Prescription (Rx) Drug Misuse: What’s the Problem? Larissa Mooney, M.D. Thomas E. Freese, Ph.D.
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Transcript of Prescription (Rx) Drug Misuse: What’s the Problem? Larissa Mooney, M.D. Thomas E. Freese, Ph.D.
Prescription (Rx) Drug Misuse: Prescription (Rx) Drug Misuse: What’s the Problem?What’s the Problem?
Larissa Mooney, M.D.Larissa Mooney, M.D.Thomas E. Freese, Ph.D.Thomas E. Freese, Ph.D.
What is Misuse?What is Misuse?
MisuseMisuse = “ = “Non-medical useNon-medical use” or any use ” or any use that is outside of a medically prescribed that is outside of a medically prescribed regimenregimen
Examples can include:Examples can include: Taking forTaking for psychoactive “high” effects psychoactive “high” effects Taking in Taking in extreme dosesextreme doses Mixing Mixing pillspills Using withUsing with alcohol or other illicit substances alcohol or other illicit substances Obtaining fromObtaining from non-medical sources non-medical sources
Commonly Misused Rx Commonly Misused Rx DrugsDrugs
Opiates: pain-killersOpiates: pain-killers Ex) Vicodin, Oxycontin, Tylenol Ex) Vicodin, Oxycontin, Tylenol
CodeineCodeine
CNS Depressants CNS Depressants (Sedatives/Tranquilizers): (Sedatives/Tranquilizers): treat anxiety and sleep disorderstreat anxiety and sleep disorders Ex) Xanax, Ativan, Valium, SomaEx) Xanax, Ativan, Valium, Soma
Stimulants: ADHD, weight lossStimulants: ADHD, weight loss Ex) Aderall, Ritalin, Concerta, Ex) Aderall, Ritalin, Concerta,
Dexedrine, FastinDexedrine, Fastin
Classified in 3 classes
Rx Drug Misuse in the Rx Drug Misuse in the U.S.U.S.
6.4 million aged 12+ used a 6.4 million aged 12+ used a Rx drug (non-medically) in the past year Rx drug (non-medically) in the past year
NSDUH, 2006
S edatives
S timulants
T ranquilizersPainkillers
4,700,000
1,800,000
1,100,000
272,000
Number of New Non-medical Users of Therapeutics
Percentage of population with past Percentage of population with past month use of pharmaceuticalsmonth use of pharmaceuticals
Rates of Prescription Narcotic Rates of Prescription Narcotic AbuseAbuse
Nonmedical use of prescription narcotics:2006: 33.5 million (13.6%) over age 121.64 million prescription narcotic users meet diagnostic criteria for opioid abuse or dependence (second only to marijuana [4.17 million]) Hydocodone (Vicodin) is most widely prescribed drug in US.
Los AngelesLos Angeles
Sales sharply increased for Sales sharply increased for oxycodoneoxycodone (84%) and (84%) and hydrocodonehydrocodone (47%) between 2001 and 2005. (47%) between 2001 and 2005.
Codeine, hydrocodoneCodeine, hydrocodone, and , and morphinemorphine were distributed in the were distributed in the largest amountslargest amounts when compared when compared with the grams of other opiates with the grams of other opiates distributed.distributed.
CEWG, 2006
Fatal Drug PoisoningBetween 1999 and 2002, the number of opioid analgesic poisonings on death certificates rose 91.2%*
During this time period, poisoning from opioid analgesics surpassed both cocaine and heroin poisoning as the most frequent type of drug poisoning found on death certificates in the U.S.*
In Florida 2007, 3 times more deaths from prescription drugs than from all illicit drugs combined. **
* Source: Paulozzi, L.J., Budnitz, D.S., Xi, Y, 2006. Increasing deaths from opioid analgesics in the United States. Pharmacoedidemiology and Drug Safety 15, 613-7.
