Prescription Drug Prescription Drug AbuseAbuse

Kyle M. Kampman MDKyle M. Kampman MD

University of PennsylvaniaUniversity of Pennsylvania

kampman_k@mail.trc.upenn.edukampman_k@mail.trc.upenn.edu

OutlineOutline

• Sedative abuseSedative abuse

• SleepersSleepers

• Stimulant abuseStimulant abuse

• Oral pain reliever Oral pain reliever

abuseabuse

Teaching PointsTeaching Points

The ability to competently manage prescription The ability to competently manage prescription drug abuse in clinical practice is raredrug abuse in clinical practice is rare

Major issue – learning when to prescribe, what Major issue – learning when to prescribe, what drug at what dose – and when drug at what dose – and when notnot to, i.e., the to, i.e., the management of substance abuse/addictionmanagement of substance abuse/addiction

This lecture is focused on getting across the This lecture is focused on getting across the basics of management of: 1) sedative abuse, 2) basics of management of: 1) sedative abuse, 2) use of sleeping medication, 3) stimulant abuse, use of sleeping medication, 3) stimulant abuse, and 4) oral pain reliever medicationand 4) oral pain reliever medication

Pre-Lecture ExamPre-Lecture ExamQuestion 1Question 1

The mechanism of action of benzodiazepine:The mechanism of action of benzodiazepine:

a.a. Inhibits Gaba AInhibits Gaba A

b.b. Potentiates Gaba A Potentiates Gaba A

c.c. Inhibits SERInhibits SER

d.d. Stimulates Alpha 1Stimulates Alpha 1

e.e. A and DA and D

Pre-Lecture ExamPre-Lecture ExamQuestion 2Question 2

Stimulant drugs can be effective for:Stimulant drugs can be effective for:

a.a. ADHDADHD

b.b. ADDADD

c.c. SchizophreniaSchizophrenia

d.d. Weight reductionWeight reduction

e.e. NarcolepsyNarcolepsy

Pre-Lecture ExamPre-Lecture ExamQuestion 3Question 3

Physical dependence is:Physical dependence is:

a.a. A normal responseA normal response

b.b. An abnormal responseAn abnormal response

c.c. Does not cause toleranceDoes not cause tolerance

d.d. Does not cause dependenceDoes not cause dependence

e.e. Is all of the aboveIs all of the above

Pre-Lecture ExamPre-Lecture ExamQuestion 4Question 4

Writing prescriptions for pain medication Writing prescriptions for pain medication involves all but:involves all but:

a.a. Write like a checkWrite like a check

b.b. Specify pharmacy nameSpecify pharmacy name

c.c. Get to know pharmacistGet to know pharmacist

d.d. Usually no refillsUsually no refills

e.e. Avoiding contact with familyAvoiding contact with family

BenzodiazepinesBenzodiazepines

High potencyHigh potencyshort half lifeshort half life

alprazolam (Xanax)alprazolam (Xanax)lorazepam (Ativan)lorazepam (Ativan)triazolam triazolam (Halcion) (Halcion)

long half-lifelong half-lifeclonazepam clonazepam

(Klonopin)(Klonopin)

BenzodiazepinesBenzodiazepines Low potencyLow potency

short half-lifeshort half-lifeoxazepam (serax)oxazepam (serax)temazepam (Restoril)temazepam (Restoril)

long half-lifelong half-lifechlordiazepoxide (Librium)chlordiazepoxide (Librium)Chlorazepate (Tranxene)Chlorazepate (Tranxene)diazepam (Valium)diazepam (Valium)flurazepam (Dalmane)flurazepam (Dalmane)

BenzodiazepinesBenzodiazepines

• Mechanism of actionMechanism of action–Potentiate GABA A receptor Potentiate GABA A receptor activityactivity–Similar mechanism of actionSimilar mechanism of action•BarbituratesBarbiturates•AlcoholAlcohol

–ToleranceTolerance–WithdrawalWithdrawal

BZ WithdrawalBZ Withdrawal• AnxietyAnxiety• AgitationAgitation• Increased sensitivity to lights, soundIncreased sensitivity to lights, sound• Paresthesias, strange sensationsParesthesias, strange sensations• Muscle crampsMuscle cramps• Myocolonic jerksMyocolonic jerks• InsomniaInsomnia• DizzinessDizziness• Seizures, deliriumSeizures, delirium

