90%
Given by friend or
relative
Bought from friend or
relative
Former Rx
Bought from drug dealer
Where do they get the drugs- 2010
Amphetamines-told to mark all that apply
3.90%
11.00%
20.80%
Stole from friend or
relative
19.20%
56.70%
49.60%
Bought on internet
Given by friend or
relative
Bought from friend or
relative
Former Rx
Bought from drug dealer
Epidemiology
(Youth risk Behavioral Survey data)
 2009- 20.2% of respondents grades 9-12 had used a
prescription drug without a prescription
Annual % of prescription drug use
30.00%
20.00%
15.10%
18.20%
22.70%
25.80%
10.00%
Annual % of prescription
drug use
0.00%
9th grade 10th grade 11th grade 12th grade
 Almost identical to Monitoring the Future data
Why?
 56% of teens do not see great risk in trying
prescription pain relievers without a doctor’s Rx
50%
40%
30%
41%
Safer to use than illicit
drugs
37%
31%
20%
20%
Less shame attached to
using them
Fewer side effects than
illicit drugs
10%
0%
Reasons
Parents don’t' care as
much if you get caught
 Parents are NOT talking as much about abuse of prescription and over-
the-counter drugs as they do about illicit drugs
Partnership Attitude Tracking Study (PATS), 2007
Stimulants- ADHD medications
 correct doses
 increased concentration at the expense of anorexia,
nervousness, headache, insomnia
 Some misuse these stimulants for the anorexia effect
 Even low risk (all As) students will misuse the
medication during exam weeks to help them study
better
 Detected in urine for about 1-2 days
ADHD medications
 Can be snorted or injected
 Medication fillers are not water soluble- When injected
can block blood vessels
 Complications









Ischemia
local infection
cutaneous foreign body reactions
endocarditis of the tricuspid valve
pulmonary granulomatous disease and pulmonary hypertension
Thalhammer C, Aschwanden M, Kliem M, Sturchler M, Jager KA. Acute ischemia after intraarterial drug injection. Dtsch Med Wochenschr.
2004;129:2405–8.
Elenbaas RM, Waeckerie JF, McNabney WK. Abscess formation as a complication of parenteral methylphenidate abuse. JACEP. 1976;5:977–
80.
Hahn HH, Schweid AI, Beaty HN. Complications of injecting dissolved methylphenidate tablets. Arch Intern Med. 1969;123:656–9.
Lewman LV. Fatal pulmonary hypertension from intravenous injection of methylphenidate (Ritalin) tablets. Hum Pathol. 1972;3:67–70.
Stimulant-Intoxication
 General






Hyperalert
Elevated temp
Anorexia
nausea
Sweating
Dry mouth
 Eyes- Dilated pupils
 Neurological
 Tremor
 hyperactive reflexes
 parathesias
 Psychiatric







Elation, euphoria
insomnia
Anxiety
irritable
aggressive
Suspicious feelings
Skin picking (formication)
 Cardiac
 Hypertension
 tachycardia
-Greene JP, Ahrendt D, Stafford EM. Adolescent abuse of other drugs. Adolesc Med. 2006;17:283-318.
-Neinstein LS, Heischober BS. Miscellaneous Drug: Stimulants, Inhalants, Opiates, Depressants and Anabolic Steroids. In Neinstein LS. Adolescent
Health Care, 4th ed. Philadelphia., PA: Lippincott Williams & Wilkins, 2002.
Stimulant- overdose
 Gen
 Psychiatric
 Even higher temperatures
 Psychosis
 More sweating
 Paranoia
 Neurological
 Anxiety
 Seizures
 Delirium
 Facial grimaces
 Hallucinations
 Headace
 Coma
 Cardiac
 Angina
 Arrhythmias
 Chest pain
 CV collapse
Cardiac complications
 Myocardial ischemia and infarction
 Usually within 3 hours of excessive use
 ALWAYS ask about stimulant use/abuse use when presented
with an adolescent or young adult with cardiac chest pain
 EKG has poor sensitivity and specificity
 Cardiac enzymes such as troponin I and T-higher specificity
 Arrhythmias
 Numerous types, atrial and ventricular
 Disappear when drug metabolized (unless MI occurred)
Treatment of overdose
 ABCs
 Most arrhythmias
 O2, benzodiazepines, PALS, ACLS
Caution against the use of beta-blockers
 unopposed alpha activity
 increased vasoconstriction and ischemia
 Chest pain
 O2, Nitrates (nitroglycerin) and benzodiazepines
 Admit all for observation
 Hypertension
 Benzodiazepines
 May need nitroprusside if unresponsive

