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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 lwalter@ucla.edu www.uclaisap.org.

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prescription drug abuse
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

lwalter@ucla.edu

www.uclaisap.org

prescription drug abuse scope of the talk
Prescription Drug Abuse: Scope of the Talk
  • What and which drugs?
  • Why now?
  • Who abuse prescription drugs?
  • What can we do?
definitions what s abuse behavior to us
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-IVdiagnostic 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)

drugs of abuse not just opioids
Drugs of Abuse: Not Just Opioids
  • Opioids and other pain killers
  • Stimulants
  • Anti-anxiety drugs
  • Sedative/hypnotics
  • Feel good drugs (antidepressants)
  • Look good drugs (steroids)
  • Feeling goofy drugs (psychedelics)
pain prescription abuse
Pain Prescription Abuse
  • In 2002, nearly 30 million people over 12 used prescribed pain relievers non-medically
  • 1.5 million dependent/abused prescribed pain relievers; 2nd. only to marijuana
under the counter july 7 2005 casa
Under the CounterJuly 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)
commonly abused opioids
Commonly Abused Opioids

Diacetylmorphine Heroin

Hydromorphone Dilaudid

Meperidine Demerol

Hydrocodone Lortab, Vicodin

Oxycodone OxyContin,

Percodan,

Percocet, Tylox

oxycodone and oxycodone cr
Oxycodone and Oxycodone CR
  • Oxycodone: OxyIR, Roxycodone
    • Acute pain
    • 4-6 hrs duration of action
    • Tabs, caps, liquid
  • Oxycodone CR: Oxycontin
    • Chronic pain; already tolerant to opioids
    • 12 hrs duration of action
    • Not for prn use
    • Tablets only
emergency dept mentions of single entity oxycodone
Emergency Dept. MentionsOf Single-Entity Oxycodone

2002 National Survey on Drug Use and Health (NSDUH), SAMHSA, Sept 5, 2003

slide14

“Some reasons why you should consider using this pharmacy”

No prescription required!

Easy Access: Role of the Internet?

“Delivered in the Privacy of your Home”

prescription abusing populations
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)
youth prescription abuse
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
the elderly prescription opioid abuser
The Elderly Prescription Opioid Abuser
  • 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
women and prescription drug abuse
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
women and prescription drug abuse20
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
prescription drug abuse in pain patients
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
slide22

Odds Ratio

Source: NESARC Study

Is pain associated with opioid disorders?

Opioid Disorders According to Different Levels of

Past 4 Week Interference Due to Pain

Nearly Linear Relationship of Pain and Opioid Use Disorder

as prescriptions increase emergency room reports have increased at the same or faster rate

24000

80000

.

Hydrocodone

70000

prescriptions

18000

emergency

60000

50000

ED Mentions

Number of Prescriptions (in 1000s)

12000

40000

Oxycodone

30000

prescriptions

6000

emergency

20000

10000

0

0

1994

1995

1996

1997

1998

1999

2000

2001

Source: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department Mentions

As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster rate
the fateful triangle opioids pain and addiction
The Fateful Triangle: Opioids Pain and Addiction
  • Under treatment of pain
  • Increasing availability of opioid analgesics
  • Increase in abuse of prescription opioids
slide25
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

opium
Opium
  • “It banishes melancholy, begets confidence, converts fear into boldness, makes the silent eloquent and bastards brave”

John Brown

opium27
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

from pain relief to addiction role of the opiates
From Pain Relief to Addiction: Role of the Opiates
  • Relieve pain
  • Relieve pain and suffering
  • Relieve suffering and misery
  • Make you feel better
  • Make you feel good
  • Make you “high”
characterizing pain
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

acute vs chronic pain
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?

.

pain more than a feeling
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

chronic pain and addiction common features
Chronic pain

Early trauma

Loss of mastery

Loss of control

Loss of sense of self

Cognitive error

“personalization”

Over interpretation

“catastrophy”

Addiction

Early trauma

Loss of mastery

Loss of control

Loss of self efficacy

Cognitive error

“nirvana”

Denial

Chronic Pain and Addiction: Common Features
addiction in pain patients
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;

who s at risk and how to tell
Who’s at Risk and How to Tell?
  • Four ways to identify patients at risk:
    • History: personal history & family history
    • Screening instruments
    • Behavioral check lists
    • Therapeutic maneuver
history
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

screening instruments
Screening Instruments
  • CAGE
  • MAST
  • DAST
    • Nonspecific for pain patients
ongoing warning signs
Ongoing Warning Signs
  • 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
slide38

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

Improved functioning

Absence of toxicity

Unimproved functioning

Presence of toxicity

therapeuticdependence

Addictive disease

pseudoaddiction

can addicts be treated with opiates
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
treating pain with opioids what can we expect to achieve
Treating Pain with Opioids: What Can We Expect to Achieve?
  • Reduction in pain and suffering
    • Meaningful pain reduction
  • Improved functionality
    • Meaningful improvement in activities
meaningful pain reduction how much
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

meaningful functional improvement my favorites
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
conclusion prescription drug abuse
Conclusion: Prescription Drug Abuse
  • Escalating problem
  • Heterogeneous population
  • Youth
  • Elderly
  • Women and minorities
  • Chronic pain patients
  • Pain and addiction – complex disorder
acknowledgment and thanks
Acknowledgment and Thanks
  • Conference organizers
  • Friends and colleagues:
    • ISAP & elsewhere
  • NIDA
  • You the audience