Fall 2009 CATES Training Series
Emerging Trends:
Addressing the Prescription
Drug Abuse Problem
Thomas E. Freese, PhD, Beth A. Rutkowski,
MPH, and Sherry Larkins, PhD
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs
UCLA David Geffen School of Medicine, Dept. of Psychiatry
Goals of the Training
• As a result of participating in this training,
participants will be able to:
– Describe the scope of prescription/over-thecounter drug abuse and list key at-risk
populations
– Compare and contrast major categories of
prescription drugs and at least two effects of the
drugs from each category
– Discuss various strategies to prevent
prescription drug abuse
– List at least three behavioral or medicationassisted treatment approaches
Training Topics
• Epidemiology and user demographics
• Neurochemical impact on the brain
• Recommendations from CA State Task
Force on Prescription Drug Misuse
• Prevention strategies
• Medical treatments
• Behavioral treatments
• Coordinated care
• Interactive Exercises and Small Group Work
Prescription (Rx) Drug Misuse:
What’s the Problem?
What is Misuse?
• Misuse = “Non-medical use” or any use that
is outside of a medically prescribed regimen
• Examples can include:
–
–
–
–
–
Taking for psychoactive “high” effects
Taking in extreme doses
Mixing pills
Using with alcohol or other illicit substances
Obtaining from non-medical sources
Prescription Drugs are
Easy to Obtain
• Easily obtainable from family, friends, and
health care professionals (doctors, dentists,
pharmacists)
• Medicine cabinets are likely source
• Internet – online pharmacies
– Credit card number + access to computer
– No prescription necessary
– Inappropriate identify verification
• Unsafe storage and improper disposal
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Methods of Prescription Diversion:
Four Major Pathways
– Pharmaceuticals manufactured lawfully, but
stolen during distribution
– Medications obtained inappropriately from
legitimate end-users
– Fraudulent prescriptions written on stolen
prescribing pads
– “Doctor shopping” (e.g., a method where
individuals see several doctors in an attempt
to obtain multiple prescriptions without
revealing what they are doing).
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
The Prescription Drug Epidemic is
Unique in Some Ways
• Prescription drugs are not inherently bad
• When used appropriately, they are safe and
vitally needed
• Threat comes from misuse, abuse, and
diversion
• Just because prescription drugs are legal
and are prescribed by an MD, they are not
necessarily safer than illicit substances.
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Factors Fueling the Epidemic
• Increase in legitimate commercial production
and distribution of pharmaceuticals
• Increase in marketing to physicians and
public re: pain medications
• Physicians have become more willing to
prescribe medications, esp. for pain
management
• 150% increase in prescriptions written for
controlled drugs
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Slang Terms
•
•
•
•
•
•
•
•
•
Xbrs / Xanibars (Xanax)
Vic (Vicodin)
Skittles / Triple C’s
Trail Mix
Pharm Party
Parachuting
Smurf Snot (Adderall)
Smurf Coke (Adderall)
Others?
Twin Epidemics: Prescription Drug
Abuse and Unrelieved Pain
• 50 million Americans live with chronic pain
• An additional 25 million live with acute pain
• Mismanagement of pain has far reaching
societal consequences.
• In fighting illicit misuse, must not hinder
patients’ access to beneficial medical
treatments.
• Prescription drugs are potent and must be
monitored and managed appropriately (N.
Katz, Tufts University).
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Federal Drug Schedules
Federal Controlled Substances Act (CSA) of 1970
• Schedule I: No medical use, high abuse potential
(heroin)
• Schedule II: Accepted medical use, high abuse
potential (OxyContin, Ritalin)
• Schedule III: Accepted medical use, less abuse
potential than I or II (Vicodin)
• Schedule IV: Accepted medical use, less abuse
potential than I-III (Valium, Xanax)
• Schedule V: Accepted medical use, lowest abuse
potential (Robitussin AC)
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.
Commonly Misused Rx Drugs
Classified in 3 classes
– Opiates: pain-killers
• Ex) Vicodin, OxyContin, Tylenol
Codeine
– CNS Depressants
(Sedatives/Tranquilizers):
treat anxiety and sleep disorders
• Ex) Xanax, Ativan, Valium, Soma
– Stimulants: ADHD, weight loss
• Ex) Aderall, Ritalin, Concerta,
Dexedrine, Fastin
Media Attention
SPLENDID FOR
Wind, Colic, Griping in
the Bowels, Diarrhea
Cholera and Teething
Troubles
A Global Look at Prescription Drug
Abuse: World Drug Report, 2008
% of global population aged 15-64.
SOURCE: UNODC, World Drug Report 2008.
Drug Prevalence in the
United States
• Marijuana = most commonly abused illicit
drug
• Non-medical use of prescription drugs = 2nd
most commonly abused drug category
• Prescription drug abuse is 3x more prevalent
than illicit use of cocaine, crack, and
hallucinogens
SOURCE: CA ADP, PDM Summary Report, 2009.
Past Year Non-Medical
Psychotherapeutic Use: 2006-2007
14,000
5% of respondents
2006
2007
12,000
10,000
8,000
2%
6,000
4,000
1%
2,000
0.5%
0
Pain Relievers
Tranquilizers
Stimulants
Sedatives
SOURCE: SAMHSA, NSDUH, 2007 Results.
Percentage of US Population with
Past Month Drug Use
SOURCE: SAMHSA, NSDUH, 2008 Results.
Percentage of US Population with
Past Month Use of Pharmaceuticals
SOURCE: SAMHSA, NSDUH, 2008 Results.
Rx Drug Misuse in the U.S.
6.2 million aged 12+ used a
Rx drug (non-medically) in the past year
904,000
234,000
4.7 million
1.8 million
Pain Relievers
Tranquilizers
Stimulants
Sedatives
SOURCE: SAMHSA, NSDUH, 2008 Results.
Number of New Non-medical Users of
Therapeutics
SOURCE: SAMHSA, NSDUH.
Specific Drug Used When Initiating Drug
Use: NSDUH, 2008
SOURCE: SAMHSA, NSDUH, 2008 Results.
New Users of Psychotherapeutics
• 2.5 million persons aged 12 or older used
psychotherapeutics non-medically for the first time within
the past year
– 2.2 million for pain relievers
– 1.1 million for tranquilizers
– 599,000 for stimulants
– 181,000 for sedatives
• Average of ~7,000 initiates per day.
• 2008 estimate was significantly lower than in 2004
(2.8 million).
• In 2008, the average age at first nonmedical use of any
psychotherapeutics was 22.0 years
– 21.2 years for pain relievers, 24.4 years for
tranquilizers, 21.3 years for stimulants, and 21.6 years
for sedatives.
SOURCE: SAMHSA, NSDUH, 2008 Results.
Substance Use and Dependence:
NSDUH, 2008
SOURCE: SAMHSA, NSDUH, 2008 Results.
Treatment Admissions for Primary
Prescription Drug Abuse: U.S.
Opiates/Synthetics
Tranquilizers
Stimulants
Sedative/Hypnotics
6
5
4
3
2
1
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
SOURCE: SAMHSA, Treatment Episode Data Set, 2007 results.
Californians in Treatment
Drug of Abuse Reported at Admission
Alcohol
17.8%
Cocaine
10.6%
Heroin
11.9%
Marijuana
16.9%
Methamphetamine
39.2%
Other Drug
3.6%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
Percent
SOURCE: CA ADP, Fact Sheet: Californians in Treatment, FY 2006-07.
Californians in Treatment
Primary Drug by Gender at Admission
16.9%
18.3%
Alcohol
Female
Male
10.0%
11.0%
Cocaine
10.8%
12.5%
Heroin
12.9%
Marijuana
19.3%
44.8%
Methamphetamine
35.8%
4.5%
3.1%
Other Drug
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
Percent
SOURCE: CA ADP, Fact Sheet: Californians in Treatment, FY 2006-07.
Prescription Drug Misuse among
California Household Population
• California-specific data is consistent with
national pattern of age-related prescription
drug misuse
– 214,000 youth (aged 12-17)
– 456,000 young adults (aged 18-25)
– 812,000 adults (26 and older)
= nearly 1.5 million Californians!
SOURCE: SAMHSA, NSDUH, 2006 Results.
Los Angeles
• Sales sharply increased for oxycodone
(84%) and hydrocodone (47%) between
2001 and 2005.
• Codeine, hydrocodone, and morphine