** New York Times, June 14, 2008.
Media AttentionMedia AttentionMedia AttentionMedia Attention
SPLENDID FORWind, Colic, Griping in the Bowels, Diarrhea Cholera and Teething Troubles
Epidemiology of Rx and OTC Epidemiology of Rx and OTC Drug Misuse Among YouthDrug Misuse Among Youth
GHBGHB
HeroinHeroin
KetamineKetamine
LSDLSD
MethMeth
EcstasyEcstasy
Cough MedicineCough Medicine
Crack/CocaineCrack/Cocaine
MarijuanaMarijuana 8.6 8.6 millionmillion4.5 million4.5 million
2.4 million2.4 million
2.4 million2.4 million
1.3 million1.3 million
1.9 million1.9 million
1.9 million1.9 million
1.1 million1.1 million
1 million1 million
1 million1 million
Prescription MedicinePrescription Medicine
NSDUH, 2006
New Landscape of Drug Abuse among Teens
High Rates in Non-medical Use of Oxy & VicodinHigh Rates in Non-medical Use of Oxy & Vicodin
0.00.0
2.02.0
4.04.0
6.06.0
8.08.0
10.010.0
12.012.0
OxyContin OxyContin Vicodin Vicodin
Per
cen
tP
erce
nt
20022002 20032003 20042004
9.69.610.510.5
9.39.3
4.04.04.54.5 5.05.0
Nearly 1 in 10 12th Graders Abused Vicodin Last YearNearly 1 in 10 12th Graders Abused Vicodin Last Year
Source: Monitoring the Future Study, 2004.Source: Monitoring the Future Study, 2004.
Generation RxGeneration Rx Rx/OTC med abuse has penetrated teen culture 18% of teens have abused Vicodin 20% tried Ritalin or Adderall without Rx 9% abused OTC cough syrup to get high Equal or greater abuse of OTC/Rx than cocaine, Ecstasy,
LSD, ketamine, heroin, GHB, ice Believe that Rx Meds safer (50%), less addictive (33%) Ease of access: medicine cabinets “Drugs are fun” vs “Drugs help kids when they are
having a hard time”
April 21, 2005. Partnership for a Drug Free America. 17April 21, 2005. Partnership for a Drug Free America. 17thth annual study of teen drug annual study of teen drug abuse. N= 7,300, error margin +/- 1.5%abuse. N= 7,300, error margin +/- 1.5%
Misuse of Rx Drugs in CA High Misuse of Rx Drugs in CA High SchoolsSchools
MisuseMisuse of of painkillerspainkillers (no prescription) to (no prescription) to get highget high:: 15% of 11th 15% of 11th gradersgraders 9% of 9th 9% of 9th gradersgraders 4% of 7th graders4% of 7th graders
California Student Survey 2006
Older AdultsOlder Adults
RX Drug Abuse in Older RX Drug Abuse in Older AdultsAdults
Older Adults Older Adults account for account for 1/3 1/3 of of all medications all medications prescribedprescribed in the U.S. in the U.S.
7.2 million 7.2 million (21.7%)(21.7%) receivereceive at least 1 Rx at least 1 Rx annually.annually.
Older adults use Rx drugs Older adults use Rx drugs 3 times more3 times more than the than the general population.general population.
On average, older persons take On average, older persons take 4.5 medications 4.5 medications perper dayday..
2.8 million 2.8 million older adults older adults abuseabuse Rx drugs in the last Rx drugs in the last yearyear..
SAMHSA, 2006; NIDA, 2005
An estimated An estimated one in fiveone in five older adults older adults are negatively affected by combined are negatively affected by combined
difficulties with difficulties with alcoholalcohol andand Rx medication abuseRx medication abuse..
Older AdultsOlder Adults Risks FactorsRisks Factors
Prescribed Prescribed multiple multiple medicationsmedications..
Long-termLong-term prescriptions prescriptions cancan lead to lead to unintentional misuseunintentional misuse -- taking different doses.taking different doses.
PrescribedPrescribed inappropriately inappropriately high doseshigh doses..
Medical Exposure to Rx DrugsMedical Exposure to Rx Drugs
12
18.620.1
27.3
20.4
28.3
19.4
24.8
0
5
10
15
20
25
30
65-69 70-74 75-79 80+
Male Female
Simoni-Wastila et al, 2006
•Older women more likely to be exposed to Rx drugs for medical reasons than men.
