Transcript Prescription Drug Abuse Walter Ling MD Integrated Substance Abuse Programs Semel Institute for Neuroscience and Human Behavior UCLA Western Conference on Addiction Universal City, California Sunday November.

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Prescription Drug Abuse
Walter Ling MD
Integrated Substance Abuse Programs
Semel Institute for Neuroscience and Human Behavior
UCLA
Western Conference on Addiction
Universal City, California
Sunday November 13, 2005
[email protected]
www.uclaisap.org
Prescription Drug Abuse:
Scope of the Talk
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What and which drugs?
Why now?
Who abuse prescription drugs?
What can we do?
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Definitions:
What’s “abuse behavior” to us?
Any non-prescribed use of a drug
(NIDA, 2002 & DEA, 1970)
Non-medical use of a substance for
psychic effect, dependence, or suicide
attempt or gesture (SAMHSA, 2002)
Any harmful use, irrespective of whether
the behavior constitutes a “disorder” in
the DSM-IV diagnostic nomenclature
(IOM, 1996)
A maladaptive pattern of substance use,
leading to clinically significant impairment
or distress, as manifested by one or more
behaviorally-based criteria (APA, 1994)
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Drugs of Abuse: Not Just Opioids
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Opioids and other pain killers
Stimulants
Anti-anxiety drugs
Sedative/hypnotics
Feel good drugs (antidepressants)
Look good drugs (steroids)
Feeling goofy drugs (psychedelics)
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Number of new non-medical users
of therapeutics
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Pain Prescription Abuse
• In 2002, nearly 30 million people over 12
used prescribed pain relievers nonmedically
• 1.5 million dependent/abused prescribed
pain relievers; 2nd. only to marijuana
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Under the Counter
July 7, 2005 CASA
• “More than 15 million American abuse
Opioids, Depressants & Stimulants in 2003
– Rx abuse among teens triple in 10 years
– From 1992 to 2003, abuse of controlled Rx drugs
grew at the rate 2x that of marijuana; 5x that of
cocaine; 60x that of heroin
– In 2003, 2.3 million teens 12-17 y.o. (1/10) abused
a controlled Rx, 83% opioids
– ER visits related to opioid medication more than
doubled between 1994 and 2001 (DAWN 2002)
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Commonly Abused Opioids
Diacetylmorphine
Hydromorphone
Meperidine
Hydrocodone
Oxycodone
Heroin
Dilaudid
Demerol
Lortab, Vicodin
OxyContin,
Percodan,
Percocet, Tylox
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Oxycodone and Oxycodone CR
• Oxycodone: OxyIR, Roxycodone
– Acute pain
– 4-6 hrs duration of action
– Tabs, caps, liquid
• Oxycodone CR: Oxycontin
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Chronic pain; already tolerant to opioids
12 hrs duration of action
Not for prn use
Tablets only
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Emergency Dept. Mentions
Of Single-Entity Oxycodone
14,996
16000
14000
11,100
12000
10000
8000
6000
3,792
4000
2000
372
1034
1,804
0
1997
1998
1999
2000
2001
2002
2002 National Survey on Drug Use and Health (NSDUH), SAMHSA, Sept 5, 2003
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Increased Media Attention
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Oxycodone
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Easy Access: Role of the Internet?
“Delivered in the Privacy of your Home”
“Some reasons
why you should
consider using this
pharmacy”
No
prescription
required!
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Prescription Abusing Populations
• Prescription drug abusers
– Youths, elderly, women, minorities
• Pain patients who abuse opiate medication
• Users with comorbid psychiatric conditions
• Substance abusers
– Prescription drugs only
– Prescription drugs plus other substances such as
heroin (polydrug abusers)
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Youth Prescription Abuse
• Youth obtain prescription opioids from
peers family and friends
• Fastest growing prescription abuse group
• Females users out number males
• Prevention programs don’t work
• Not reached by treatment programs
• Largely unknown later consequences
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The Elderly Prescription Opioid Abuser
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Multiple medical problems
Higher incidence of chronic pain
Misunderstand directions: misuse vs abuse
Multiple prescribers
Rationalization and denial among family
members, peers or care providers
– Deficits presumed to be due to age
• Interaction with alcohol or other drugs
• Over representation of females
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Women and Prescription Drug Abuse
• Similar rates as men
• More likely to use abusable prescription
drugs, especially opioids and anxiolytics
– 2-3 x more inclined to be diagnosed with
depression and given more psychotherapeutics
– Twice more prone to be addicted to drugs
• Combine with alcohol more often
• More elderly women, more prescriptions
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Women and Prescription Drug Abuse
• 4 million women abuse prescription drugs
• Among 12-17 year olds female surpass
males in use of cigarettes, cocaine, inhalants
and prescription drugs
• Women account for 60% of ER visits for
prescription drug abuse
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Prescription Drug Abuse in Pain Patients
• Complex relationship between drug abuse and use
of opioids in pain management
• Overlapping vulnerability and psychopathology
• Somatoform pain disorders
• Consumption of other substances
• Iatrogenic factors
– Uncritical prescribing, inadequate monitoring,
– absence of functional improvement
– Inadequately treated pain
• J Jage Euro J Pain 2005 9:157-162
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Is pain associated with opioid disorders?
