Medicine Misuse /Abuse
Montgomery County, Maryland
Safe & Drug Free Schools
2006 Symposium
University of MD
Shady Grove Campus
----------------------Wm. Ray Bullman
National Council on Patient
Information and Education
June 20, 2006
1
Objectives: Medicine Misuse / Abuse
 Define
the problem
 Review National Data
 Licit
and illicit drug use
 Review
the 2004 MD State Dept of Ed.
Maryland Adolescent Survey
 Licit
and illicit drug use
 Discuss
next steps: In search of solutions!
Pharming
Kids “getting high” using Rx or OTC drugs
Vicodin
Andro
GHB
Creatine
Desired: Appropriate Drug Use
 Over
the Counter (OTC) Medicines
 High
margin of safety (but surprises happen)
 Through
 For
Indicated Use
Listed
 For
 By
prescription by licensed provider
on the FDA regulated package insert
“Off-Label” Use
regulated prescription (with DEA number)
 for
known drugs of potential abuse
Desired: Shared Decision Making
 Provider-patient
 Provider
shared decision for drug use
believes drug useful for treatment
Communicates
rationale to patient
Benefits outweigh the risks
 Patient
agrees that drug will be useful
Understands
rationale
Accepts risks for desired benefit
 Patient
takes medicine as directed
 Provider gets patient feedback
Problem: Medicine Misuse
 Drugs
not taken as intended
 Provider
prescribes for “wrong reason”
 Patient does not take drug as directed
Unintentional:
forgetfulness, too many drugs, mindaltering drug interactions
Intentional: patient doesn’t feel need or believes drug
not working and doesn’t discuss with the provider
 Drugs
diverted to another person
 Potential
problem & illegal (with prescribed drugs)
Problem: Medicine Abuse
 Interactions
 Individual
affecting decision-making
- a voluntary decision to use
Psychologically
pleasurable
Physically enhancing for specific outcomes
 Environmental
Drug
– friends & groups affect decision
is available at a “reasonable” price
Drug enhances group bonding
Drug connected to desired group activities
"Generation Rx“

Today's teenagers are more likely to have abused
medications than a variety of illegal drugs like
Ecstasy, cocaine, crack, and methamphetamine.

Nearly one in five teens (19 percent or 4.5 million)
report abusing prescription medications to get high

One in 10 (10 percent or 2.4 million) report abusing
cough medicine to get high.
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
"Generation Rx“

1 in 4 teens report having a fried who abuses medicines to get high

1 in 3 report being offered an Rx or OTC medicine for the purpose of
abuse

Teen abuse of Rx & OTC medicines is greater than the combined abuse
of ecstasy, meth, and heroin.

Every day, 2,700 teens try an Rx medicine to get high for the first time*
This suggests: Rx & OTC abuse has penetrated teen culture and become
“normalized.”
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study; * 2004 National Survey on Drug Use and Health)
Any Illicit Drug Use in Past Month
among Youths Aged 12 to 17, by State
(Percentages, Annual Averages Based on 2003 and 2004 NSDUHs. SAMHSA)
Teen Drug Abuse – We’re all in it together….
Any Illicit Drug Use Other Than Marijuana in
Past Month among Youths Aged 12 to 17
(Percentages, Annual Averages Based on 2003 and 2004 NSDUHs, SAMHSA)
Some Even Worse than Others…
Non-medical Use of Pain Relievers in Past Year
among Youths Aged 12 to 17
(Percentages, Annual Averages Based on 2003 and 2004 NSDUHs, SAMHSA)
For Both Illicit & Licit Drugs…
New Landscape of Substance Abuse
# of Teens Who Have Ever Tried: (in millions)
Marijuana
Inhalants
Rx Medicine
Cough Medicine
Crack/Cocaine
Ecstasy
Meth
LSD
Heroin
Ketamine
GHB
8.6 million
4.7 million
4.5 million
2.4 million
2.4 million
1.9 million
1.9 million
1.3 million
1.1 million
1 million
1 million
(Partnership Attitude Tracking Study, 2005)
Rx Abuse: ? on the Continuum
Abuse of Rx medicines falls in the middle of the teen drug use continuum – less common than
marijuana and more common than other drugs:
Lifetime Use
Marijuana
Inhalants
Prescription Medicine
Cough Medicine
Cocaine / Crack
Methamphetamine
Ecstasy
LSD
Heroin
Ketamine (Special K)
GHB
%
37
30
19 (not prescribed for them)
10
10
8
8
6
5
4
4
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
Thank Goodness it’s only Pot ….
Drugged Driving As Common As Alcohol-Impaired Driving Among Teens

Each day 9,000+ new driver's licenses are issued to 16and 17-year-olds, those @ greatest risk for marijuana
use. These same teens say that cars are the second
most popular place for smoking marijuana.
Monitoring the Future survey reports that
approximately one in six (15%) teens reported driving
under the influence of marijuana, a number nearly
equivalent to those who reported driving under the
influence of alcohol (16%).