Risk of Rx Drug Misuse in Older Risk of Rx Drug Misuse in Older WomenWomen
Live longer: greater likelihood for exposure Live longer: greater likelihood for exposure to Rxsto Rxs
Propensity for care seeking Propensity for care seeking greater greater exposure to Rxsexposure to Rxs
Biology/Metabolic differences Biology/Metabolic differences
Metabolize alcohol & drugs differently Metabolize alcohol & drugs differently than men, and have lower tolerance to Rx than men, and have lower tolerance to Rx drugs and alcoholdrugs and alcohol
Side Effects can be Lethal if…Side Effects can be Lethal if…
Combining Combining Rx & OTCRx & OTC medications. medications. Taking Rx and OTC meds with Taking Rx and OTC meds with alcoholalcohol.. Using Rx and OTC with Using Rx and OTC with other illicit other illicit
drugsdrugs.. Interactions: Interactions: Rx & OTCRx & OTC meds with other meds with other
physical medications (i.e., physical medications (i.e., HIV or HIV or Hepatitis)Hepatitis)
Efforts in CaliforniaEfforts in California Establishment of statewide Establishment of statewide Rx Drug Rx Drug
Task force charged Task force charged with:with: Monitoring trends and strategies Monitoring trends and strategies at the at the
state and local levels.state and local levels.
Developing prevention strategies Developing prevention strategies for Rx for Rx & OTC drug abuse.& OTC drug abuse.
Developing intervention strategies Developing intervention strategies for for Rx & OTC drug abuse in treatment Rx & OTC drug abuse in treatment settings.settings.
Questions?Questions?
Prescription Drug Prescription Drug AbuseAbuse
Larissa Mooney, M.D.Larissa Mooney, M.D.Assistant Professor of Psychiatry Assistant Professor of Psychiatry
UCLA Integrated Substance Abuse UCLA Integrated Substance Abuse ProgramsPrograms
David Geffen School of Medicine at David Geffen School of Medicine at UCLAUCLA
OverviewOverview
Three classes of commonly abused Three classes of commonly abused Rx drugs (opioids, sedatives, Rx drugs (opioids, sedatives, stimulants)stimulants) What are they? What are they? How do they act in the brain and body?How do they act in the brain and body? What are their effects?What are their effects? NeurobiologyNeurobiology
What are opioids? What are opioids?
Opiate: derivative of opium poppyOpiate: derivative of opium poppy MorphineMorphine CodeineCodeine
Opioid: any compound that binds to opiate Opioid: any compound that binds to opiate receptorsreceptors Semisynthetic (including heroin)Semisynthetic (including heroin) Synthetic Synthetic Oral, transdermal and intravenous formulationsOral, transdermal and intravenous formulations
Narcotic: legal designationNarcotic: legal designation
Opioid ReceptorsOpioid Receptors
Receptor typesReceptor types mu, delta, kappamu, delta, kappa
Receptors located throughout bodyReceptors located throughout body Pain relief: central and peripheral nervous Pain relief: central and peripheral nervous
systemsystem Reward and reinforcement: deep brain Reward and reinforcement: deep brain
structuresstructures Side effects: constipation, sedation, itch, mental Side effects: constipation, sedation, itch, mental
status changesstatus changes Receptor interactions Receptor interactions
Full agonistsFull agonists Partial agonistsPartial agonists AntagonistsAntagonists
SOURCE: National Institute on Drug Abuse, www.nida.nih.gov.