were distributed in the largest amounts
when compared with the grams of other
opiates distributed.
SOURCE: Automation of Reports and Consolidated Orders System (ARCOS),
http://www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html
Prescription Drug-Related
Emergency Department Visits
• Out of 113 million ED visits in 2006:
• 1.7 million (1.5%) associated with drug
misuse or abuse
• 741,125 (42.5%) involved non-medical use
of Rx/OTC drugs or dietary supplements
• Narcotic pain relievers = #1 (201,280)
• Benzodiazepines = 2nd (195,625)
• Majority involved multiple drugs
• 36% increase in benzodiazepines and 39%
increase in narcotic analgesics from 2004-06
SOURCE: SAMHSA, Drug Abuse Warning Network, 2006 Results.
Poisoning Deaths Involving
Opioid Analgesics
Rates per 100,000 Population
7
6
5
4
Total
Female
Male
3
2
1
0
1999
2000
2001
2002
2003
2004
2005
NCHS Data Brief ■ No. 22 ■ September 2009
2006
Poisoning Deaths Involving
Opioid Analgesics
NCHS Data Brief ■ No. 22 ■ September 2009
Prescription Drug Use
Among Teens
Continuing Brain Development
Early in development, synapses are rapidly created and
then pruned back. Children’s brains have twice as many
synapses as the brains of adults.
Shore, 1997
Brain Development
Ages 5-20 years
 MRI scans of healthy children and teens compressing
15 years of brain development (ages 5–20).
 Red indicates more gray matter, blue less gray matter.
 Neural connections are pruned back-to-front.
 The prefrontal cortex ("executive" functions), is last to mature.
Information taken from NIDA’s Science of Addiction
http://www.drugabuse.gov/ScienceofAddiction/
Source: Paul Thompson, Ph.D.
UCLA Laboratory of Neuroimaging
The interaction between the
developing nervous system and drugs
of abuse leads to:
 Difficulty in decision making
 Difficulty understanding the consequences of
behavior
 Increased vulnerability to memory and attention
problems
This can lead to:
 Increased experimentation
 Opioid (and other substance) addiction
Feillin, 2009
Young Brains Are Different
from Older Brains
 Alcohol and drugs affect the brains of
adolescents and young adults differently than
they do adult brains
– Adolescent rats are more sensitive to the
memory and learning problems than adults*
– Conversely, they are less susceptible to
intoxication (motor impairment and
sedation) from alcohol*
 These factors may lead to higher rates of
dependence in these groups
*Hiller-Sturmhöfel., and Swartzwelder (NIAAA Publication 213)
Prescription Drug Abuse among
U.S. High School Seniors
• More than 12% of high school seniors said they
had used opioid-based prescription drugs for
non-medical purposes at least once in their
lifetime.
• Eight percent did so within the past year.
• Reasons for use included: to relax, relieve
tension, get high, experiment, relieve pain, or
have a good time with their friends.
• Those who used the drugs for reasons other
than pain relief were more likely to use other
addictive drugs and have signs of addictive
disorders.
SOURCE: Join Together Online, August 6, 2009; NIDA, MTF Survey, 2008.
New Landscape of Drug Abuse among Teens
Marijuana
8.6 million
4.5 million
Prescription Medicine
Cough Medicine
Crack/Cocaine
Ecstasy
Meth
LSD
Heroin
2.4 million
2.4 million
1.9 million
1.9 million
1.3 million
1.1 million
Ketamine
1 million
GHB
1 million
SOURCE: SAMHSA, NSDUH, 2006 Results.
Age Distribution of Prescription
Drug Misuse in the Past Year
SOURCE: SAMHSA, NSDUH, 2006 Results.
Generation 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. High
percentages of these also use other substances.
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”
SOURCE: PDFA, Participant Attitude Tracking Study, 2005.
Percentage
Source of Prescription Medicines
Misused in the Past Year Among Youth
(Ages 12-17), 2005-2006
SOURCE: SAMHSA, NSDUH, 2005-2006.
Over-the-Counter Drug Misuse
among Young Adults
• 3.1 million 12-25 year olds reported lifetime use of
OTC cough and cold medications to get high
• 1 million reported past year use
• Even gender distribution
• Female 12-17 year olds more likely to misuse OTC
drugs than male counterparts
• 82% of lifetime OTC drug users also reported
lifetime use of marijuana
• Lower rates of lifetime use of hallucinogens,
ecstasy, or inhalants
SOURCE: CA ADP, Rx Drug Summary Report, 2009.
Summary of 2007 CSS Results
• Prescription pain killers 2nd to marijuana in
11th grade and 3rd in 9th grade, just after
inhalants.
• All non-marijuana drugs exceeded by
recreational use of cold/cough medicine (“to
get high”), and equal to marijuana in 9th
grade.
• Previous levels of substance use
underestimated by under-assessing
“medicinal” drugs.
SOURCE: WestEd, California Student Survey, 12th Biennial Survey (2007-08).
Lifetime Prevalence
Street Drugs
Prescriptions
SOURCE: WestEd, California Student Survey, 12th Biennial Survey (2007-08).
Aggregated Lifetime
Categories of Drug Use
W/ Prescription
Alcohol
Marijuana
Prescription Drugs
OTC Cold/Cough Medicines
Prescription/OTC
Any Drug Except Marijuana
Total Drugs
Total AOD Use
W/ OTC
9 th
11 th
9 th
11 th
9 th
11 th
(%)
(%)
(%)
(%)
(%)
(%)
47
25
18
26
31
21
31
52
66
42
23
25
35
28
46
69
29
37
54
36
50
70
39
45
60
45
57
74
SOURCE: WestEd, California Student Survey, 12th Biennial Survey (2007-08).
Illicit and Prescription Drug Use among
So Cal Undergraduate Students
50
45
40
35
30
25
20
15
10
5
0
Marijuana
General
Ritalin/Adderall
18-24 year old
Soma/MR
Cocaine
Campus Residents
Ecstasy
Fraternity/Sorority
SOURCE: Lange, 2007, unpublished study.
Prescription Drug Use
Among Older Adults
Potential Issues for Older Adults
• Prescription drug abuse begins with misuse due
to inappropriate prescribing or lack of
compliance
• Age-related physiological changes (metabolism
and response)
• Greater likelihood of undiagnosed psychiatric
and medical comorbidities
• Difficulties with complying with complex drug
regimens
• Drug interactions
SOURCE: CA ADP, Rx Drug Summary Report, 2009.
Rx Drug Abuse among Older Adults
• Older Adults account for 13% of US population
but use 1/3 of all medications prescribed.
• 7.2 million (21.7%) receive at least 1 Rx annually.
• Older adults use Rx drugs 3 times more than the general
population.
• On average, older persons take 4.5 medications per day.
• Nationally, 9.2 million (4.9%) of older adults abused Rx
drugs in the last year while in California, 812,000 (3.7%).
SOURCES: SAMHSA, 2006; NIDA, 2005
Extent of the Problem:
Medical Exposure
• General US population1
– Women = 20.0%
– Men = 12.5%
• Among elders aged 65 and older, 21.7%, or
7.22M, receive at least 1 abusable Rx
annually2
– Women = 24.6%
– Men = 17.7%
SOURCE: Simoni-Wastilla et al., Sub Use and Misuse, 2004; Simoni-Wastilla et al., 2004.
Medical Exposure to Abusable Rx Drugs
by Gender and Age
30
28.3
27.3
24.8
25
20
15
18.6
20.1
20.4
70-74
75-79
19.4
12
10
5
0
65-69
Male
80+
Female
SOURCE: Simoni-Wastilla et al., 2004.
Types of Drugs Used
by Past Month Illicit Drug Users:
Age 50+, 2002-2003 Annual Averages
Other
14%
Prescription
Drugs Only
33%
Marijuana
Only
6%
47%
Only Marijuana
& Prescription
Drugs
1.4 Million Illicit Drug Users (1.8%)
SOURCE: SAMHSA, NSDUH, 2002-03.
Side Effects can be Lethal if…
•
•
•
•
Combining Rx & OTC medications.
Taking Rx and OTC meds with alcohol.
Using Rx and OTC with other illicit drugs.
Interactions: Rx & OTC meds with other
physical medications (i.e., HIV or Hepatitis)
Gallery Walk: Attitudes and
Beliefs regarding Prescription
Drug Abuse
Prescription Drug Abuse:
What are we talking about?
What are Psychoactive Drugs?
“…Any chemical substance which, when taken into
the body, alters its function physically and/or
psychologically....”
(World Health Organization, 1989)
“…any substance people consider to be a drug, with
the understanding that this will change from culture
to culture and from time to time.”
(Krivanek, 1982)
What are Psychoactive Drugs?