0

50,000

100,000

150,000

200,000

ER

Men

tion

s

Benzos 1995 Benzos 2002 Cocaine 2002

E R Mentions of BenzodiazepinesE R Mentions of Benzodiazepines

Rationale Benzodiazepine Rationale Benzodiazepine UseUse

• Consider other alternativesConsider other alternatives• Avoid benzos for drug Avoid benzos for drug abusersabusers• Avoid writing large scripts Avoid writing large scripts • Avoid refillsAvoid refills• Avoid the most abusable Avoid the most abusable

Treating InsomniaTreating Insomnia• Look for an underlying causeLook for an underlying cause

• Start with sleep hygieneStart with sleep hygiene

• Medication optionsMedication options•AntihistamineAntihistamine•Non - benzodiazepine hypnoticNon - benzodiazepine hypnotic•Sedating antidepressantSedating antidepressant•benzodiazepinebenzodiazepine

Stimulant drugsStimulant drugs• Amphetamines Amphetamines • Dextroamphetamine (Dexadrine)Dextroamphetamine (Dexadrine)

• Mixed (Adderall)Mixed (Adderall)

• Diet Pills - Phentermine et al.Diet Pills - Phentermine et al.

• Methylphenidate (Ritalin)Methylphenidate (Ritalin)

Stimulant drug Stimulant drug abuseabuse

0 5 10 15

Lifetime nonmedical use (millions)

Methamphetamine

Diet Pills

Methylphenidate

Dex/Adderall

020,00040,00060,00080,000

100,000120,000

ER M

entio

ns

1995 1996 1997 1998 1999 2000 2001 2002

Drug abuse related ED visits involving narcotic analgesics 1995-2002

0.6%

11.6%

0%

5%

10%

15%

20%

25%%

Usin

g Pa

st Y

ear

1995 2002

Use of prescription pain relievers ages 12-17Use of prescription pain relievers ages 12-17

Favorite NarcoticsFavorite Narcotics

• HydrocodoneHydrocodone

• OxycontinOxycontin

• Combo meds are schedule IIICombo meds are schedule III

• Oxycontin can be snorted or Oxycontin can be snorted or

chewedchewed

Sources of NarcoticsSources of Narcotics

• Deceived physiciansDeceived physicians

• Dishonest physiciansDishonest physicians

• Genuine pain patientsGenuine pain patients

• Thefts or diversion from Thefts or diversion from

pharmaciespharmacies

• InternetInternet

The Availability The Availability of Opiates over of Opiates over the Internetthe Internet

Robert F. Forman, Robert F. Forman, Ph.DPh.DTreatment Treatment Research Institute Research Institute University of University of PennsylvaniaPennsylvania

Pain and AddictionPain and Addiction

•Can the treatment of pain cause addiction?Can the treatment of pain cause addiction?•How is pain managed in the addicted?How is pain managed in the addicted?

Inadequate treatment Inadequate treatment of cancer painof cancer pain

• 40-60% oncology patients--inadequate 40-60% oncology patients--inadequate medicationmedication

• Minorities -3 times more likely Minorities -3 times more likely • WomenWomen• ElderlyElderly• Fears: respiratory depression, tolerance, Fears: respiratory depression, tolerance,

addictionaddiction• Confusion between “Dependence” and Confusion between “Dependence” and

“Addiction”“Addiction”

Physical Dependence Physical Dependence (Normal response)(Normal response)

• Tolerance - reduced effect from level Tolerance - reduced effect from level

dose, may begin with 1st dose dose, may begin with 1st dose

• Withdrawal - Characteristic Withdrawal - Characteristic

symptoms when drug abruptly symptoms when drug abruptly

stopped, may continue for days, stopped, may continue for days,

weeks, monthsweeks, months

Dependence (Addiction)Dependence (Addiction)

• ToleranceTolerance• WithdrawalWithdrawal• More use than intendedMore use than intended• Unsuccessful efforts to cut downUnsuccessful efforts to cut down• Spends excessive time in acquisitionSpends excessive time in acquisition• Activities given up because of useActivities given up because of use• Uses despite negative effectsUses despite negative effects

DSM-IVDSM-IV

Pseudo-addictionPseudo-addiction• Focus on obtaining opioids for pain Focus on obtaining opioids for pain

reliefrelief

• Looks like addictionLooks like addiction

•manipulation, manipulation,

• doctor shopping, doctor shopping,

•multiple ED visitsmultiple ED visits• But it disappears with adequate medsBut it disappears with adequate meds

Pseudo-addictionPseudo-addictionOpioid Renewal Clinic at PVAMCOpioid Renewal Clinic at PVAMC• 170 consecutive chronic pain patients170 consecutive chronic pain patients

• Referred by primary care providersReferred by primary care providers• All identified with “aberrant behavior”All identified with “aberrant behavior”