Treatment
 Agitation and psychosis
 Keep yourself safe


No sudden movements or loud talking
Do not touch the patient or approach from behind
 Benzodiazepines

If unresponsive use haloperidol
 Hyperthermia
 Cooling blanket
 Ice packs
 Check for rhabdomyolysis and other end organ effects
 CK, lfts, chemistry
 Rhabdomyolysis

aggressive fluid management, alkalinization of urine
 Fluid resuscitation
Withdrawal
 Depression, anhedonia, suicidality
 Hypersomnia, hunger
 Lethargy and weakness
 Tolerance
 Quick peak and short duration lead to tolerance
 No tolerance to cardiac effects
 No emergency treatment for withdrawal
Opiates- intoxication
 Euphoria
 Floating feeling
 Flushing
 Sleepiness
 Pinpoint pupils
 Constipation
 Impaired judgment, and social functioning
-Greene JP, Ahrendt D, Stafford EM. Adolescent abuse of other drugs. Adolesc Med. 2006;17:283-318.
-Neinstein LS, Heischober BS. Miscellaneous Drug: Stimulants, Inhalants, Opiates, Depressants and Anabolic Steroids. In Neinstein LS.
Adolescent Health Care, 4th ed. Philadelphia., PA: Lippincott Williams & Wilkins, 2002.
Opiates- overdose
 General
 Neurological
 Decreased temperature
 Pinprick analgesia
 hypotension
 Ataxia
 bradycardia
 Stupor
 slow shallow respirations
 pulmonary edema
 cyanosis
 Coma
 Eyes
 Pinpoint pupils
 Hypotonia
 Psychiatric
 Dysphoria
 Delirium
 CV Circulatory collapse
Opiates- Treatment of overdose
 ABCs, positive pressure for pulmonary edema,
volume expanders and pressors for hypotension
 Nalaxone (Narcan)
 0.4 to 2mg (lower if known narcotic abuser), repeated