Psychoactive drugs interact with the central
nervous system (CNS) affecting:
• mental processes and behavior
• perceptions of reality
• level of alertness, response time, and
perception of the world
Important Terminology
1. Psychological craving
2. Tolerance
3. Withdrawal symptoms
Psychological Craving
Psychological craving is a strong desire or urge
to use drugs. Cravings are most apparent
during drug withdrawal.
Tolerance
Tolerance is a state in which a person no
longer responds to a drug as they did
before, and a higher dose is required to
achieve the same effect.
Withdrawal
The following symptoms may occur when drug use is
reduced or discontinued:
• Tremors, chills
• Cramps
• Emotional problems
• Cognitive and attention deficits
• Hallucinations
• Convulsions
• Death
Overview
• Three classes of commonly abused Rx drugs
(opioids, sedatives, stimulants)
– What are they?
– How do they act in the brain and body?
– What are their effects?
– Neurobiology
What are opioids?
• Opiate: derivative of opium poppy
– Morphine
– Codeine
• Opioid: any compound that binds to opiate
receptors
– Semisynthetic (including heroin)
– Synthetic
– Oral, transdermal and intravenous formulations
• Narcotic: legal designation
Opioids
Opioids: Acute Effects
– Euphoria
– Pain relief
– Suppresses cough reflex
– Histamine release
– Warm flushing of the skin
– Dry mouth
– Drowsiness and lethargy
– Sense of well-being
– Depression of the central nervous system
(mental functioning clouded)
Long-Term Effects of Opioids
 Fatal overdose
 Collapsed veins
 Infectious diseases
 Higher risk of HIV/AIDS and hepatitis
 Infection of the heart lining and valves
 Pulmonary complications & pneumonia
 Respiratory problems
 Abscesses
 Liver disease
 Low birth weight and developmental delay
 Spontaneous abortion
 Cellulitis
Opioid Receptors
• Receptor types
– mu, delta, kappa
• Receptors located throughout body
– Pain relief: central and peripheral
nervous system
– Reward and reinforcement: deep brain
structures
– Side effects: constipation, sedation, itch,
mental status changes
SOURCE: National Institute on Drug Abuse, www.nida.nih.gov.
Endogenous Opioids
• Produced naturally in body
• Act on opioid receptors
• Examples: endorphins, enkephalins,
dynorphins, endomorphins
• Produce euphoria and pain relief; naturally
increased when one feels pain or
experiences pleasure
Pain: The Fifth Vital Sign
• JACHO Guidelines 2000:
– Mandated pain assessment and treatment
– Nurse and physician education required
• When opioids prescribed properly for pain,
addiction rare in patients without underlying
risk factors
– Vulnerabilities same as for other addictions:
genetic, peer and social influences, trauma and
abuse history
Pain Control and Addiction
• “Pseudoaddiction”:
– Presence of drug-seeking behavior in context
of inadequate pain control
– Behavior stops with adequate pain relief
– Description of a clinical interaction (not a true
diagnosis)
• Physical dependence
– with continued use, withdrawal syndrome
produced by rapid dose reduction; occurs via
neuroadaptation
• Not synonymous with addiction
Opioid Withdrawal
•
•
•
•
•
•
•
•
•
•
•
Dysphoric mood
Nausea or vomiting
Diarrhea
Tearing or runny nose
Dilated pupils
Muscle aches
Goosebumps
Sweating
Yawning
Fever
Insomnia
Morphine
• Routes: oral, intramuscular, intravenous, rectal
• Sustained release preparations:
– MS Contin®
– Oramorph®
– Kadian®
– Avinza®
Codeine
•
•
•
•
Opiate (naturally occurring in poppy)
Low potency
Pain relief via 10% conversion to morphine
Most commonly prescribed opioid in the
world
• Probably the most widely used analgesic
– (Excluding aspirin)
Semisynthetic Opioids
• Hydrocodone with Tylenol:
–
–
–
–
•
•
•
•
•
Norco®
Lortab®
Vicodin®
Lorcet®
Hydrocodone with ibuprofen: Vicoprofen®
Hydromorphone: Dilaudid®
Oxycodone with Tylenol: Percocet®
Oxycodone with aspirin: Percodan®
OxyContin®
OxyContin
• Used to treat pain associated with arthritis, lower
back injuries, and cancer
• Most commonly in tablet form: 10mg, 20mg, 40mg,
60mg, and 80mg tablets
• Dosed every 12 hours, half-life 4.5 hours
• Abuse: may be chewed, crushed, snorted or
injected
– Eliminates time-release coating
– Enhances euphoria, “rush”
– Increases risk for serious medical consequences
Synthetic Opioids
•
•
•
•
•
Methadone
Demerol® (meperidine)
Fentanyl®
Suboxone® /Subutex® (buprenorphine)
Tramadol®
– Complex mechanism of action
– Nonscheduled, less abuse potential
Opiates and Reward
Opiates bind to opiate receptors in the nucleus
accumbens: increased dopamine release
Sedative-Hypnotics
• Used to treat anxiety and sleep disorders
• Mechanism: enhances GABA
– acts to slow normal brain function
• Barbiturates
– Phenobarbital®
– Pentobarbital®
– Fioricet® (butalbital/acetaminophen/caffeine)
Sedative-Hypnotics Cont’d
• Benzodiazepines
–
–
–
–
–
–
Librium® (chlordiazepoxide HCL)
Valium® (diazepam)
Restoril® (tempazepam)
Klonopin® (clonazepam)
Ativan® (lorazepam)
Xanax® (alprazolam)
• Non-benzo hypnotics
– Ambien® (zolpidem)
– Sonata® (zaleplon)
– Lunesta® (eszopiclone)
• Soma® (carisoprodol)
• Cross-tolerance with alcohol (GABA related)
Sedative-Hypnotic Effects
•
•
•
•
•
•
•
Sedation
Slurred speech
Incoordination
Unsteady gait
Impaired attention or memory
Stupor or coma
Overdose risk increased with opioids or in
combination with other sedatives, including
alcohol
Sedating Drugs and Overdose
Other Sedative-Hypnotic Risks
• No significant adverse medical
consequences of long-term use
• Amnesia
– Difficulty with recent memory
• Tolerance, physiological dependence,
addiction
– Addiction risk factors same as for other drugs of
abuse
Sedative-Hypnotic Withdrawal
•
•
•
•
•
•
•
Increased pulse, blood pressure, or sweating
Hand tremor
Nausea or vomiting
Transient hallucinations or illusions
Agitation
Anxiety
Seizures
Protracted Withdrawal
• Abstinence syndrome
– Anxiety
– Muscle twitching
– Low mood
– Sweating
– Headache
– Derealization
• Rebound insomnia
– Especially with short-acting benzodiazepines
Sedative-Hypnotic
Neurobiology
SOURCE: www.ccforum.com
Prescription Stimulants
• Stimulants (i.e., amphetamines) are often
prescribed to treat individuals diagnosed
with attention-deficit hyperactivity disorder
(ADHD).
• Substantial amounts of pharmaceutical
amphetamines are diverted from medical
use to non-prescription use.
• Amphetamines increase wakefulness and
alertness and have been used by:
– The military, by pilots, truck drivers, and other
workers to keep functioning past their normal
limits
SOURCE: Erowid.org
Short-Term Effects
•
•
•
•
•
•
Euphoria
Increased energy/productivity
Increased concentration
Decreased appetite
Increased libido
Decreased sleep
Medical Risks
• Norepinephrine release causes constriction
of blood vessels, elevated blood pressure
and rapid heart rate
• Increased activity levels
• Dangerously high body temperatures
• Increased risk of seizures
• Potentially fatal arrhythmias, heart attack, or
stroke
Psychiatric Symptoms
• Psychiatric symptoms associated with use of
larger doses of amphetamines include
depression, anxiety, psychosis, and suicidal
ideation
• Symptoms may depend on differences in
sensitivity, frequency and quantity of use, and
method of administration
• Abstinence syndrome may occur (dysphoria,
anhedonia, irritability, insomnia/hypersomnia,
anxiety, low energy)
Stimulants: Withdrawal
Symptoms
– Dysphoric mood (sadness, anhedonia)
– Fatigue
– Insomnia or hypersomnia
– Psychomotor agitation or retardation
– Craving
– Increased appetite
– Vivid, unpleasant dreams
Long-Term Effects of Stimulants
 Strokes, seizures, headaches
 Depression, anxiety, irritability, anger
 Memory loss, confusion, attention problems
 Insomnia, hypersomnia, fatigue
 Paranoia, hallucinations, panic reactions
 Suicidal ideation
 Nosebleeds, chronic runny nose,
hoarseness, sinus infection
 Dry mouth, burned lips, worn teeth
 Chest pain, cough, respiratory failure
 Disturbances in heart rhythm and heart
