OxyContin, Vicodin, and Heroin Abuse: What's a Clinician to Do?

2. OxyContin, Vicodin, and Heroin Abuse: What's a Clinician to Do? Peter A. DeMaria, Jr., M.D., FASAM Tuttleman Counseling Services Temple University Clinical Associate Professor of Psychiatry Temple University School of Medicine

3. Disclosures • Dr. DeMaria serves as a treatment advocate for Reckitt-Benckiser Pharmaceutical • Generic versus Trade drug names • Off-label use of medication

4. College Student Developmental Stage • Invincible • Subject to peer pressure • Risk-taking • Want to be independent ADOLESCENCE

5. Some Factors Affecting Drug Experimentation/Continued Use/Addiction Peer Pressure Genetics Psychiatric problems Stress Availability Boredom Curiosity Trauma/abuse

6. The Life History of A Substance User Abstinence Abstinence Experimentation Abuse Dependence Relapse to Use Sobriety Recovery

7. Core Alcohol & Drug Survey-2005 (A sample of 33,379 undergraduate students from about 53 colleges in the United States) 30 Day Prevalence Rate by Drug Type

8. College Student Opioid Use–CORE Study If Temple has 33,000 students, then 429 used in the last year & 198 used in last 30 days

9. Monitoring the FutureAnnual Prevalence for College Students

10. Papaver somniferum (Opium poppy)

11. Patterns of Use • Heroin: $10 bags • Snorted, injected, smoked • Average habit = $80-100/day • Prescription Narcotics (Opioids) • Oxycodone [C-II] • Percocet (~$5/pill) • OxyContin (~$0.50/mg.) • Tylenol w/Codeine #3,4 (~$1-5/pill) [C-III] • Lortab/Vicodin (hydrocodone), [C-III]

13. Prescription Opioid Drugs Vicodin Percocet OxyContin Dilaudid Tylenol #4 w/codeine Lortab

14. Opioids - Intoxication/Withdrawal/Overdose • Intoxication • Rush, nod, miosis, constipation • Withdrawal -Craving -Anxiety -Mydriasis -Insomnia -Weakness -Diaphoresis -Yawning -Lacrimation -Myalgias/arthalgias -Diarrhea -Piloerection -Rhinorrhea -Muscle twitches • Overdose • Classic triad (Miosis, Respiratory depression, Coma)

15. Cycle of Addiction Drug Use Obtain drugs Physical dependence Obtain money for drugs Withdrawal symptoms Need for drugs

16. Inability to attend classes/do schoolwork Breakdown of relationships Decrease in self-care Inability to work Financial problems (cash flow) Illegal behavior Medical risks Psychiatric illness Consequences of Addiction

17. Progression of Opioid Use Prescription Opioid Medication Snort Heroin Inject Heroin

18. How People Change Precontemplation Contemplation Preparation Prochaska J, DiClemente C, Norcross J. In search of how people change: applications to addictive behaviors. Amer Psychol 47:1102-1114, 1992. Action Maintenance

19. General Principles of Treatment • Comprehensive evaluation • Engagement in treatment • Treatment setting • Detoxification vs. maintenance • Counseling (Individual, Group) • Self-Help (12 step)

21. Using Buprenorphine to Treat Opioid Dependent University Students: Opportunities, Successes, and Challenges. • Peter A. DeMaria, Jr., M.D., FASAM Robert C. Sterling, Ph.D. Robin Risler, Psy.D. Jeremy Frank, Ph.D., CAC • Journal of Addiction Medicine • Available on-line: Published Ahead of Print • http://journals.lww.com/journaladdictionmedicine/ toc/publishahead

22. The Temple Experience • Retrospective chart review of treated students. • Time period = 1/04 through 4/08 • 27 students inducted and treated at least 3 months • Average age = 22.37 ± 2.89 years old • 63% Male • 85% Caucasian • 97% Academic juniors or higher • 41% Not involved in a relationship

23. Year in School at Presentation

24. Opioid Use at Admission – Self Report

25. Initial Urine Drug Screen

26. Population Characteristics • Average length of use = 33.4 ± 28.79 months (range = 4-132 months) • 56% Use drugs IV • 67% Smoke tobacco • 56% Dink alcohol • No HIV or HCV infections • Family History • Psychiatric = 52% • Drug & alcohol = 70% • 59% Report a history of past addiction treatment • 30% Report a legal history

27. Psychiatric Diagnosis15/27 (55.6%) had a history of a psychiatric diagnosis

28. Treatment Characteristics • Average Suboxone dose = 13.8 ± 5.69 mg (range = 4-24 mg). • Well tolerated; no serious adverse events • Most common side effect = constipation • One student became pregnant and delivered

29. Urine Drug Screen ResultsN = 237 UDS, M = 8.8/student, Range = 0 - 33

30. Disposition of Admitted PatientsLength of Treatment = M = 12.00 ± 11.49 months Range = 1 to 36 months

31. Treatment Received

32. Predicting Treatment Outcome • Opioid positive UDS at follow-up • Use of heroin → (+) • Use of other substances → (+) • Time in treatment (p = 0.06) → (-) • Time in treatment • No significant indicators

33. Challenges • Accept the disease of addiction • Commit to sobriety • Acknowledge that marijuana is a drug • Engage in treatment • Finances • Managing free time/boredom

34. Study Limitations • Uncontrolled • Retrospective • No comparison group • Small sample size • Limited to one university

35. Conclusions Opioid dependent university students: • Are a unique group of substance users • Can be safely and effectively treated with buprenorphine in a university counseling center