More than 2.9 million driving-age teens reported lifetime
use of marijuana, and last year more than 750,000 16and 17-year-olds reported driving under the influence of
illicit drugs. According to the 2004-2005 PRIDE
Surveys, when asked where they use, approximately
one in seven (14%) high school seniors cited "in a
car," making cars the second most popular
location after at "a friend's house" (20.4%).
Gentlemen, don’t start Your engines……

Marijuana impairs many of the skills required for safe
driving, such as concentration, coordination, perception
and reaction time, and these effects can last up to 24
hours after smoking the drug-It is critical that parents
know the dangers associated with drugged driving and
are vigilant in monitoring their teen drivers.
(Alliance for Consumer Education)
Attitudes – Rx Medicine Abuse
% Agree strongly / somewhat
Rx drugs easier to get than illegal drugs
56
Rx drugs, even if not prescribed by doctor,
are much safer to use than illegal drugs
40
There is nothing wrong with using Rx drugs
w/out a doctor’s prescription once in a while
31
Rx pain relievers, even if they are not prescribed
by a doctor, are not addictive.
29
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
% Great Risk
’04
‘05

Trying Rx pain relievers (Vicodin,
Oxycontin, Tylox) that a doctor did
not prescribe for you
48
44

Trying the Rx drugs Ritalin or Adderall
that a doctor did not prescribe for you
54
51
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
Good News / Not So Good News

2005 Partnership Attitude Tracking Study shows that
substance abuse among 7th -12th graders continues to
decline. After years of  adolescent drug use seen in the mid
90’s, the trend continues to reverse. The two exceptions are:
inhalant and Prescription (Rx) medicine abuse.

The use of alcoholic beverages has generally been in decline
among American teens for the last several years, and that
decline continued (in all three grades) in 2005.
(Sources: Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study; 7,300 teens in
grades 7–12; Univ. of MI, Monitoring the Future, Dec. 2005)
Rx Abuse = Entrenched Behavior (1)

Teen smoking & drinking continue to , but teenage abuse
of Rx drugs has become "an entrenched behavior" that
many parents fail to recognize (May 2006)

For a third straight year, PD-FA study showed that about 1
in 5 teens have tried Rx painkillers such as Vicodin or
OxyContin to get high -- about 4.5 million teens. (Univ. of
MI study showed 1 in 10 H.S. seniors had experimented
with Rx painkillers)

Many teens feel experimenting with Rx drugs is safer than
illegal highs.
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study; 7,300 teens in grades 7 – 12)
Rx Abuse = Entrenched Behavior (2)
 40%
said Rx medicines were "much safer"
than illegal drugs, while 31% said there was
"nothing wrong" with using prescription drugs
"once in a while."
 The
study further found that 29% of teens
believe Rx pain relievers are non-addictive.
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
Reasons for Rx Pain Reliever Abuse?
 Widespread
 Generally
 Less
availability and generally easy access.
cheap
of a stigma attached to their use (than others)
 Relatively
easy to get on the Internet
 Generally
regarded as safer than “street drugs”
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
Past Month Illicit Drug Use among
Persons Aged 12 or Older, by Age
(2004 National Survey on Drug Use and Health, SAMHSA)
Past Month Use of Selected Illicit
Drugs among Youths Aged 12 to 17
(2002 - 2004 National Survey on Drug Use and Health, SAMHSA)
Youths Aged 12 to 17

Among 12 or 13 year olds: 1.7% used Rx-type drugs non-medically, 1.2% used inhalants, and 1.1%
used marijuana.

Among 14 or 15 year olds: Marijuana was the dominant drug used (7.3%), followed by Rx-type
drugs used non-medically (4.1%) and inhalants (1.6%).

Among 16 or 17 year olds: Marijuana also was the most commonly used drug (14.5%), followed by
Rx-type drugs used non-medically (5.1%), hallucinogens (1.7%), and cocaine (1.1%). Only 0.9% of
youths aged 16 or 17 used inhalants.