attack
 Loss of libido
 Weight loss, anorexia, malnourishment,
 Skin problems
Ritalin
• When used to treat ADHD, patients may
report increased attention, decreased
impulsivity, and decreased hyperactivity.
• Milder stimulant that works by affecting the
levels of chemicals (neurotransmitters) in
the nervous system.
• May also be used in the treatment of
depression in certain cases
• Long-acting form: Concerta®
SOURCE: WebMD
Adderall
• Adderall® is used to treat attention deficit
hyperactivity disorder (ADHD).
• Adderall® is a combination of stimulants
(amphetamine and dextroamphetamine).
• It increases the ability to pay attention,
focus, and control behavior problems.
• This drug may also be used to treat certain
sleeping disorders (narcolepsy).
Neurobiology of Stimulants
Over-the-Counter Drugs
• Available without a doctor’s prescription
• Increasingly used among adolescents and young adults
– Cough and cold medications containing
Dextromethorphan (DXM)
• Coricidin®, Robitussin®, Nyquil®
– Sleep aids
• Unisom®
– Antihistimines
• Benadryl ®
– Anti-nausea agents
• Gravol®, Dramamine®
Dextromethorphan
• Over-the-counter cough suppressant
• Structurally related to morphine
• Mechanism: NMDA antagonist
• Dissociative psychedelic properties in excess
doses (like ketamine, PCP)
Efforts in California
• Establishment of statewide Rx Drug
Task force charged with:
– Monitoring trends and strategies at the state
and local levels.
– Developing prevention strategies for Rx &
OTC drug abuse.
– Developing intervention strategies for Rx &
OTC drug abuse in treatment settings.
SOURCE: http://www.adp.ca.gov/Director/pdf/Prescription_Drug_Task_Force.pdf
Task Force Recommendations
• Five categories:
– Lack of awareness (#1-6)
– Training and education (#7-12)
– Availability (#13-14)
– Tracking information on prescription drug use (#15)
– Policies for identifying and treating prescription drug
use (#16-18)
Lack of Awareness
1. Educate family members on signs,
symptoms of abuse, and potential services
for assistance
2. Education middle and high school
students on potential harm associated with
Rx drug/OTC misuse, poly drug use
3. Educate college students on dangers and
potential harms and how to use
medications responsibly
Lack of Awareness, continued
4. Increase public awareness on the proper
use and disposal of prescription drugs
5. Engage veteran community in
understanding risks, proper pain
medication, and access to treatment
6. Increase physician and medical
providers’ awareness on accessing and
using prescription drug monitoring program
to minimize doctor shopping
Training and Education
7. Adequate screening tools (public
health/education)
8. Brief interventions and proper treatment referrals
9. Empirically-based treatment and prevention
models; nature of specific types of Rx drugs;
effects; medical withdrawal risks/protocols
10. Medical withdrawal risks and effective
pharmacotherapies
11. Recognition of Rx drug abuse
12. Adequate screening tools (student health/
counseling centers)
Availability
13. Strengthen CURES (increasing automation
and reporting capabilities)
14. Explore enforcement options (industry
marketing and advertising practices)
Tracking Information on
Prescription Drug Use
15. Implement a comprehensive system to
monitor nonmedical prescription drug use
and its consequences in CA
Policies for Identifying and
Treating Prescription Drug Use
16. Enact emergency regulations to allow MediCal reimbursement for Suboxone
17. Allow Medi-Cal reimbursements for SBIRT
(CPT codes 99408 and 99409)
18. Support ongoing work of Senate Bill 966
examining appropriate and environmentally
friendly return of unused and expired
prescription drugs
Have a good lunch!
Preventing Prescription
Drug Abuse
Existing Campaigns
–
–
–
–
–
–
–
Above the Influence, Nat’l Youth Anti-Drug Media
Campaign, Parents – the Anti-Drug (ONDCP)
SAMHSA’s Prevent Prescription Drug Abuse
The Buzz Takes Your Breath Away Permanently
(FDA)
A Family Guide to Keeping Youth Mentally Healthy
and Drug Free (SAMHSA)
Community Prevention Initiative
• Prevention Tactics
• My Prevention Community – free social utility
network
Partnership for a Drug-Free America
Local Campaigns?
Social Norms Theory
•
•
•
Individual behavior is influenced by perceptions of
what other people accept and expect, and how
they behave.
Individual perceptions of what others accept,
expect and do with respect to substance use and
other potentially harmful behaviors are often
inaccurate.
Correcting these misperceptions will strengthen
individual feelings that their desire to resist
negative behaviors is in fact normal.
SOURCE: Prevention Tactics, 8:9 (2005).
Three Types of Misperceptions
•
•
•
Pluralistic Ignorance: majority of individuals
falsely assume that most of their peers
behave or think differently when in fact they
are similar.
False consensus: incorrect belief that
others are like oneself when they are not.
False uniqueness: individuals exaggerate
the difference between their own behavior
and the behavior of others.
SOURCE: Prevention Tactics, 8:9 (2005).
Prevention Interventions
•
•
•
Universal intervention: directed at all
members of a population.
Selective intervention: directed at an at-risk
group in which members experience risk
factors or circumstances that put them at
risk.
Indicated intervention: directed at
individuals who already are experiencing
alcohol or drug use problems.
SOURCE: Prevention Tactics, 8:9 (2005).
Key Roles in Preventing
Prescription Drug Abuse
• Physicians and Other Health Care Providers
– Screen appropriately
– Help patients recognize potential problems
– Note changes in increases in amount of
medication needed or unscheduled refill
requests
– Be aware of “doctor shopping”
SOURCE: NIDA Research Report Series, 2005.
Assessing Potential Prescription
Drug Abuse: Four Simple Questions
• Have you ever felt the need to cut down on
your use of prescription drugs?
• Have you ever felt annoyed by remarks
your friends or loved ones made about your
use of prescription drugs?
• Have you ever felt guilty or remorseful
about your use of prescription drugs?
• Have you ever used prescription drugs as a
way to "get going" or to "calm down?"
SOURCE: About.com, 2009.
Key Roles in Preventing
Prescription Drug Abuse
• Pharmacists
– Information on appropriate use of medication
– Side effects and interactions
– Monitor prescriptions for falsification or
alterations
– Be aware of “doctor shopping”
SOURCE: NIDA Research Report Series, 2005.
Key Roles in Preventing
Prescription Drug Abuse
• Patients
– Follow prescribed directions
– Be aware of drug interactions
– Discuss dosing changes or cessation of use with
prescribing physician
– Disclose use of all medications and dietary
supplements
SOURCE: NIDA Research Report Series, 2005.
Developing Strategies to
Prevent Prescription/
OTC Drug Abuse
In Small Groups…
• What campaigns are in existence in your
community?
• How can you help to implement the Task
Force’s recommendations?
Task Force Recommendations
• Five categories:
– Lack of awareness (#1-6)
– Training and education (#7-12)
– Availability (#13-14)
– Tracking information on prescription drug use (#15)
– Policies for identifying and treating prescription drug
use (#16-18)
Medication-Assisted Treatment Myths
Myth #1: Medications are not a part of treatment.
 The pharmacotherapies that are FDA-approved for
treatment of addiction should be used in conjunction
with psycho-social-educational-spiritual therapy.
Therefore, medications can be used as a part of
treatment, but only one part.
 Medications are used in the treatment of many
diseases, including addiction.
 Making the final decision about whether or not
medications are a part of a client’s treatment is out
of the counselor’s scope of practice.
Medication-Assisted Treatment Myths
Myth #2: Medications are drugs, and you cannot
be clean if you are taking anything.