every 5 minutes until reaction
if no response after 3 doses- consider another drug
Does not reverse histamine mediated hypotension
Lasts only 1-2 hours, will need to re-dose
Observe at least 6 hours
Opiates- withdrawal
 Not deadly but very severe
 General
 Aches, chills, flu like symptoms, N/V, piloerection,
sweating, tachypnea and tachycardia
 Psychiatric
 Depression, fatigue, poor self esteem
 Neurological
 Parathesias, tremors, dilated pupils
 Cardiac- HTN, tachycardia
 GI- cramps and diarrhea
Opiates- drug detection
 detected in urine for 1- 5 days
 Review medications to ensure no recent prescription
 Standard 5 panel urine test detects heroin, codeine and
morphine and metabolites
 Standard test may not detect Oxycontin (Oxycodone) and or
Vicodin (hydrocodone)
 Urine drug screens available that can detect Oxycodone and
hydrocodone for up to 1-2 days after use
 If suspect make sure laboratory tests specifically for these drugs
 False positive with poppy seeds
 Not after 48 hours and only if low cut-off
 Screens are confirmed with GS/MS
Barbiturates- intoxication
 General
 Fatigue sedation
 floating feeling
 yawning
 Neurologic
 Ataxia
 dysmetria
 hypotonia
 slow comprehension
 poor memory
 Eye findings
 lateral nystagmus
 normal sized pupils
 Psychiatric
 Depressed mood
 euphoria
 Presents much like alcohol
-Greene JP, Ahrendt D, Stafford EM. Adolescent abuse of other drugs. Adolesc Med. 2006;17:283-318.
-Neinstein LS, Heischober BS. Miscellaneous Drug: Stimulants, Inhalants, Opiates, Depressants and Anabolic Steroids. In Neinstein LS.
Adolescent Health Care, 4th ed. Philadelphia., PA: Lippincott Williams & Wilkins, 2002.
Barbiturates-overdose
 Neurological
 Pinprick analgesia, ataxia, delirium, irritability,
increased hypotonia
 Coma
 Orthostatic hypotension and bradycardia
 Slow shallow respirations
 Death- more than 3 g of short acting or blood level
> 2g/dl
 Synergistic with other depressants such as alcohol
 Combining depressants greatly increases chance of
lethal overdose
Barbiturates- treatment
 ABCs as per PALS, ACLS
 ABGs, chemistry, urine pH
 Gastric lavage if recent, then activated charcoal
 Decreased gastric motility can result in continued
absorption if not addressed
 Alkalinization of urine
 Consider Narcan for possible narcotic overdose as well
Barbiturates- withdrawal
 Can be fatal
 Parallels strength, duration and the dose of the
drug
 General
 Abdominal cramps, flushing, N//V, sweating, increased
temp, weakness
 Neurological
 Seizures, headaches, hyperactive reflexes, tremor
 Psychiatric
 Tachycardia, orthostatic hypotension, CV collapse
Barbiturates-Treatment of withdrawal
 Consider starting on anyone using > 500mg per day for
at least one month
 Done in an in-patient detoxification unit
 Initial phenobarbital dose is computed, kept on dose
for next 24-48 hours then weaned by 10-20% per day
Barbiturates- tolerance
 Induction of hepatic enzymes occurs quickly leading
to increased metabolism
 CNS adapts to drug effects as well
 However, lethal doses stay the same
tranquilizers
 Major- not commonly abused
 Phenothiazines (thorazine)
 Minor- benzodiazepines
 Valium, Xanax
 Short and long acting
 Short acting likely to be abused
 Augment GABA’s inhibitory effects
-Greene JP, Ahrendt D, Stafford EM. Adolescent abuse of other drugs. Adolesc Med. 2006;17:283-318.
-Neinstein LS, Heischober BS. Miscellaneous Drug: Stimulants, Inhalants, Opiates, Depressants and Anabolic Steroids. In Neinstein LS.
Adolescent Health Care, 4th ed. Philadelphia., PA: Lippincott Williams & Wilkins, 2002.
Benzodiazepines- effects
 Intoxication similar to barbiturates
 When taken alone, little potential for overdose
 Overdose symptoms suggest concomitant use of
alcohol or other sedative
 Can use flumazenil at incremental doses of 0.2mg/min
 Re- dose if overdose of long acting drug
 If patient on TCAs - seizures
Benzodiazepines- Addiction potential and
withdrawal
 less likely than with barbiturates, BUT possible
 Withdrawal can still be fatal
 Treat with long acting benzodiazepines and slowly taper
in an in-patient setting
sedatives- drug detection
 Can be detected on most standard urine drug screens
 Short acting detected up to 2-3 days
 Long acting up to 2-3 weeks
Dextromethorphan effects
(robo-tripping)
 Binds to sigmoid opioid receptors, not Mu or delta
 No signs of opioid toxicity
 In high doses the active metabolite, dextrorphan,
inhibits NMDA receptors
 Results in neurobehavioral effects similar to ketamine and
phencyclidine (PCP)

hallucinations, "out of body" sensation, and dissociation
 Inhibits adrenergic neurotransmitter reuptake in the
peripheral and central nervous system
 tachycardia, hypertension, and diaphoresis
Boyer EW. Dextromethorphan abuse. Pediatr emer Care 2004; 20: 858.
Dextromethorphan effects
(robo-tripping)
 Different stages of effect referred to as “plateaus” by users-
(typical dose used to suppress coughs is 5-30 mg)
 Mild stimulation (first "plateau"): 1.5 mg/kg (adult dose:100 to
200 mg)
 Euphoria and hallucinations (second "plateau"): 2.5 to 7.5 mg/kg
(adult dose: 200 to 400 mg)
 Dissociative "out of body" state (third "plateau"): 7.5 to 15 mg/kg
(adult dose: 300 to 600 mg)
 Complete dissociation with unresponsiveness (fourth "plateau"):
15 mg/kg (adult dose: >600 mg)
http:// www.erowid.org
Dextromethorphan effects- signs
 Neurobehavioral
 Euphoria, hallucinations, inappropriate laughing, psychosis,
dissociative features, agitation, coma