Among all youths aged 12 to 17 in 2004, 10.6% were current illicit drug users: 7.6% used
marijuana, 3.6% used Rx-type drugs non-medically, 1.2% used inhalants, 0.8% used hallucinogens,
and 0.5 % used cocaine.

The rate of current illicit drug use among youths aged 12 to 17 gradually declined between
2002 and 2004. The rate was 11.6% in 2002, 11.2% in 2003, and 10.6% in 2004. This represents a
statistically significant change between 2002 and 2004, but not between 2002 and 2003 or between
2003 and 2004.
(2004 National Survey on Drug Use and Health, SAMHSA)
Q: What types of Rx medications
are teens abusing?
A: The National Survey on Drug Use and Health identifies 4
types of Rx medications that are commonly abused:
Pain relievers
Stimulants
Sedatives
Tranquilizers
11% of teens aged 12-17 reported lifetime non-medical
use of pain relievers and 4% reported lifetime non-medical
use of stimulants.
They’re Getting them
from Somewhere!
%
‘04
‘05
Use Rx pain relievers such as Vicodin,
Oxycontin, Tylox, that a doctor did not
prescribe for them
37
37
Use the Rx drugs Ritalin or Adderall
that a doctor did not prescribe for them
29
29
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
…Meet Willie Sutton…

Willie Sutton (aka "The Actor" & "Slick Willie“) for his ingenuity in executing
robberies in various disguises. Fond of expensive clothes, Sutton was described as
being an immaculate dresser. Although he was a bank robber, Sutton had the
reputation of a gentleman; people present at his robberies stated he was quite
polite. One victim said witnessing one of Sutton's robberies was like being at the
movies, except the usher had a gun. When asked why he robbed banks, Sutton
simply replied, "Because that's where the money is.“
…May I Use Your Bathroom?…
 The
source of drugs is now the family
medicine cabinet more than any dealer.
 PD-FA
found 62% of teens said Rx pain
relievers are easy to find at home. And 52%
say Rx pain relievers are "available
everywhere."
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
“Because That’s Where
the Drugs Are ”
Easy to get from parents’ medicine cabinet
Are available everywhere
They are not illegal drugs
Easy to get through other people’s Rxs
Teens can claim they have a prescription if caught
They are cheap
Safer to use than illegal drugs
Less shame attached to using
Easy to buy over Internet
Parents don’t care as much if you get caught
(Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study)
%
62
52
51
50
49
43
35
33
32
21
OTC Medicine Abuse
“Chugging cough medicine for an instant high certainly isn't a new practice for teens…
recent coverage of the dangerous, potentially deadly practice of intentionally overdosing on
cough and cold medicine has put parents, educators, and emergency departments on the
alert.”
Why Are Kids Abusing Cough and Cold Remedies?
Before the FDA replaced the narcotic codeine with dextromethorphan as an OTC cough
suppressant in the 1970s, teens were simply guzzling down cough syrup for a quick buzz. Over the
years, teens have discovered they could get high by taking mass quantities of any of the multitude
of OTCs containing DXM. Found in tablets, capsules, gel caps, and lozenges, as well as syrups,
dextromethorphan-containing products are labeled DM, cough, cough suppressant, or Tuss (or
contain "tuss" in the title).
Medicines containing dextromethorphan are easy to find, affordable for cash-strapped teens, and
perfectly legal. And because it's found in over-the-counter medicines, many teens are naively
assuming that DXM can't be that dangerous.
(http://kidshealth.org/parent/positive/talk/cough_cold_medicine_abuse.html
What Happens When Teens Abuse DXM?

Taking mass quantities of products containing DXM can cause hallucinations,
loss of motor control, and "out-of-body" (disassociative) sensations.

Other possible side effects of DXM abuse include: confusion, impaired
judgment, blurred vision, dizziness, paranoia, excessive sweating, slurred
speech, nausea, vomiting, abdominal pain, irregular heartbeat, high blood
pressure, headache, lethargy, numbness of fingers and toes, redness of face,
dry and itchy skin, loss of consciousness, seizures, brain damage, and even
death.

Large quantities can also cause a high fever. This is a real concern for teens
who take DXM while in a hot environment or while exerting themselves at a
rave or dance club, where DXM is often sold and passed off as similar-looking
drugs like PCP.
(http://kidshealth.org/parent/positive/talk/cough_cold_medicine_abuse.html)
Q: What cough medicines are
target for abuse (contain dextromethorphan, or DXM?)