The field needs to change terminology to reflect current trends.
“Drugs” are illicit psychoactive substances that are used to achieve a
“high.” “Medications” are available by prescription and are used to
treat an illness, disorder or disease.

Millions of Americans use medications (e.g., Zyban, nicotine patches)
to quit smoking, and this practice is widely encouraged by addiction
professionals.


Physical dependence and addiction are not the same thing.
The goal of addiction treatment is to assist a client in stopping his or
her compulsive use of drugs or alcohol and love a normal, functional
life.
Medication-Assisted Treatment Myths
Myth #2: Medications are drugs, and you cannot
be clean if you are taking anything.
 If appropriately administered, medication-assisted
treatment for addiction will not produce euphoric
effects.
 Pharmacotherapies are effective.
Clinical data
suggest that clients perform better in treatment when
psycho-social-educational-spiritual therapy is
combined with appropriate pharmacotherapies.
Medication-Assisted Treatment Myths
Myth #3: Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) does not support the
use of medications.
 Neither Alcoholics Anonymous (AA)/Narcotics
Anonymous (NA) literature nor its founding members
spoke or wrote against using medications.
 Even today, AA/NA does not endorse encouraging
AA/NA participants to not use prescribed medications
or to discontinue taking prescribed medications for the
treatment of addiction.
Medication-Assisted Treatment Myths
Myth #3: Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) does not support the
use of medications.
• The Big Book states, “God has abundantly supplied
this world with fine doctors, psychologists, and
practitioners of various kinds. Do not hesitated to take
your health problems to such persons. Most of them
give freely of themselves, that their fellows may enjoy
sound minds and bodies. Try to remember that though
God has wrought miracles among us, we should never
belittle a good doctor or psychiatrist. Their services
are often indispensable in treating a newcomer and in
following his case afterward.” (Chapter 9, Emphasis added)
Stages of Change Model
The Stages of Change Model identifies five
independent stages of behavior and thinking that
patients experience when making changes.
By identifying which stage of change a patient is
currently in, addiction professionals can better
determine treatment options are most appropriate.
Behavioral Interventions
Without question, medication interventions
have been extremely effective and
beneficial to the patient in early, as well
as long-term recovery.
However, it is imperative that
pharmacotherapies are paired with some
form of evidence-based behavioral
therapeutic intervention.
Behavioral Interventions
Psychosocial therapy interventions that have been
thoroughly researched and have shown good efficacy
include:
 Cognitive Behavioral Therapy (CBT)
 Motivational Interviewing (MI)
 Motivational Incentives/Contingency Management
 Screening, Brief Intervention & Referral to Treatment
The Addiction Technology Transfer Centers (ATTC) have
developed helpful resources for evidence-based
practices: www.nattc.org/resPubs/bpat/index.html .
Cognitive Behavioral
Therapy (CBT)
What is CBT and how is it used in
addiction treatment?
•
CBT is a form of “talk therapy” that is used to teach,
encourage, and support individuals about how to
reduce / stop their harmful drug use.
•
CBT provides skills that are valuable in assisting
people in gaining initial abstinence from drugs (or in
reducing their drug use).
•
CBT also provides skills to help people sustain
abstinence (relapse prevention)
What is relapse prevention (RP)?
Broadly conceived, RP is a cognitive-behavioural treatment
(CBT) with a focus on the maintenance stage of addictive
behaviour change that has two main goals:
– To prevent the occurrence of initial lapses after a
commitment to change has been made and
– To prevent any lapse that does occur from escalating
into a full-blow relapse
Because of the common elements of RP and CBT, we will
refer to all of the material in this training module as CBT
Why is CBT useful? (1)
•
CBT is a counseling-teaching approach wellsuited to the resource capabilities of most
clinical programs
•
CBT has been extensively evaluated in
rigorous clinical trials and has solid empirical
support
•
CBT is structured, goal-oriented, and
focused on the immediate problems faced by
substance abusers entering treatment who
are struggling to control their use
Why is CBT useful? (2)
•
CBT is a flexible, individualized approach that can
be adapted to a wide range of clients as well as a
variety of settings (inpatient, outpatient) and
formats (group, individual)
•
CBT is compatible with a range of other
treatments the client may receive, such as
pharmacotherapy
Important concepts in CBT (1)
In the early stages of CBT treatment, strategies
stress behavioural change. Strategies include:
•
planning time to engage in non-drug related
behaviour
•
avoiding or leaving a drug-use situation.
Important concepts in CBT (2)
CBT attempts to help clients:
– Follow a planned schedule of low-risk activities
– Recognise drug use (high-risk) situations and avoid
these situations
– Cope more effectively with a range of problems and
problematic behaviours associated with using
Important concepts in CBT (3)
As CBT treatment continues into later phases
of recovery, more emphasis is given to the
“cognitive” part of CBT. This includes:
– Teaching clients knowledge about addiction
– Teaching clients about conditioning, triggers, and
craving
– Teaching clients cognitive skills (“thought
stopping” and “urge surfing”)
– Focusing on relapse prevention
Motivational
Interviewing
What is Motivational
Interviewing?
It is:
A style of talking with people constructively
about reducing their health risks and
changing their behavior.
What is Motivational
Interviewing?
It is designed to:
Enhance the client’s own motivation to
change using strategies that are empathic
and non-confrontational.
What is Motivational
Interviewing?
It can be defined as:
A patient-centered directive method for
enhancing intrinsic motivation to change by
exploring and resolving ambivalence.
How does MI differ from
traditional counseling?
1. Patient and practitioner are equal partners in
relationship (collaborative effort between two
experts)
How does MI differ from traditional or
typical medical counseling?
• People are almost always ambivalent about
change – ambivalence is normal
• Lack of motivation
can be viewed as
unresolved
ambivalence.
How does MI differ from traditional or
typical medical counseling?
• AMBIVALENCE is the key issue to be
resolved for change to occur.
• People are more likely to change when they
hear their own discussion of their ambivalence.
• This discussion is called “change talk”
in MI.
• Getting patients to engage in “change talk” is a
critical element of the MI process.
*Glovsky and Rose, 2008
How can MI be helpful for us in working
with our consumers/patients?
• The successful MI therapist is able to inspire
people to want to change
• Use of MI can help engage and retain
consumers in treatment
• Using MI can help increase participation and
involvement in treatment (thereby improving
outcomes)
Contingency Management
What is Contingency
Management
• Consequences impact people’s behavior
• People often behave in the way they do to:
– 1.gain something positive (e.g., financial
benefits, recognition) and
– 2.avoid something negative (e.g., fines,
interpersonal conflict)
• A contingency is the specific relationship
between a behavior and its consequences
What is Contingency
Management
• The contingency between the behavior and
the receipt of the reward is what changes the
behavior, not the delivery of the reward alone
• Using reinforcers to modify behavior has the
most impact if the reward is given
contingently, which means rewards should
be given as soon as possible after the
behavior occurs to increase the probability
that the behavior will occur again
Why does Contingency
Management Work?
• A desirable activity or behavior is more
likely to reoccur if it is followed by some
kind of positive reinforcement
• The probability of a behavior occurring
again increases if reinforcers are given
right after the behavior occurs
• Positive reinforcements or rewards are
more effective than punishment in
changing behavior
• Contingency management can be used in
a variety of settings
Disadvantages of Punishments
• Punishments do not teach people what to do,
they teach people what not to do
• Contingent punishments will stop behavior in
specific contexts, but will not promote new
behavior or generalize to other behaviors or
settings
• Punishment sets a negative tone, implying
failure
Rewards
• In contrast to punishment, rewards can teach
new behaviors and promote growth
• Can be used to teach a person what to do
• Behaviors can generalize across settings
and situations
• Rewards encourage positive expectations
and emphasize accomplishments
• A plan that rewards good behavior may be
easier to establish than punishing
inappropriate behavior
Reinforcing each small step
toward success
• A better outcome can be achieved if you
reinforce all of the steps along the way
rather than simply rewarding the final goal
• Celebrate each attendance at a meeting or
each drug free test result
• Material goods such as movie passes or
food vouchers help to initiate and maintain
positive changes
Steps to designing a contingency
management intervention
1. Pick a behavior you want to change
2. Pick a reinforcer
3. Design a monitoring and reinforcing
schedule Decide upon a time frame for reassessment
4. Ensure that reinforcer is frequent and
immediate
5. Ensure consistent application of procedure
Screening, Brief Intervention
and Referral to Treatment
(SBIRT)
What is SBIRT?
SBIRT is a comprehensive, integrated, public
health approach to the delivery of early
intervention and treatment services
• For persons with substance use disorders
• Those who are at risk of developing these
disorders
Primary care centers, trauma centers, and other
community settings provide opportunities for
early intervention with at-risk substance users
Before more severe consequences occur
SBIRT: Core Clinical
Components
• Screening: Very brief screening that identifies
substance related problems
• Brief Intervention: Raises awareness of risks
and motivates client toward acknowledgement of
problem
• Brief Treatment: Cognitive behavioral work with
clients who acknowledge risks and are seeking
help
• Referral: Referral of those with more serious
addictions
Benefits of screening
• Provides opportunity for education, early
intervention
• Alerts provider to risks for interactions with
medications or other aspects of treatment
• Offers opportunity to engage patient further
• Has proved beneficial in reducing high-risk
activities for people who are not dependent
(Source: NCETA, 2004)
Characteristics of a good
screening tool
– Brief (10 or fewer questions)
– Flexible
– Easy to administer, easy for patient
– Addresses alcohol & other drugs
– Indicates need for further assessment or
intervention
– Has good sensitivity and specificity
Fitting
Pharmacotherapies
into Treatment
Four Legs of Addiction
Think of this concept as a chair, with each leg
representing a component of a patient’s treatment plan.
Psychological
Biological
Spiritual
Social
All four legs are required to “support” the patient, and if
one leg is missing, the chair will be unstable and unable
to accomplish its goal.
Holistic Treatment
The treatment plan must also address the
multiple needs of the individual:
 sexual orientation

