Implementing Effective Prescription Drug Abuse

Prevention Strategies

Jim Middleton, Pharmacist

Carol Meyer-Niedzwiecki,

SAC Prevention Director

Today's Goals!

1. Increase knowledge 2. Learn about interventions

3. Obtain tools and develop an action plan

Topics to Get There

National issues with Local Significance

Background Education for the Layperson

The Misdirection of AssistanceResearch, News and Updates

Some of the Challenges:

OVERALL PICTURE – Youth and adultPrescription drug abuse is rising

We live in a culture of “pain relief”

Youth Perception – Prescription drugs are safer than 'street drugs,' they are 'non-addictive,' and there is

less 'stigma' to their use

Some of the problem

Highly publicized

From the CDC: Enough painkillers

were prescribed in

2010 to medicate

every American adult

around the clock

for a month.

(Nov, 2011 report)

Some of the Problem

More than 40 people die

every day from ODs involving narcotic

pain relievers(CDC&P)

Some of the Problem

National Data tells us:

14,800 people in the U.S. died from painkiller ODs in 2008. Greater than threefold increase

from 4,000 deaths in 1999. (CDC&P)

36,450 deaths from prescription and other illegal drugs in 2008 compared with 39,973 vehicle

crashes. (AP)

Why is there abuse?

The “usual suspects” here:

get high, experimentation, cope, focus, peer pressure, lose weight, bulk up, self medicate, easy to get,

“It won't happen to me” and the proliferation of advertising

Monitoring the Future Survey 2010

Annual prevalence of narcotics (other than heroin) amongst 12th Gr: 3.3% (1992) 9.5% (2004)

OXYCONTIN Gr 8 2.1%

Gr10 4.6%

Gr 12 5.1%

VICODIN Gr 8 2.7%

Gr 10 7.7%

Gr 12 8.0%

NSDUHPDs #2 (marijuana #1) illicit drug used

Non-medical use of PDs by persons 12 yrs of age and older 2.5% (2008) 2.8% (2009)

Use rates overall higher in 2000's than 1990's

PAIN RELIEVERS 2002 2010

Youth 3.2% 2.5%

Young adults 4.1% 4.5%

Michigan Data tells us:BRFSS 2009 (only ask about barbiturate use without a doctor's

prescription)

Ever In past 30 days

Gr 9 8% 4%

Gr 10 9% 5%

Gr 11 13% 8%

Gr 12 11% 5%

And where are the drugs coming from?

And where are the drugs coming from?

From a friend or relative – 55%By a direct prescription from a physician – 17.3%

Bought from a friend or relative – 11.4%Stolen from a friend or relative – 4.8%

From a dealer or stranger – 4.4%“Other” (ie, robbed a pharmacy, went to Mexico) – 7.1%

And where are the drugs coming from?

Looking at it a different way:

By a direct prescription from a physician – 17.3%By an indirect prescription from a physician – 71.2%

What We Look For

1. Patients who know more about prescription drugs than I do

2. Patients who know more about insurance coverage than I do, or insist they have no prescription coverage but like particular brands of drugs

3. Very thin, asymptomatic, agitated, toothless 20-somethings wanting Sudafed 24-hour capsules

4. And sadly, incoming patients who are perhaps a bit too friendly

What We Look For

6. Elaborate Excuses, generally involving trips to Tennessee, an ex-spouse, neighbor's dog, a funeral, a bathroom sink, a kitchen sink, a neighbor's spouse, a neighbor's dog, a neighbor's ex-spouse from Tennessee with a dog....

7. A phone call that starts with “OK, it's like this....”

Overall Causes of Death - US

Compared to motor vehicle accidental death rates

Accidental Drug Deaths since 1999

Accidental Deaths by Drug

Death by opioids vs sales

Rates in US overall

Consequences of overdoses

Death

Death always reported as a drug reaction?

– not in Battle Creek

– homicides labeled “result of a gunshot wound”, not “individual, while on meth, attempted to rob a crack house and was shot in the process”

Analysis of one (of 57) toxicology reports (2010)

– 41 year old Caucasian male, Battle Creek

– accidental death, toxicology revealed in blood:

7-Amino Clonazepam

Benzoylecgonine

Acetone

Methadone

Phenylpropanolamine

Amphetamine

“Let's DO something!”Legislative Updates:

The majority of states now have Prescription Drug Monitoring Programs (PDMPs)

P.A. 84 (was SB 333): electronic reporting (NPLEx), effective 1/1/12

P.A. 85: product placement, ID buyer, record saleH.B. 4564: misdemeanor if purchaser uses fake ID to buy

ephedrine productH.B. 5089: establish an unused PD repository program.

Participating pharmacies would have to offer disposal programs for turned in meds

Legislation Can Have Unintended Consequences

My personal gateway drug...

Rising to the Challenge

The need to balance access for therapeutic use vs easy access for abuse

The body does not know the difference between a 'legal' and an 'illegal' use of a drug

The body regards all drugs, foods, environmental chemicals with the same level of priority – it behaves unconsciously

The body uses chemicals to maintain

a healthy balanceSerotoninDopamine

EpinephrineAcetylcholine

InsulinGABA

Electrolytes

In very tiny quantities

Drugs Affect These Same Chemicals

SerotoninDopamine

EpinephrineAcetylcholine

InsulinGABA

Electrolytes

In very LARGE quantities

How the brain sees drugs:

So, treat those conditions! (well...)