Tachycardia
Dilated pupils
Diaphoresis
Ataxic gait
If combined with SSRIs or other serotonergic agentsserotonin syndrome
 Altered MS, seizures, hypertonicity, high temperture,
diarrhea
Boyer EW. Dextromethorphan abuse. Pediatr emer Care 2004; 20: 858.
Chronic use
 Rapid tolerance develops
 Higher doses increase chance of toxic levels
 Withdrawal symptoms of intense craving and
dysphoria has been described
Hinsberger A, Sharma V, Mazmanian D. Cognitive deterioration from long term-abuse of dextromethorphan: a case report J Psychiatry
Neurosci. 1994 November; 19(5): 375–377.
Co-ingestions
 Often taken as OTC cough and cold formulations
 Antihistamine overdose- anticholinergic effects
 Tachycardia, hypertension, flushing, warm and dry skin,
delirium
 Pseudoephedrine
 Tachycardia, hypertension, agitation, headache
 Acetaminophen
 Hepatotoxicity, liver failure, death
 Must get acetaminophen level if suspect someone has
overdosed on DXM
Treatment
 Largely supportive
 Consider use of activated Charcoal
 Nalaxone- binds to opioid receptor- can reverse respiratory
depression and coma
 First and foremost protect yourself
 Use extreme caution, do not try talking down




Benzodiazepines for seizures
Benzodiazepines/ Haloperidol for psychosis
CV, hyperthermia support, watch for rhabdomylysis
Treat acetaminophen, anticholergic/antihistamine and
pseudoephedrine toxicity
Boyer EW. Dextromethorphan abuse. Pediatr emer Care 2004; 20: 858.
Obtaining the history
 Supportive, non-threatening, and nonjudgmental
demeanor
 Must make every attempt to talk to teens alone
 Offer confidentiality, but explain that
confidentiality may have to be broken
 if you feel the teen’s life is at risk
 Different thresholds for different providers about
what amount of use signifies serious risk
Obtaining the history
 The manner in which questions are asked will change response.
 MD #1 : Do you use drugs or alcohol?
 Teen: no.
 Vs.
 MD # 2: I know drugs and alcohol are common in schools these