disabilities
 gender differences

employment issues
 homelessness

developmental needs
 family dynamics

co-occurring disorders
 children/prenatal care
 cultural, racial, religious norms
 legal issues
Medical Treatments for
Opioid Addiction
Partial vs. Full Opioid Agonist
death
Opiate
Effect
Full Agonist
(e.g., methadone)
Partial Agonist
(e.g. buprenorphine)
Antagonist
(e.g. Naloxone)
Dose of Opiate
A Brief History of
Opioid Treatment
A Brief History of
Opioid Treatment
• Neolithic era (9000 B.C.E. to 3000 B.C.E.)
Opium cultivated for food, anesthesia, and
ritual purposes
• 15th Century: Recreational use of opium
reported, but use was limited by its rarity and
expense
• 1874: Heroin was first synthesized
A Brief History of
Opioid Treatment
• 1964: Methadone is approved.
• 1974: Narcotic Treatment Act limits
methadone treatment to specifically licensed
Opioid Treatment Programs (OTPs).
• 1984: Naltrexone is approved, but has
continued to be rarely used (approved in 1994
for alcohol addiction).
• 1993: LAAM is approved (for non-pregnant
patients only), but is underutilized.
A Brief History of Opioid
Treatment, Continued
• 2000: Drug Addiction Treatment Act of 2000
(DATA 2000) expands the clinical context of
medication-assisted opioid treatment.
• 2002: Tablet formulations of buprenorphine
(Subutex®) and buprenorphine/naloxone
(Suboxone®) were approved by the Food and
Drug Administration (FDA).
• 2004: Sale and distribution of ORLAAM® is
discontinued.
Medications to Treat Addiction
• Addiction is a chronic, relapsing brain
disease characterized by compulsive use
despite harmful consequences
• Medications as part of comprehensive
treatment plan
• Treatment approaches:
– Medications (Bio)
– Therapy, lifestyle changes (Psycho-Social)
• Thorough evaluation and diagnosis essential
Pharmacotherapy in Substance
Use Disorders
• Treatment of withdrawal (“detox”)
• Treatment of psychiatric symptoms or cooccurring disorders
• Reduction of cravings and urges
• Substitution therapy
Naltrexone General Facts

Generic Name:
naltrexone hydrochloride

Marketed As:
ReVia and Depade

Purpose:
To discourage opioid use by reducing or eliminating the
euphoric effects experienced by consuming exogenous
administered opioids.

Indication:
In the treatment of alcohol dependence and for the
blockade of the effects of exogenous administered
opioids.
 Year of FDA-Approval: 1984
Naltrexone Administration
Amount: one 50mg tablet
Method: mouth
Frequency: once a day
Can be crushed, diluted or mixed with food.
Abstinence requirements: must be taken at least 710 days after last consumption of opioids;
abstinence from alcohol is not required;
Appropriate Populations
Age Range:
 18 to 65 years old
Adolescents:
 Has not been tested or FDA-approved.
Elderly:
 Has not been tested or FDA-approved.
Pregnancy:
 Has not been adequately tested on pregnant or nursing
women; Pregnancy Category C designation, used only if
the potential benefit justifies the potential risk to the fetus.
Polysubstance Abusers:
 Has not been adequately tested with this population.
Additional Information
Addictive Properties:
 Has not been found to be addictive or produce withdrawal
symptoms when the medication is ceased.
 Administering naltrexone will invoke opioid withdrawal
symptoms in patients who are physically dependent on
opioids.
Cost:
 $110.68 per month, which is around $3.69 a day.69
Third-Party Payer Acceptance:
 Covered by most major insurance carriers, Medicare,
Medicaid, and the VA.68
How Does Naltrexone Work?
1. Opioids enter the system and activate the areas of
the brain known as the ventral tegmental area and
the nucleus accumbens (the pleasure centers).
2. In response to this increased endogenous opioid
activity, dopamine is released.
3. Since dopamine is a main reward neurotransmitter,
increases in the nucleus accumbens makes the user
feel good.
4. The brain remembers those good feelings
caused by the dopamine and opioids.
5. The brain desires to repeat the behavior again to get
the same good feelings.
How Does Naltrexone Work?
• Naltrexone is an opioid
receptor antagonist
and blocks opioid
N
receptors.
By blocking opioid
receptors, the
“reward” and acute
reinforcing effects
from dopamine are
diminished, and
alcohol consumption
is reduced.
N
= naltrexone
N
N
Post-Synaptic Neuron
N
Opioid
Receptor
N
N
Side Effects of Naltrexone
The following side effects occurred in 2% or more
of patients during the clinical trials:
 nausea
 anxiety
 vomiting
 fatigue
 headache
 insomnia
 nervousness
 dizziness
 drowsiness
Naltrexone Contraindications

Should not be administered to patients with opioid physical
dependence or undergoing acute opiate withdrawal.