Endogenous OpioidsEndogenous Opioids
Produced naturally in body Produced naturally in body Act on opioid receptors Act on opioid receptors Examples: endorphins, enkephalins, Examples: endorphins, enkephalins,
dynorphins, endomorphinsdynorphins, endomorphins Produce euphoria and pain relief;
naturally increased when one feels pain or experiences pleasure
Pain: the Fifth Vital SignPain: the Fifth Vital Sign
JACHO Guidelines 2000:JACHO Guidelines 2000: Mandated pain assessment and treatmentMandated pain assessment and treatment Nurse and physician education requiredNurse and physician education required
When opioids prescribed properly When opioids prescribed properly for pain, addiction rare in patients for pain, addiction rare in patients without underlying risk factorswithout underlying risk factors Vulnerabilities same as for other Vulnerabilities same as for other
addictions: genetic, peer and social addictions: genetic, peer and social influences, trauma and abuse historyinfluences, trauma and abuse history
Pain PathwayPain Pathway
www.ccac.cawww.ccac.ca
Pain Control and Pain Control and AddictionAddiction
“Pseudoaddiction”: Presence of drug-seeking behavior in
context of inadequate pain control Behavior stops with adequate pain reliefBehavior stops with adequate pain relief Description of a clinical interaction (not Description of a clinical interaction (not
a true diagnosis)a true diagnosis) Physical dependencePhysical dependence
with continued use, withdrawal with continued use, withdrawal syndrome produced by rapid dose syndrome produced by rapid dose reduction; occurs via neuroadaptation reduction; occurs via neuroadaptation Not synonymous with addictionNot synonymous with addiction
Opioid WithdrawalOpioid Withdrawal
Dysphoric moodDysphoric mood Nausea or vomitingNausea or vomiting DiarrheaDiarrhea Tearing or runny noseTearing or runny nose Dilated pupilsDilated pupils Muscle achesMuscle aches GoosebumpsGoosebumps SweatingSweating YawningYawning FeverFever InsomniaInsomnia
MorphineMorphine
Routes: oral, intramuscular, intravenous, Routes: oral, intramuscular, intravenous, rectalrectal
Sustained release preparations:Sustained release preparations: MS ContinMS Contin OramorphOramorph KadianKadian Avinza Avinza
CodeineCodeine
Opiate (naturally occurring in poppy)Opiate (naturally occurring in poppy) Low potency Low potency Pain relief via 10% conversion to Pain relief via 10% conversion to
morphinemorphine Most commonly prescribed opioid in the Most commonly prescribed opioid in the
worldworld Probably the most widely used analgesicProbably the most widely used analgesic
(Excluding aspirin)(Excluding aspirin)
Semisynthetic OpioidsSemisynthetic Opioids
Hydrocodone with Tylenol:Hydrocodone with Tylenol: Norco Norco Lortab Lortab Vicodin Vicodin Lorcet Lorcet
Hydrocodone with ibuprofen: VicoprofenHydrocodone with ibuprofen: Vicoprofen Hydromorphone: Dilaudid Hydromorphone: Dilaudid Oxycodone with Tylenol: Percocet Oxycodone with Tylenol: Percocet Oxycodone with aspirin: Percodan Oxycodone with aspirin: Percodan OxyContinOxyContin
OxyContinOxyContin
Used to treat pain associated with arthritis, Used to treat pain associated with arthritis, lower back injuries, and cancerlower back injuries, and cancer
Most commonly in tablet form: 10mg, Most commonly in tablet form: 10mg, 20mg, 40mg, 60mg, and 80mg tablets 20mg, 40mg, 60mg, and 80mg tablets
Dosed every 12 hours, half-life 4.5 hoursDosed every 12 hours, half-life 4.5 hours Abuse: may be chewed, crushed, snorted or Abuse: may be chewed, crushed, snorted or
injectedinjected Eliminates time-release coatingEliminates time-release coating Enhances euphoria, “rush” Enhances euphoria, “rush” Increases risk for serious medical consequencesIncreases risk for serious medical consequences
Synthetic OpioidsSynthetic Opioids MethadoneMethadone Demerol (meperidine)Demerol (meperidine) FentanylFentanyl Suboxone/Subutex (buprenorphine)Suboxone/Subutex (buprenorphine) TramadolTramadol
Complex mechanism of actionComplex mechanism of action Nonscheduled, less abuse potential Nonscheduled, less abuse potential
Opiates and Reward
Opiates bind to opiate receptors in Opiates bind to opiate receptors in the nucleus accumbens: increased the nucleus accumbens: increased dopamine releasedopamine release
DextromethorphanDextromethorphan
Over-the-counter cough suppressantOver-the-counter cough suppressant Structurally related to morphineStructurally related to morphine Mechanism: NMDA antagonistMechanism: NMDA antagonist Dissociative psychedelic properties in Dissociative psychedelic properties in