Add Dopamine to control Parkinsonism, you can develop signs of mental illness

Block Dopamine to control Schizophrenia, you can develop symptoms that look like Parkinsonism

The primitive brain is very compact (the Limbic system)

Dopamine is a pleasure transmitter

– Increased levels result from chocolate, CNS stimulants

– Increasing the levels artificially leads to mania(Parkinson's patients developing gambling obsession)

At what age do we introduceour children to drugs?

Define “drugs”

Children aren't stupid! Really!!!

– Survey of parents thought their children on Ritalin or Adderall were at least 97% compliant with treatment

– reality was 75%

The Drugged Society and Its Consequences

– “Oh, I take my husband's Xanax all the time. That doesn't interact with my Ambien, does it?”

– (call received Saturday, 19 Feb 2011)

So we try to rise to the challenge,but maintain a proper balance

For example, in the 1880s, morphine abuse was nearly epidemic

We needed a heroic replacement to treat pain but not cause the addiction

The best chemists of the day worked on the problem – lo and behold, they created.......

Heroin!

Unregulated Marketing 1905

Unregulated Marketing 1905

Regulated Marketing - 1919

In the 1930s

Scientists were searching for a drug that would

work to control seizure disorders (epilepsy)

Sometimes you just have to wonder...

Narcotic Analgesia

– Opiates have a natural product base – opium

poppy

– Opioids are the product of the chemist's bench – ie meperidine (Demerol)

Consider these effects on

– Migraine

– GI disorders

– Bone pain (calcitonin breaks down bone)

– Estrogen-receptor type breast cancer

– Ability to control pain – the same 'benefit' will require larger and larger doses

Relaxation in a tablet...

– The “Benzos” - benzodiazepines

– It all began with chlordiazepoxide (Librium), then diazepam (Valium), then lorazepam (Ativan), then chlorazepate dipotassium (Tranxene)... then alprazolzam (Xanax) …. a 50 year legacy of pharmacotherapeutic alternatives to facing stressors in our lives...

GABA – gamma amino butyric acid

- “butyric” for “butter” (butter is 3-4% butyrate)

- hmmm.... dairy products to relax us.....

What Parents and Educators Should Look for

– Sedation or erratic behavior of sudden onset

– Constipation and stomach complaints

– Loss of weight, loss of teeth, bleeding or infected gums

– Sudden interest in who in the family is ill, perhaps with cancer

– A need to refill your prescription meds early, especially if they have a sticker that reads “May Cause Drowsiness or Sedation”

The Duty to Warn

Ancillary labels

– The wrong education provided? HIPAA challenges

– The hearing impaired in a

public arena

The Right to be Pain Free

A JCAHO mandate A State of Michigan mandate Question: What is the definition of pain?

– Whatever the patient says it is! Sources for pain management

– Where did the notion originate?

– Is a dental office an appropriate starting point?• OxyContin as a first-line pain treatment for 14 year

olds?

Diversion Flags

What is observed....

Free Speech and Marketing

Free Speech and Marketing

Drug Take-Back Programs

– Collects unused drugs

– Offers a method of removing controlled substances from easy access

– Drugs do not enter the water supply, but are incinerated as medical waste (at 3000 degrees)

– Typical day of take back brings in 200,000 – 300,000 tablets

– Drug companies are VERY supportive of this

Misdirected SolutionsAnd

Why We Are Here

Control of Pseudoephedrine (Sudafed)

The Problem:

– no requirement for general oversight

– county-by-county monitoring of logs and usage varies wildly

– monitoring often gets cut with budget challenges (Kalamazoo county)

– user can hop from one pharmacy to the next

The Challenged Response to the Challenge

- The Problem:

Narcotic Prescriptions are being prescribed at an overwhelming volume and are becoming harder to track....

- The Solution:

Cut the triplicate-script program, extend the amount of time to fill powerful narcotics and stimulants, and allow for multiple prescriptions – to make access more convenient

The Challenged Response to the Challenge

- The Problem:

Abuse of Vicodin/Norco/Lortab type narcotics is leading to liver damage due to the amount of acetaminophen in each tablet

- The Solution:

Don't control the hydrocodone use – restrict the amount of acetaminophen in each tablet

The Challenged Response to the Challenge

- The Problem:

Sudafed sales are directly related to the number of meth labs being created. Making Sudafed/pseudo- ephedrine a prescription seems to be the only real solution

- The Solution (in Michigan):

Keep Sudafed as an OTC but subscribe to a 'signature log' database without useful oversight – and cut police

The Challenged Response to the Challenge

In other words, you may see a reduction in meth labs, because there's nobody to go after them!

The Challenged Response to the Challenge

- The Problem:

Overmarketing prescription drugs directly to the consumer and mail-order distribution has escalated the amount of drugs available for misuse or abuse

- The Solution

Encourage take-back programs coordinated by volunteers

The Challenged Response to the Challenge

- The Problem:

A 'top-down' solution runs into the danger of becoming manipulated, diverted, or politicized

- The Solution:

You. Here. Today.

“Bottom's up!”