Opioid Disorders According to Different Levels of
Past 4 Week Interference Due to Pain
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7
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Odds
Ratio
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4
3
Total
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1
0
it
ly
ly
all
bit
b
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ttl
rem
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Nearly Linear Relationship of Pain and
Opioid Use Disorder
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Source: NESARC Stud
As Prescriptions Increase,
Emergency Room Reports Have Increased at
the Same or Faster rate
Number of Prescriptions (in 1000s)
24000
80000
70000
. 18000
Hydrocodone
prescriptions
emergency
60000
50000
12000
40000
30000
Oxycodone
prescriptions
emergency
20000
6000
10000
0
1994
1995
1996
1997
1998
1999
2000
0
2001
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Source: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department
The Fateful Triangle:
Opioids Pain and Addiction
• Under treatment of pain
• Increasing availability of opioid
analgesics
• Increase in abuse of prescription
opioids
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Opium
“…Lull all pain and anger, and bring
forgetfulness of every sorrow.”
- Odyssey
“Among the remedies which it has pleased
Almighty God to give to man to relieve
his suffering, none is so universal and so
efficacious as opium.”
- Thomas Syndenham, 1680
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Opium
• “It banishes melancholy, begets
confidence, converts fear into
boldness, makes the silent
eloquent and bastards brave”
John Brown
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Opium
Opiate—an unlocked door in the prison of
identity. It leads into the jail yard.
- Ambrose Bierce, The Devil’s Dictionary
The junk merchant does not sell his product to
the consumer, he sells the consumer to the
product. He does not improve and simplify
his merchandise, he degrades and simplifies
the client.
- Burroughs
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From Pain Relief to Addiction:
Role of the Opiates
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Relieve pain
Relieve pain and suffering
Relieve suffering and misery
Make you feel better
Make you feel good
Make you “high”
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Characterizing Pain
• Pain: An unpleasant sensory and
emotional experience arising from the
actual or potential tissue damage or
described in terms of such damage.
It is always subjective. Each individual
learns the application of the word
through experiences related to injury in
early life.—IASP
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Acute vs Chronic Pain
• Acute pain is for survival
• Chronic pain serves no purpose
Sufferers of chronic pain suffer for nothing
• Concern in acute pain: what pain does
the patient have?
• Concern in chronic pain: what patient
does the pain have?
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Pain: More than a Feeling
Feeling (sensory experience) : Pain
Meaning (emotional & cognitive): Suffering
--Historical—early life
– Learned—experience
– Private—subjective
– Unique—individual
Action– Expression of the “word”: Behavior
Chronic pain is not having lots of pain; its having
pain and behaving like a chronic pain patient
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Chronic Pain and Addiction:
Common Features
• Chronic pain
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Early trauma
Loss of mastery
Loss of control
Loss of sense of self
Cognitive error
“personalization”
Over interpretation
“catastrophy”
• Addiction
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Early trauma
Loss of mastery
Loss of control
Loss of self efficacy
Cognitive error
“nirvana”
Denial
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Addiction in Pain Patients
• Published rates of abuse and/or addiction in
chronic pain populations are ~ 10% (3-18%)*
• Known risk factors in the general population
also predict prescription opioid abuse in pain
patients
Fishbain, 1986, 1992; Kouyanou et al., 1997
*Adams et al., 2001; Brown, 1996;
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Who’s at Risk and How to Tell?
• Four ways to identify patients at risk:
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History: personal history & family history
Screening instruments
Behavioral check lists
Therapeutic maneuver
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History
• What predicts addiction?
– Personal history of drug abuse
– Family history of drug abuse
– Current addiction to alcohol or cigarettes
– History of problems with prescriptions
– Co-morbid psychiatric disorders
Same predictors as in non-pain patients
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Screening Instruments
• CAGE
• MAST
• DAST
– Nonspecific for pain patients
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Ongoing Warning Signs
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Altered/forged prescription
Theft of prescription pads
Frequent requests to move appointments up
Keep pain appointments; miss others
Grossly disheveled/impaired
Request early refills/frequent phone calls
Lost/stolen prescriptions
Frequent unauthorized dose escalations
Positive urine tests for illicit drugs
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Is the pain patient addicted?
(“Drug-seeking”  Addiction)
Drug-seeking or increased requests for pain medication
 pathology/pain of new source
Detailed pain work-up
No new pain pathology
 opioid dose
Unimproved functioning
Presence of toxicity
Addictive disease
Improved functioning
Absence of toxicity
pseudoaddiction
therapeutic
dependence39
Can Addicts be Treated with
Opiates?
• Yes, but with caution
– Increase recovery activities
– Provide support systems
– Treat co-morbidity
• Remember Non-opioid analgesics
• Non-pharmacological treatments
– Cognitive behavior therapies
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Treating Pain with Opioids:
What Can We Expect to Achieve?
• Reduction in pain and suffering
– Meaningful pain reduction
• Improved functionality
– Meaningful improvement in activities
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Meaningful Pain Reduction:
How Much?
• Using a VAS or Numeric scale of 0-10
– (4-6= mod pain; 7-10= severe pain)
• For Moderate pain ( mean=6)
– Meaningful reduction=2.4 (40%)
– Very much better=3.5 (45%)
• For Severe pain (mean=8)
– Meaningful reduction=4.0 (50%)
– Very much better=5.2 (56%)
M. Soledad Cepeda et al.
Proc 10th world Cong on Pain vol 24; pp 601-609
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Meaningful Functional Improvement:
My Favorites
• Patient perspective of “improvement”
– Used to do, can’t do now, would like to do again
– Could be physical, social, recreational
– With friends, family, church
• Achievable, enjoyable and meaningful
– Hobbies
– Volunteer work
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Conclusion:
Prescription Drug Abuse
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Escalating problem
Heterogeneous population
Youth
Elderly
Women and minorities
Chronic pain patients
Pain and addiction – complex disorder
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Acknowledgment and Thanks
• Conference organizers
• Friends and colleagues:
– ISAP & elsewhere
• NIDA
• You the audience
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