• Followed in special clinic (ORC)Followed in special clinic (ORC)• Nurse practitioner, pharmacist Nurse practitioner, pharmacist • Clinical algorhythms, treatment agreementsClinical algorhythms, treatment agreements• Close follow up and monitoringClose follow up and monitoring

• 58 patients (34%) behavior resolved58 patients (34%) behavior resolved• 22 patients (13%) addicted22 patients (13%) addicted

Chronic painChronic pain• Headache (various types)Headache (various types)• Backache (various etiologies)Backache (various etiologies)• Reflex sympathetic dystrophyReflex sympathetic dystrophy• Diabetic NeuropathyDiabetic Neuropathy• FibromyalgiaFibromyalgia• Tic douloureuxTic douloureux• Post-herpetic (Shingles)Post-herpetic (Shingles)• Ulcerative colitisUlcerative colitis

Chronic Pain and AddictionChronic Pain and Addiction

• Few trials conductedFew trials conducted

• Some say addiction not increasedSome say addiction not increased

• Others show high rates drug abuseOthers show high rates drug abuse

• Often addiction precedes painOften addiction precedes pain

Multi-disciplinary Multi-disciplinary treatment approachtreatment approach

• Diagnosis of pain etiologyDiagnosis of pain etiology

• Psychological evaluationPsychological evaluation

• Multimodal treatmentMultimodal treatment

Non- opiate optionsNon- opiate options• AcetominophenAcetominophen• IbuprophenIbuprophen• AspirinAspirin• Combinations - caffeine adjuvantCombinations - caffeine adjuvant• Tramadol (low opiate receptor Tramadol (low opiate receptor

activity)activity)• Carbamazepine, GabapentinCarbamazepine, Gabapentin• Anti-depressants (amitryptiline et al)Anti-depressants (amitryptiline et al)

Non medication strategiesNon medication strategies• BiofeedbackBiofeedback• HypnosisHypnosis• Group and individual psychotherapyGroup and individual psychotherapy• Cognitive therapyCognitive therapy• Family therapyFamily therapy• ExerciseExercise• AcupunctureAcupuncture• TENS and related stimulationTENS and related stimulation• Nerve blocksNerve blocks

Patients with substance Patients with substance abuse historyabuse history

• Substance abuse may be a risk factorSubstance abuse may be a risk factor

• Extra care is necessaryExtra care is necessary

• Specialty trained clinicianSpecialty trained clinician

• Signed contractSigned contract

• Close monitoringClose monitoring

Careful with prescriptionsCareful with prescriptions• One prescriber onlyOne prescriber only• Write like a checkWrite like a check• No pre-printed DEA no.No pre-printed DEA no.• Specify pharmacy nameSpecify pharmacy name• Get to know pharmacistGet to know pharmacist• Usually no refillsUsually no refills• Stay in touch with familyStay in touch with family

kampman_k@mail.trc.upenn.edukampman_k@mail.trc.upenn.edu

Post-Lecture ExamPost-Lecture ExamQuestion 1Question 1

The mechanism of action of benzodiazepine:The mechanism of action of benzodiazepine:

a.a. Inhibits Gaba AInhibits Gaba A

b.b. Potentiates Gaba A Potentiates Gaba A

c.c. Inhibits SERInhibits SER

d.d. Stimulates Alpha 1Stimulates Alpha 1

e.e. A and DA and D

Post-Lecture ExamPost-Lecture ExamQuestion 2Question 2

Stimulant drugs can be effective for:Stimulant drugs can be effective for:

a.a. ADHDADHD

b.b. ADDADD

c.c. SchizophreniaSchizophrenia

d.d. Weight reductionWeight reduction

e.e. NarcolepsyNarcolepsy

Post-Lecture ExamPost-Lecture ExamQuestion 3Question 3

Physical dependence is:Physical dependence is:

a.a. A normal responseA normal response

b.b. An abnormal responseAn abnormal response

c.c. Does not cause toleranceDoes not cause tolerance

d.d. Does not cause dependenceDoes not cause dependence

e.e. Is all of the aboveIs all of the above

Post-Lecture ExamPost-Lecture ExamQuestion 4Question 4

Writing prescriptions for pain medication Writing prescriptions for pain medication involves all but:involves all but:

a.a. Write like a checkWrite like a check

b.b. Specify pharmacy nameSpecify pharmacy name

c.c. Get to know pharmacistGet to know pharmacist

d.d. Usually no refillsUsually no refills

e.e. Avoiding contact with familyAvoiding contact with family

Answers to Pre and Post Answers to Pre and Post Lecture ExamsLecture Exams

1.1. BB

2.2. DD

3.3. AA

4.4. EE