days. Do you know of anyone using drugs.
Teen: A few people, I guess.
MD # 2: It is not uncommon for some teens to try some of these
drugs. Do any of your friends.
Teen: a few use my friend’s Adderal every now and then.
MD# 2: How do you handle these situations. Do you ever try.
Teen: a few times I have taken one, but I do not like the affects and I
don’t plan to use again.
History-Level of use
 Daily, weekly, experimental
 Route of administration
 Assess for dependency and abuse
 Abuse: a maladaptive pattern of substance use leading to
clinically significant impairment or distress (at home,
work, relationship, trouble with the law
 Dependence: abuse plus tolerance and withdrawal
 Various screening instruments can be applied (a topic
all to itself)
History- Important topics
 Other stress factors in the family, peers or school
 Level of substance abuse by friends
 any depression, anxiety or other mental disorder
 Does patient have a physical disability
 FH of drug or ETOH abuse
 Patient’s stage of change
Motivational interviewing
What is it?
 A style of communication in which you talk WITH
(not to) the patient (collaboration)
 Facilitate change by exploring reasons for and against
change (pros and cons)
 Help the patient resolve ambivalence regarding their
values, goals and beliefs with their current behavior
 Point out discrepancies
 Let the adolescent decide if and when they will change
(Autonomy)
Kokotailo, PK, Gold MA. Motivational Interviewing with Adolescents. Adolesc med. 2008; 19:54-68.
When to use it
 Used with the stages of change model
 Used with those not interested in change
(precontemplative) or are thinking about change but not
ready to make the commitment (contemplative)
 Best for regular users, BUT not those who have substance
abuse or dependence
• Addicts should be treated by inpatient or intensive outpatient
facilities
 Precontemplative- goal is to increase awareness of need to
change
 Contemplative- Motivate and increase confidence in ability
to change
4 fundamental principles
DARES
 Developing discrepancy (precontemplative)
 Elicit from the teen differences between current
behavior and personal values, beliefs or goals
 Help them become aware of internal inconsistencies
 Hopefully this provokes an attempt by the teen to makes
changes that are more consistent with their OWN goals
4 fundamental principles
 Empathy
 Teens do NOT respond well to authoritarian attempts at
direct persuasion (“Don’t take your friend’s Adderal, its
bad for you”)
 Empathy allows the patient to not feel judged- Promotes
self-focus
 Do not give advice until asked or you specifically ask.
Then give your perspective.
4 fundamental principles
 Rolling with resistance
 Avoid argumentation
 Makes teen feel pushed
 Support self-efficacy (contemplative)
 Increase confidence in ability to change
 Discuss that change is a slow, gradual process that is not all or
nothing
 Help the teen see that there is a variety of ways to achieve a
goal
 Identify past successes and strengths
 Reframe previous failures as learning opportunities
How to do MI- techniques and
strategies
 Many different techniques
 Do not have to use all of them. Interchange these
strategies depending on time and familiarity with
patient.
Ask permission
 Seems obvious, but not always done
 “Would it be OK if I gave you some advice on
Oxycontin use”
 “Would it be OK to talk about your Xanax use”
 If “no” move on to another topic that they might find
OK to talk about
 Don’t assume that if they don’t want to talk about one
topic that all topics are closed off
Elicit- Provide- Elicit
 1) Elicit what the patient already knows (ie Xanax makes
you drowsy) about a topic

Teens “tune out” when you tell them info they already know
◦ or options for behavior change

If the ideas are good- help patient make a plan to change
behavior based on their own ideas
 2)If missing or inaccurate knowledge, ask permission to
PROVIDE information
 3)Elicit from the teen what they think of this new
information. “ How might this information change things
for you”
Decisional Balance
 Ask about pros and cons of a behavior or of change
 “Not so good” less threatening than “bad”
 Precontemplative- pros and cons of status quo
 Contemplative- pros and cons of change
Importance and confidence rulers
 Helps determine if you need to focus on reasons to
change versus confidence to change
 Scale of 1-10. Ten most important or confident
Importance and confidence rulers
 Example: If the importance of stopping Vicodin is a 4.
Ask “why is it not a 2 or a 1?”
 What would have to happen to make stopping Vicodin
a little more important to you
 Not why is it not a higher number- this focuses on
barriers
 Same way if focusing on confidence
Does this really work?! (for you
skeptics)
 Difficult to study-hard to standardize MI techniques
 Studies mostly involve ETOH and drug use
 MI given to group of 18-19 y/o alcohol using teens in the ER.
Followed 6 m later*
◦ NO decreased ETOH use BUT LESS
◦ Drinking and driving
◦ ETOH related injuries
 Single MI session on use of contraception and ETOH- followed 1
month later**
◦ Intervention group showed increased use of contraception and
decreased risky drinking of ETOH


*-Monti PM, Spirito A, Myers M, et al. Brief intervention for harm reduction with alcohol-positive older adolescents in a
hospital emergency department. J Consult Clin Psychol. 1999; 67 (6): 989-994.
**-Ingersoll KS, Ceperich SD, Nettleman MD, et al. Reducing alcohol-exposed pregnancy risk in college woman: Initial
outcomes of a clinical trial of a motivational intervention. J subst Abuse Treat. 2005;29( 3): 173-180
Does this really work?!
 2 Cochrane data base systematic reviews*
 1st review*- most studies thrown out, but 2 showed strong
analysis and design and consistent pattern of results
indicating potential value
 2nd review**- Too few studies to make firm conclusions as
difficult to assess, but one well designed study showed MI
was beneficial in preventing cannabis use
 Numerous other studies on various behaviors
◦ Many with methodological issues, but almost all with positive
results