excess doses (like ketamine, PCP)excess doses (like ketamine, PCP)
Sedative-HypnoticsSedative-Hypnotics
Used to treat anxiety and sleep Used to treat anxiety and sleep disordersdisorders
Mechanism: enhances GABAMechanism: enhances GABA acts to slow normal brain functionacts to slow normal brain function
BarbituratesBarbiturates PhenobarbitalPhenobarbital PentobarbitalPentobarbital Fioricet Fioricet
(butalbital/acetaminophen/caffeine)(butalbital/acetaminophen/caffeine)
Sedative-Hypnotics Sedative-Hypnotics Cont’dCont’d
BenzodiazepinesBenzodiazepines Librium (chlordiazepoxide HCL)Librium (chlordiazepoxide HCL) Valium (diazepam)Valium (diazepam) Restoril (tempazepam) Restoril (tempazepam) Klonopin (clonazepam)Klonopin (clonazepam) Ativan (lorazepam)Ativan (lorazepam) Xanax (alprazolam)Xanax (alprazolam)
Non-benzo hypnoticsNon-benzo hypnotics Ambien (zolpidem)Ambien (zolpidem) Sonata (zaleplon)Sonata (zaleplon) Lunesta (eszopiclone)Lunesta (eszopiclone)
SomaSoma Cross-tolerance with alcohol (GABA related)Cross-tolerance with alcohol (GABA related)
Sedative-Hypnotic Sedative-Hypnotic EffectsEffects
SedationSedation Slurred speechSlurred speech IncoordinationIncoordination Unsteady gaitUnsteady gait Impaired attention or memoryImpaired attention or memory Stupor or coma Stupor or coma Overdose risk increased with opioids Overdose risk increased with opioids
or in combination with other or in combination with other sedatives, including alcohol sedatives, including alcohol
Sedating Drugs and Sedating Drugs and OverdoseOverdose
Other Sedative-Hypnotic Other Sedative-Hypnotic RisksRisks
No significant adverse medical No significant adverse medical consequences of long-term useconsequences of long-term use
Amnesia Amnesia Difficulty with recent memoryDifficulty with recent memory
Tolerance, physiological Tolerance, physiological dependence, addictiondependence, addiction Addiction risk factors same as for other Addiction risk factors same as for other
drugs of abusedrugs of abuse
Sedative-Hypnotic Sedative-Hypnotic WithdrawalWithdrawal
Increased pulse, blood pressure, or Increased pulse, blood pressure, or sweatingsweating
Hand tremorHand tremor Nausea or vomitingNausea or vomiting Transient hallucinations or illusionsTransient hallucinations or illusions AgitationAgitation AnxietyAnxiety SeizuresSeizures
Protracted WithdrawalProtracted Withdrawal
Abstinence syndromeAbstinence syndrome AnxietyAnxiety Muscle twitchingMuscle twitching Low moodLow mood SweatingSweating HeadacheHeadache DerealizationDerealization
Rebound insomniaRebound insomnia Especially with short-acting Especially with short-acting
benzodiazepinesbenzodiazepines
Sedative-Hypnotic Sedative-Hypnotic NeurobiologyNeurobiology
SourceSource: :
www.ccforum.comwww.ccforum.com
Prescription StimulantsPrescription Stimulants Stimulants (i.e., amphetamines) are often Stimulants (i.e., amphetamines) are often
prescribed to treat individuals diagnosed prescribed to treat individuals diagnosed with attention-deficit hyperactivity with attention-deficit hyperactivity disorder (ADHD). disorder (ADHD).
Substantial amounts of pharmaceutical Substantial amounts of pharmaceutical amphetamines are diverted from medical amphetamines are diverted from medical use to non-prescription use.use to non-prescription use.
Amphetamines increase wakefulness and Amphetamines increase wakefulness and alertness and have been used by:alertness and have been used by: The military, by pilots, truck drivers, and The military, by pilots, truck drivers, and
other workers to keep functioning past their other workers to keep functioning past their normal limitsnormal limits
Source: Erowid.org
Short-Term EffectsShort-Term Effects
EuphoriaEuphoria Increased energy/productivityIncreased energy/productivity Increased concentrationIncreased concentration Decreased appetiteDecreased appetite Increased libido Increased libido Decreased sleepDecreased sleep
RitalinRitalin When used to treat ADHD, patients may When used to treat ADHD, patients may
report increased attention, decreased report increased attention, decreased impulsivity, and decreased hyperactivity. impulsivity, and decreased hyperactivity.
Milder stimulant that works by affecting Milder stimulant that works by affecting the levels of chemicals the levels of chemicals (neurotransmitters) in the nervous (neurotransmitters) in the nervous system.system.