Should not be administered to patients receiving opioid analgesics.
This can be ensured by administering the naloxone challenge test
and/or a urine screen.

Should not be administered to patients who have previously shown
hypersensitivity to naltrexone or any other components of the
medication.

Should not be administered to patients with acute hepatitis or liver
failure. Naltrexone is NOT contraindicated for patients who have
mild to moderate hepatic (liver) impairment, but caution should be
exercised when using naltrexone with this population.
Opioid Replacement Goals
•
•
•
•
•
Reduce symptoms & signs of withdrawal
Reduce or eliminate craving
Block effects of illicit opioids
Restore normal physiology
Promote psychosocial rehabilitation and nondrug lifestyle
Methadone General Facts
(information from medication package insert)
 Generic Name:
methadone hydrochloride
 Marketed As:
Methadose and Dolophine
(among others)
 Purpose:
To discourage illicit opioid use due to cravings or the desire to
alleviate opioid withdrawal symptoms.
 Indication:
For the treatment of moderate to severe pain not responsive to
non-narcotic analgesics; for detoxification treatment of opioid
addiction; for maintenance treatment of opioid addiction, in
conjunction with appropriate social and medical services.
 Year of FDA-Approval: 1964
Methadone General Facts
(information from medication package insert)
•
•
•
Amount: maintenance dose of 80 to 120mg
Method: mouth
Frequency: once a day
•
The effect of consuming food with methadone has not been
evaluated and therefore, is not recommended.
•
Abstinence requirements: must be abstinent from opioids long
enough to experience mild to moderate opioid withdrawal
symptoms.
•
Initial dose will vary depending upon the client’s usage pattern,
but should not exceed 40mg.
Risk of Overdose: Just like with any opioid, overdose is
possible. In the event of an overdose, appropriate medical
treatment should be sought.
Methadone General Facts
(information from medication package insert)

Pregnancy:
Methadone is the preferred method of treatment for
medication-assisted treatment for opioid dependence in
pregnant women. An expert review of published data on
experiences with methadone use during pregnancy
concludes that it is unlikely to pose a substantial risk. But,
there is insufficient data to state that there is no risk.
Methadone has not been adequately tested on pregnant
women. Therefore, methadone has a Pregnancy Category C
designation, meaning that it should be used during
pregnancy only if the potential benefit justifies the potential
risk to the fetus. Caution should be exercised when using
methadone with this population.
Methadone General Facts
(information from medication package insert)
 Pregnancy:
 Detoxification is relatively contraindicated unless done in
hospital with monitoring.
 Babies born to mothers who have been taking opioids
regularly prior to delivery may be physically dependent and
may experience opioid withdrawal symptoms. It is known
that methadone is excreted through breast milk, and a
decision should be made whether to discontinue nursing or
to discontinue the medication, taking into account the
importance of the medication to the mother and continued
illicit opioid use.
Methadone General Facts
(information from medication package insert)

Addictive Properties:
Chronic administration produces physical dependence.
Since methadone is an opioid, it does have a high abuse
liability and does produce withdrawal symptoms when the
medication is ceased too abruptly or tapered down too
quickly.

Third-Party Payer Acceptance:
Covered by most major insurance carriers, Medicare,
Medicaid and the VA.
Understanding
DATA 2000
Drug Addiction Treatment Act
of 2000 (DATA 2000)
• Expands treatment options to include both
the general health care system and opioid
treatment programs.
– Expands number of available treatment slots
– Allows opioid treatment in office settings
– Sets physician qualifications for prescribing
the medication
DATA 2000:
Physician Qualifications
Physicians must:
• Be licensed to practice by his/her state
• Have the capacity to refer patients for
psychosocial treatment
• Originally limited to 30 patients later
expanded to allow for 100 patients after
the first year of experience
• Be qualified to provide buprenorphine and
receive a license waiver
DATA 2000:
Physician Qualifications
A physician must meet one or more of the following
qualifications:
–
–
–
–
Board certified in Addiction Psychiatry
Certified in Addiction Medicine by ASAM or AOA
Served as Investigator in buprenorphine clinical trials
Completed 8 hours of training by ASAM, AAAP, AMA,
AOA, APA (or other organizations that may be
designated by Health and Human Services)
– Training or experience as determined by state medical
licensing board
– Other criteria established through regulation by Health
and Human Services
Development of
Tablet Formulations of Buprnorphine
• Buprenorphine is marketed for opioid treatment
under the trade names of Subutex®
(buprenorphine) and Suboxone®
(buprenorphine/naloxone)
• Over 25 years of research
• Over 5,000 patients exposed during clinical trials
• Proven safe and effective for the treatment of
opioid addiction
Buprenorphine:
A Science-Based Treatment
Clinical trials have established the effectiveness of
buprenorphine for the treatment of heroin
addiction. Effectiveness of buprenorphine has
been compared to:
• Placebo (Johnson et al. 1995; Ling et al. 1998;
Kakko et al. 2003)
• Methadone (Johnson et al. 1992; Strain et al.
1994a, 1994b; Ling et al. 1996; Schottenfield et
al. 1997; Fischer et al. 1999)
• Methadone and LAAM (Johnson et al. 2000)
Buprenorphine Research
Outcomes
• Buprenorphine is as effective as moderate
doses of methadone.
• Buprenorphine is as effective as moderate
doses of LAAM.
• Buprenorphine's partial agonist effects make
it mildly reinforcing, encouraging medication
compliance.
• After a year of buprenorphine plus
counseling, 75% of patients retained in
treatment compared to 0% in a placebo-pluscounseling condition.
The Role of Buprenorphine in
Opioid Treatment
• Partial Opioid Agonist
– Produces a ceiling effect at higher doses
– Has effects of typical opioid agonists—these effects
are dose dependent up to a limit
– Binds strongly to opiate receptor and is long-acting
• Safe and effective therapy for opioid maintenance
and detoxification
Advantages of Buprenorphine in
the Treatment of Opioid Addiction
1. Patient can participate fully in treatment
activities and other activities of daily living
easing their transition into the treatment
environment
2. Limited potential for overdose
3. Minimal subjective effects (e.g., sedation)
following a dose
4. Available for use in an office setting
5. Lower level of physical dependence
Disadvantages of Buprenorphine in the
Treatment of Opioid Addiction
1. Greater medication cost
2. Lower level of physical dependence (i.e.,
patients can discontinue treatment)
3. Not detectable in most urine toxicology
screenings
Advantages of Buprenorphine/Naloxone
in the Treatment of Opioid Addiction
•
Combination tablet is being marketed
for U.S. use
6. Discourages IV use
7. Diminishes diversion
8. Allows for take-home dosing
Why was Buprenorphine/Naloxone
Combination Developed?
• Developed in response to increased reports
of buprenorphine abuse outside of the U.S.
• The combination tablet is specifically
designed to decrease buprenorphine abuse
by injection, especially by out of treatment
opioid users.
Why Combining Buprenorphine and
Naloxone Sublingually Works
• Buprenorphine and naloxone have different
sublingual (SL) to injection potency profiles
that are optimal for use in a combination
product.
SL Bioavailability
Injection to Sublingual
Potency
Buprenorphine 40-60%
Buprenorphine ≈
Naloxone 10% or less
Naloxone
SOURCE: Amass et al., 2004.
2:1
≈ 15:1
Buprenorphine/Naloxone:
What You Need to know
• Basic pharmacology, pharmacokinetics, and
efficacy is the same as buprenorphine
alone.
• Partial opioid agonist; ceiling effect at higher
doses
• Blocks effects of other agonists
• Binds strongly to opioid receptor, long acting
The Use of Buprenorphine in the
Treatment of Opioid Addiction
Induction
Maintenance
Tapering Off/Medically-Assisted
Withdrawal
Induction
Induction Phase
Working to establish the appropriate
dose of medication for patient to
discontinue use of opiates with minimal
withdrawal symptoms, side-effects, and
craving
Direct Buprenorphine Induction
from Short-Acting Opioids
• Ask patient to abstain from short-acting opioid
(e.g., heroin) for at least 6 hrs. and be in mild
withdrawal before administering
buprenorphine/naloxone.
• When transferring from a short-acting opioid, be
sure the patient provides a methadone-negative
urine screen before 1st buprenorphine dose.
SOURCE: Amass, et al., 2004, Johnson, et al. 2003.
Direct Buprenorphine Induction
from Long-Acting Opioids
• Controlled trials are needed to determine
optimal procedures for inducting these
patients.
• Data is also needed to determine whether
the buprenorphine only or the
buprenorphine/naloxone tablet is optimal
when inducting these patients.
SOURCE: Amass, et al., 2004; Johnson, et al. 2003.
Direct Buprenorphine Induction
from Long-Acting Opioids
• Clinical experience has suggest that induction
procedures with patients receiving long-acting
opioids (e.g. methadone-maintenance patients) are
basically the same as those used with patients
taking short-acting opioids, except:
– The time interval between the last dose of medication and
the first dose of buprenorphine must be increased.
– At least 24 hrs should elapse before starting
buprenorphine and longer time periods may be needed
(up to 48 hrs).
– Urine drug screening should indicate no other illicit opiate
use at the time of induction.
Stabilization and
Maintenance
Stabilization Phase
Patient experiences no withdrawal
symptoms, side-effects, or craving
Maintenance Phase
Goals of Maintenance Phase:
Help the person stop and stay away from
illicit drug use and problematic use of
alcohol
1. Continue to monitor cravings to prevent
relapse
2. Address psychosocial and family issues
Maintenance Phase
Psychosocial and family issues to be addressed:
a) Psychiatric comorbidity
b) Family and support issues
c) Time management
d) Employment/financial issues
e) Pro-social activities
f) Legal issues
g) Secondary drug/alcohol use
Buprenorphine Maintenance:
Summary
• Take-home dosing is safe and preferred by patients,
but patient adherence will vary and this can impact
treatment outcomes.
• 3x/week dosing with buprenorphine/naloxone is safe
and effective as well (Amass, et al., 2001).
• Counseling needs to be integrated into
any buprenorphine treatment plan.
Medically-Assisted
Withdrawal
(a.k.a. Dose Tapering)
Buprenorphine Withdrawal
• Working to provide a smooth transition from a
physically-dependent to non-dependent state, with
medical supervision
• Medically supervised withdrawal (detoxification) is
accompanied with and followed by psychosocial
treatment, and sometimes medication treatment
(i.e., naltrexone) to minimize risk of relapse.
Medically-Assisted Withdrawal
(Detoxification)
• Outpatient and inpatient withdrawal are both
possible
• How is it done?
– Switch to longer-acting opioid (e.g.,
buprenorphine)
• Taper off over a period of time (a few days to weeks
depending upon the program)
• Use other medications to treat withdrawal symptoms
– Use clonidine and other non-narcotic medications
to manage symptoms during withdrawal
Importance of
Coordinated Care
A case study
A Model of Coordinated Care
Role
Physician
Addiction
Counselor
Screening/Assessment