There are over 100 OTC medicines that contain DXM, either as the only
active ingredient or in combination with other active ingredients, including:
-Alka-Seltzer Plus Cold & Cough Medicine
-Dayquil LiquiCaps
-Dimetapp DM
-Sudafed cough products
-Tylenol Cold products
-Vicks NyQuil LiquiCaps
-Coricidin HBP Cough/Cold
-Robitussin cough Products
-Triaminic cough syrups
-Vicks 44 Cough Relief
products
There also are a number of store brands that contain DXM.
OTC Abuse – Be on the Lookout
If you suspect that a child may be abusing OTC medicines or if your teen
often attends raves or dance clubs where DXM can likely be found in
abundance, it might be a good idea to:

Lock your medicine cabinet, or keep those OTC medicines
that could potentially be abused in a less accessible place.

Avoid stockpiling OTC medicines. Having too many OTC
medications at your teen's disposal could make abusing them
more tempting.

Keep track of how much is in each bottle or container in your
medicine cabinet.
OTC Abuse – Be on the Lookout

Keep an eye out for not only traditional-looking cough and
cold remedies in your teen's room, but also strange-looking
tablets (DXM is often sold on the Internet and at raves in its
pure form in various shapes and colors).

Look for possible warning signs of DXM abuse.

Monitor your child's Internet usage. Be on the lookout for
suspicious websites and emails that seem to be promoting
the abuse of DXM or other drugs, both legal and illegal.
Combating Abuse: 3-Step Approach
for Parents
1. Educate themselves about the medicines that kids are
abusing.
2. Communicate with their kids about the medically
appropriate use of medications, & the harmful consequences
of intentionally abusing them.
3. Safeguard their own medications & ask their friends to
do the same.
4. Flush / Don’t Flush? Pharmacy return? (Depends)
Drug Abuse in the Montgomery
County Public Schools (MCPS)
Source: Maryland Department of Education
Maryland Adolescent Survey
Data specific to Montgomery County
1994 - 2004
36
MCPS Beer, Wine, Coolers Use
% Use in Prior 12 mos
70
60
1994
1996
1998
2001
2002
2004
50
40
30
20
10
0
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS “Hard” Liquor Use
% Use in Prior 12 mos
70
60
1994
1996
1998
2001
2002
2004
50
40
30
20
10
0
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent
Survey
MCPS 5+ Drinks/Same Occasion
% Use in Prior 12 mos
70
60
1994
1996
1998
2001
2002
2004
50
40
30
20
10
0
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Cigarette Use
% Use in Prior 12 mos
50
45
40
35
30
25
20
15
10
5
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Smokeless Tobacco Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Steroids for Body Building
% Use in Prior 12 mos
2.5
2
1994
1996
1998
2001
2002
2004
1.5
1
0.5
0
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Marijuana or Hashish Use
% Use in Prior 12 mos
50
45
40
35
30
25
20
15
10
5
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS LSD Use
% Use in Prior 12 mos
20
18
16
14
12
10
8
6
4
2
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Mescaline, ‘shroom Use
% Use in Prior 12 mos
20
18
16
14
12
10
8
6
4
2
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS PCP Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Amphetamine Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Methamphetamine Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Cocaine (not crack) Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Designer Drugs -- MDMA,
Ecstasy Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Narcotic (not Heroin) Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
MCPS Barbit. or Tranquilizer Use
% Use in Prior 12 mos
10
9
8
7
6
5
4
3
2
1
0
1994
1996
1998
2001
2002
2004
6th grade
8th grade
10th grade
12th grade
Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey
Discussion
 Montgomery
County (like all other counties), has a
drug use problem
 Misuse,
 Who
abuse, and dependence
chooses to become an addict? (rhetorical
question)
 What can we do? (prevention strategies)
 Primary
– healthy community, social norms
 Secondary – identify high risk, early intervention,
prescription drug monitoring
 Tertiary – effective treatment easily accessed
 Next
steps?
Web-Based Resources
www.bemedwise.org
(NCPIE)
www.drugfree.org
(PD-FA)
www.methwatch.com
(CHPA)
www.drugabuse.gov
(NIDA)
www.teens.drugabuse.gov (NIDA)
www.rx.samhsa.gov
(SAMHSA)
www.monitoringthefuture.org (Univ. of MI)
www.inhalant.org
(ACE)
Contact Information
Wm. Ray Bullman, M.A.M.
Executive Vice President
National Council on Patient Information and Education
4915 Saint Elmo Ave., Suite 505
Bethesda, MD 20814-6082
(301) 656-8565 - Phone
bullman@ncpie.info - Email
www.talkaboutrx.org
www.bemedwise.org