May also be used in the treatment of May also be used in the treatment of depression in certain casesdepression in certain cases
Long-acting form: ConcertaLong-acting form: Concerta
* WebMD
AdderallAdderall
Adderall is used to treat attention deficit Adderall is used to treat attention deficit hyperactivity disorder (ADHD). hyperactivity disorder (ADHD).
Adderall is a combination of stimulants Adderall is a combination of stimulants (amphetamine and dextroamphetamine). (amphetamine and dextroamphetamine).
It increases the ability to pay attention, It increases the ability to pay attention, focus, and control behavior problems.focus, and control behavior problems.
This drug may also be used to treat This drug may also be used to treat certain sleeping disorders (narcolepsy).certain sleeping disorders (narcolepsy).
Medical RisksMedical Risks
Norepinephrine release causes Norepinephrine release causes constriction of blood vessels, elevated constriction of blood vessels, elevated blood pressure and rapid heart rateblood pressure and rapid heart rate
Increased activity levelsIncreased activity levels Dangerously high body temperaturesDangerously high body temperatures Increased risk of seizures Increased risk of seizures Potentially fatal arrhythmias, heart Potentially fatal arrhythmias, heart
attack, or stroke attack, or stroke
Psychiatric Symptoms Psychiatric Symptoms
Psychiatric symptoms associated with use of Psychiatric symptoms associated with use of larger doses of amphetamines include larger doses of amphetamines include depression, anxiety, psychosis, and suicidal depression, anxiety, psychosis, and suicidal ideation ideation
Symptoms may depend on differences in Symptoms may depend on differences in sensitivity, frequency and quantity of use, sensitivity, frequency and quantity of use, and method of administrationand method of administration
Abstinence syndrome may occur (dysphoria, Abstinence syndrome may occur (dysphoria, anhedonia, irritability, anhedonia, irritability, insomnia/hypersomnia, anxiety, low energy)insomnia/hypersomnia, anxiety, low energy)
Neurobiology of Neurobiology of StimulantsStimulants
Medications to Treat Medications to Treat AddictionAddiction
Addiction is a chronic, relapsing brain Addiction is a chronic, relapsing brain disease characterized by compulsive use disease characterized by compulsive use despite harmful consequencesdespite harmful consequences
Medications as part of Medications as part of comprehensive comprehensive treatment plantreatment plan
Treatment approaches:Treatment approaches: Medications (Bio) Medications (Bio) Therapy, lifestyle changes (Psycho-Social)Therapy, lifestyle changes (Psycho-Social)
Thorough evaluation and diagnosis Thorough evaluation and diagnosis essentialessential
Pharmacotherapy in Pharmacotherapy in Substance Use DisordersSubstance Use Disorders
Treatment of withdrawal (“detox”) Treatment of withdrawal (“detox”) Treatment of psychiatric symptoms or Treatment of psychiatric symptoms or
co-occurring disorders co-occurring disorders Reduction of cravings and urgesReduction of cravings and urges Substitution therapySubstitution therapy
Opioid Detoxification Opioid Detoxification
Medications used to alleviate Medications used to alleviate withdrawal symptoms:withdrawal symptoms:
- Opioid agnonists (methadone, - Opioid agnonists (methadone, buprenorphine) buprenorphine) - Clonidine - Clonidine - Other supportive medications- Other supportive medications
anti-diarrheals, anti-nausea agents, anti-diarrheals, anti-nausea agents, ibuprofen, muscle relaxants, anti-ibuprofen, muscle relaxants, anti-anxiety medicationsanxiety medications
Opioid Substitution GoalsOpioid Substitution Goals
Reduce symptoms & signs of Reduce symptoms & signs of withdrawalwithdrawal
Reduce or eliminate cravingReduce or eliminate craving Block effects of illicit opioidsBlock effects of illicit opioids Restore normal physiologyRestore normal physiology Promote psychosocial rehabilitation Promote psychosocial rehabilitation
and non-drug lifestyleand non-drug lifestyle
OOH O
N
OH
CH3 CH2CH2 CH N
CH3CH3
CH3
O
Methadone: Methadone: Clinical PropertiesClinical Properties
Synthetic opioid agonist Synthetic opioid agonist Analgesic, CNS depressantAnalgesic, CNS depressant Effects last 24 hours; once-daily dosing Effects last 24 hours; once-daily dosing