Diagnosing Rx Drug Addiction


Patient Education


Referral for Treatment


Prescribing/Dispensing
Medications

Urinalysis Testing







Case Management &
Coordination

Family Services and Treatment

Meeting ancillary needs of the
patient
Community
Support
Provider

Psychosocial Treatment
Recovery Support
12-Step
Program




Barriers to Effective Care
Coordination
• Misunderstanding respective roles
• Conflicting goals for treatment
• Confidentiality restrictions
• Control issues
• Misconception of other professional
perspectives
Attributes of Successful
Care Coordination
• Understanding roles for each participant in
the treatment team
• Ongoing communication across professions
• Personal contact between partners in the
system
CONNECT to Fight
Rx Drug Abuse
• The CONNECT project is
dedicated to educating
professionals from numerous
fields about prescription drug
abuse and exploring ways these
systems can work together to create
solutions
Collaboration is Crucial!
• The prescription drug abuse
epidemic is growing so quickly
• Many different systems need to
come together.
• How can your agency work with the other
stakeholders in your region?
• Learn more about CURES
• Work with local medical associations and
hospitals to provide assistance and
education to physicians and pharmacists in
your region.
Role of Substance Abuse
Treatment Community
• Treatment helps people
reclaim their lives and
become contributing
members of society.
• Educate clients and families about
how to keep prescription medications
from being used inappropriately.
Role of
Medical Community
• An estimated 70 percent of
Americans (approx 191million)
visit their primary care physician at
least once every two years.
• Care for patients by prescribing needed
medications
• Identify prescription drug abuse when it
exists
• Help patients recognize abuse problems
• Support patients in seeking appropriate
treatment.
Role of Prescription Drug
Monitoring Program
Community
• Collection and analysis of
controlled substance data
• Identification and investigation
of illegal prescribing,
dispensing and procurement
• Physician access can help decrease
extent of doctor shopping
CURES: CA’s Prescription Drug
Monitoring Program
• Name: Controlled Substance Utilization Review
and Evaluation System (CURES)
• Overseen by: CA Dept of Justice, Bureau of
Narcotic Enforcement
• Schedules Monitored: II, III, and IV
• Number of Prescriptions Collected Annually:
21 million
• Number of Controlled Substance Dispensers:
155,000
• Website: http://caag.state.ca.us/bne/trips.htm
This Just In! Real-Time Statewide
Prescription Drug Monitoring Program
• Internet-based technology to stop “drug seekers”
• Contains more than 100 million entries
• Instant access to patients’ controlled-substance
records (vs. fax/mail system)
• 7,500 pharmacies and 158,000 prescribers
• Goals:
– Reduce drug trafficking and abuse of dangerous
prescription medications
– Lower the number of ER visits due to Rx drug
overdose and misuse
– Reduce healthcare costs
This Just In! Real-Time Statewide
Prescription Drug Monitoring Program
Contents of database record:
– Drug Name
– Date Filled
– Quantity, strength, and number of refills
– Pharmacy name and license number
– Doctor’s name and DEA number
– Prescription number
Safe Disposal of
Prescription Drugs, Part 1
• Take unused, unneeded, or expired
prescription drugs out of their original
containers.
• Mix the prescription drugs with an
undesirable substance (e.g., coffee grounds, kitty
litter)
• Put them in impermeable, non-descript containers,
such as empty cans or sealable bags.
• Throw these containers in the trash.
Safe Disposal of
Prescription Drugs, Part 2
• Flush prescription drugs down the toilet
only if the accompanying patient
information specifically instructs it is
safe to do so.
• Return unused, unneeded, or expired prescription
drugs to pharmaceutical take-back locations that
allow the public to bring unused drugs to a central
location for safe disposal.
• Are Your Prescriptions Safe? - handout
For more information, contact:
Thomas E. Freese, PhD
tfreese@mednet.ucla.edu
Sherry Larkins, Ph.D.
larkins@ucla.edu
Beth Rutkowski, MPH
brutkowski@mednet.ucla.edu
www.psattc.org
www.uclaisap.org
Thank you for your time
and attention!