*Foxcroft DR, Ireland D. Lister-Sharp DJ, et al. Primary prevention for alcohol in young people. Cochrane Database
Syst Rev. 2002; (3) CD003024
**Gates S, McCambridge J, Smith LA, et al. Interventions for prevention of drug use by young people delivered in
non-school settings. Cochrane Database Syst Rev. 2006;(1):CD005030
Techniques for the adolescent at the
curiosity/experimental stage
 Rehearse scenarios in preventing this from ever
happening again
 Encourage parental involvement in patient’s life by
attending activities or reviewing homework
 Encourage parents to have open communication
 If obtained confidentially, clinician must decide if
even experimental use (heroin) is putting teen at great
risk
 Consider breaking confidentiality at that point and
discussing with parents
Self- treatment
 Many teens use drugs for self-medication
 Always be on the look out for a primary condition
 If primary condition not treated, teen will likely
relapse even if initial treatment is successful
 This does NOT mean to ignore the substance use
Possible discussions with parents
 Make sure parents not enabling the drug use
 Review signs of abuse and dependence
 Also review with patient
 Encourage parents to not rescue their children
from the consequences of drug use
 These consequences can aid in quitting
 Some states even have programs where parents can
write to the Family Court and allow for court
monitoring of their child
Drug Screening and laboratory testing
 Consider voluntary periodic urine drug screening
if patient willing to cut down
 For the benefit of the teen, NOT to police teen
 Consider screening lab tests
 conveys to the teen the seriousness of the concern
Treatment for the adolescent with
substance abuse or dependence
 Referral to substance abuse program is paramount
 Treatment does NOT need to be voluntary at this
point
 The criminal justice system may often need to be
involved to hold patients in treatment
 Still can be effective
 Important to triage teen to either intensive
outpatient or inpatient services
Don’t be one of these:
 Outdated provider: Use controlled drugs when better




options available (narcotics for fibromyalgia, Xanax for
anxiety)
Deceived provider: misled by patients
Distracted provider: quicker to give the controlled
substance than discuss a safer option
Defiant provider: Thinks they know more that the
literature
Dishonest provider: Thankfully very uncommonprescribes drugs for money
Longo LP, Parran T Jr, Johnson B, Kinsey W. Addiction: part II. Identification and management of the drug-seeking patient. Am Fam Physician 2000; 61:2401.
Do not
 Prescribe controlled substances to new patients prior
to reviewing the complete medical record.
 Must find a legitimate medical purpose for the
controlled substance
 Prescribe multiple controlled drugs
 Prescribe controlled drugs for extended periods of
time or at high doses
 Continue prescribing even if patient’s behavior seems
“off”
Do NOT
 Prescribe early refills
 Beware the repeated “flushed down the toilet”, “my dog
ate it”
 Agree to prescribe controlled substances on a chronic
basis if you do not know what the diagnosis is
 Prescribe controlled drugs to family members or
friends
Do
 Screen for a history of drug abuse before and after writing
for a controlled substance
 Follow a structured monitoring strategy
 Consult pain experts if you are not comfortable giving a
controlled substance for the patient’s condition
 Most chronic pain conditions (low back pain, fibromyalgia, etc) do
NOT require narcotics
 Select extended release as opposed to immediate release
controlled substance
 Always consider alternates to controlled substances if they
exist (Unless treating ADHD)
Do
 Discuss treatment endpoints
 Some pain may not ever go completely away
 Discuss with patients that controlled substances can
become physically and psychologically addictive
 Correctly write the prescription form(spelling out
numerical amounts, DEA number)
 Monitor the whereabouts of your prescription forms
and report any missing ones to the DEA
 Perform periodic toxicology testing
 If (-) likely patient selling drug
Summary
 Illicit drug use may be on the decline, but prescription
drug use has been increasing over the past decade
 Know the effects of these drugs
 recognize patients that are actively using or withdrawing
 more importantly, be able to educate users of their
deleterious effects
Summary
 Obtaining a drug history requires a non- judgmental
and open attitude. May need to breach confidentially
if use could lead to death
 With the use of motivational interviewing you may be
able to change the behavior of the prescription drug
user
 Providers have the tools to prevent our patients from
becoming addicted or selling these substances