maintains constant blood level maintains constant blood level Prevents withdrawal, reduces craving Prevents withdrawal, reduces craving
and use and use Facilitates rehabilitationFacilitates rehabilitation Clinic dispensing limits availability Clinic dispensing limits availability
CH3 CH2CH2 CH N
CH3CH3
CH3
O
Buprenorphine for Buprenorphine for Opioid DependenceOpioid Dependence
FDA approved 2002, age 16+FDA approved 2002, age 16+ Mandatory certification from DEA Mandatory certification from DEA Mechanism: partial opioid agonistMechanism: partial opioid agonist Office-based, expands availabilityOffice-based, expands availability Analgesic propertiesAnalgesic properties Ceiling effect Ceiling effect Lower abuse potential Lower abuse potential Safer in overdose Safer in overdose
Buprenorphine Buprenorphine FormulationsFormulations
Sublingual administration Sublingual administration Subutex (Buprenorphine)Subutex (Buprenorphine) Suboxone (4:1 Bup:naloxone) Suboxone (4:1 Bup:naloxone) Dose: 2mg-32mg/day Dose: 2mg-32mg/day Once-daily dosing Once-daily dosing
MYTH: Patients are still MYTH: Patients are still addictedaddicted
FACT:FACT: Addiction is pathologic use of Addiction is pathologic use of a substance and a substance and maymay or or may notmay not include physical dependence.include physical dependence.
Physical dependence on a Physical dependence on a medication for treatment of a medication for treatment of a medical problem medical problem does notdoes not mean mean the person is engaging in the person is engaging in pathologic use and other behaviors. pathologic use and other behaviors.
Medications for Sedative-Medications for Sedative-Hypnotic DependenceHypnotic Dependence
Taper: slowly decrease dose to Taper: slowly decrease dose to minimize withdrawal symptomsminimize withdrawal symptoms
May first convert to longer-acting May first convert to longer-acting agent agent
Use non-addictive medications for Use non-addictive medications for residual anxiety symptomsresidual anxiety symptoms SSRIs and other antidepressantsSSRIs and other antidepressants Other anti-anxiety agentsOther anti-anxiety agents
Treatment of Stimulant Treatment of Stimulant DependenceDependence
Behavioral therapies effective for Behavioral therapies effective for treating stimulant dependence treating stimulant dependence
At this time, there are no FDA-At this time, there are no FDA-approved medications for the approved medications for the treatment of stimulant dependence. treatment of stimulant dependence.
Outpatient taper: slowly decrease doseOutpatient taper: slowly decrease dose Medications to treat withdrawal Medications to treat withdrawal
symptoms symptoms AnxietyAnxiety DepressionDepression
* NIDA
Medications for Stimulant Medications for Stimulant DependenceDependence
Medications used to treat stimulant-Medications used to treat stimulant-induced psychiatric symptoms:induced psychiatric symptoms: AntidepressantsAntidepressants AntipsychoticsAntipsychotics Anti-anxiety agentsAnti-anxiety agents Medications to treat agitation, violenceMedications to treat agitation, violence
ER and outpatient settingsER and outpatient settings Medications to treat co-occurring Medications to treat co-occurring
psychiatric disorderspsychiatric disorders
In ConclusionIn Conclusion
Addiction is a serious, chronic and relapsing Addiction is a serious, chronic and relapsing disorder, but treatments are available disorder, but treatments are available
Medications should be considered as part of Medications should be considered as part of a comprehensive treatment plan, addressing a comprehensive treatment plan, addressing both disordered physiology and disrupted both disordered physiology and disrupted liveslives
Medications should be considered for Medications should be considered for treatment of: psychiatric sx’s, addictive d/o’s, treatment of: psychiatric sx’s, addictive d/o’s, and co-occurring d/o’sand co-occurring d/o’s
Emerging research supports use of meds in Emerging research supports use of meds in individuals with SUDs and psychiatric individuals with SUDs and psychiatric comorbiditycomorbidity
Thank you! Thank you!
Larissa Mooney, M.D.Larissa Mooney, M.D.
[email protected]@mednet.ucla.edu
Thomas E. Freese, Ph.D.Thomas E. Freese, Ph.D.
[email protected]@mednet.ucla.edu
UCLA Integrated Substance Abuse UCLA Integrated Substance Abuse ProgramsPrograms