EAP Implications of Prescription Drug Use in the Workplace Laurie Lovedale, MPH, CPS II Prescription Drug Abuse Prevention Program Coordinator

Peer Assistance Services, Inc. Mission: Dedicated to quality, accessible prevention and intervention services in workplaces and communities, focused on substance use and related issues.  Serving Colorado since 1984

Prescription Drug Abuse Prevention Program A State Priority Initiative funded by the Colorado Office of Behavioral Health 5-year funding cycle

2010-2015 Program Objectives Increase awareness of the problem Increase availability of medication disposal programs statewide Encourage responsible prescribing practices Encourage patient responsibility Track data and trends

Agenda/Objectives Drug Free Workplace Data Typology of Abuse Prescription Drug Abuse Overview National/State/Local Data Medication Overview Prevention Strategies Medication Take Back Event

Drug-Free Workplace The rate of drug use among American workers has declined by 74 percent since the Drug-Free Workplace Act was passed 25 years ago. Drug Testing Index Quest Diagnostics The figures come from the latest annual Drug Testing Index from Quest Diagnostics. The analysis examined more than 125 million urine drug tests performed by the company’s forensic toxicology labs in the U.S. on private as well as government employers. The positivity rate for the Combined U.S. Workforce declined 74%, from 13.6% in 1988 to 3.5% in 2012. The positivity rate for the Federally Mandated, Safety Sensitive Workforce declined by 38%, from 2.6% in 1992 to 1.6% in 2012. The positivity rate for the U.S. General Workforce declined by 60%, from 10.3% in 1992 to 4.1% in 2012.

Drug-Free Workplace Positive rates for certain drugs, including opiates and amphetamines, have increased substantially.

Drug-Free Workplace Prescription opioids Hydrocodone (Vicodin) Hydromorphone (Dilaudid) Oxycodone (OxyContin) Oxymorphone (Opana)   More than doubled Up 71 percent

Drug-Free Workplace Positivity rates for amphetamines, including amphetamine and methamphetamine, has nearly tripled (196% higher) in the combined U.S. workforce and, in 2012, were at the highest level since 1997. The positivity rate for amphetamine itself, including prescription medications such as Adderall®, has more than doubled in the last 10 years.

Prescription Drug Misuse? What is Prescription Drug Misuse? The use of a medication (for a medical purpose) other than as directed or as indicated.

Prescription Drug Abuse? What is Prescription Drug Abuse? The intentional self-administration of a medication for a non-medical purpose. Abuse- “Use of medication without a prescription; in a way other than prescribed; or for the experience or feeling it causes” (NIDA 2011) Includes “academic enhancement”

Why is there so much medication out there? Culture of “Pain-Free” society Blind Faith in medical system to cure anything Direct to consumer marketing from pharmaceutical companies Prescription medications are safe

The 3 R’s for Medication Safety RISKS – All medicines have RISKS as well as benefits RESPECT the power of your medicine and the value of medicines properly used Take RESPONSIBILITY for learning about how to take your medication safely

Typology of Abuse Acquired Drug with Legitimate Prescription Acquired Drug Without Legitimate Prescription Used to Self-Treat Self-treat other medical condition with previous Rx (off label use) Self-treat migraine with their own medication Use other person’s medication (sharing) Parent taking child’s medication to be productive Used to Get High/Euphoria May start off with legitimate pain med, but get addicted over time Use current medication to party/get high Using their own Rx, but taking it with alcohol to keep party going May have bought/traded with others to get medication used to get high Stealing grandparent’s and getting McCabe & Boyd, 2010 . Retrieved from http://captus.samhsa.gov/sites/default/files/capt_resource/paw-prescriptiondrug.pdf

Examples of Drugs Covered DEA Schedule Abuse Potential Examples of Drugs Covered Effects Medical Use 1 Highest Heroin, LSD, Marijuana, Bath Salts High potential for abuse, severe psychological or physical dependence, death No accepted use 2 High Morphine, Hydromorphone, Methadone, Oxycodone, Fentanyl, Adderall, Ritalin High potential for abuse which may lead to severe psychological or physical dependence Accepted use with restrictions 3 Medium Vicodin, Tylenol with codeine, Suboxone and Subutex Potential for abuse less than 1 and 2, may lead to moderate or low physical dependence or high psychological Accepted use 4 Low Xanax, Klonopin, Valium, Ativan, Halcion Low potential for abuse relative to Schedule III’s 5 Lowest Over the counter of prescriptions with codeine, Robitussin AC Low potential for abuse relative to Schedule IV’s

Main Types of Abused Prescription Medications Depressants used to treat sleep disorders and severe anxiety (Xanax & Valium) Stimulants used to treat behavior disorders such as ADHD (Ritalin & Adderall) Opioids used to treat pain (Oxycontin & Vicodin)

Why Prescription Drugs? Easy Access 70% from a friend or relative 2011 National Survey on Drug Use and Health Easier to get Rx drugs than beer Young Adults feel they are “safer” than illicit drugs

National Data

Center for Disease Control Poisoning is now the leading cause of death from injuries in the United States and nearly 9 out of 10 poisoning deaths are caused by drugs. (Centers for Disease Control 2008)

Data are from a random sample of households in the 48 continental states who had a person ages 12 to 17 living in the household. Computer-assisted telephone interviews were conducted between April 18 and May 17, 2012 with 1,003 youths who were randomly selected from the nationally representative household sample frame. The margin of error is +/-3.1 percent at a 95 percent confidence level (unadjusted for weighting). SOURCE: Adapted by CESAR from The National Center on Addiction and Substance Abuse at Columbia University (CASA), National Survey of American Attitudes on Substance Abuse XVII: Teens, 2012. Available online at http://www.casacolumbia.org/upload/2012/20120822teensurvey.pdf.

2012 NSDUH

CDC January 13, 2012/61(01): 10-13

Colorado Data

In 2012 more than twice as many people in Colorado died from poisoning due to opioid analgesics (295) than from drunk-driving related crashes (133). Department of Public Health and Environment, Health Statistics Section

2012 Prescription Opioid Deaths by Age

2012 Rx Opioid Deaths by Gender

Prescription Opioid Deaths 2012 295 of the 807 drug poisoning deaths in Colorado involved prescription opioids

Prescription Opioid Hospitalizations 2012 1,131 of the 5,291 drug poisoning hospitalizations in Colorado involved prescription opioids 21%

Youth Risk Behavior Survey Colorado National Fall 2011 9th grade – 12.4% 10th grade – 17% 11th grade – 19.1% 12th grade – 29.2% Sept. 2010 – Dec. 2011 9th grade – 16.5% 10th grade – 18.2% 11th grade – 23.3% 12th grade – 25.6%

DEPRESSANTS

Depressants (CNS depressants) Also referred to as sedatives and tranquilizers Benzodiazepines Alprazolam (Xanax) & Diazepam (Valium) Treat anxiety, acute stress reactions and panic attacks Triazolam (Halcion) Short-term treatment of sleep disorders Inhibit brain activity which produces a drowsy or calming effect

Short Term Effects Short term Slowed pulse and breathing Slurred speech Drowsiness Lowered blood pressure Poor concentration, fatigue and confusion Impaired coordination, memory and judgment. Suppress respiration/death Addiction

Long term effects Addiction Respiratory depression and respiratory arrest Death Chronic fatigue Sexual problems Sleep problems.

CNS Depressants Combining with other CNS depressants (alcohol) Affect heart rhythm Slow respiration Death Withdrawal (Work with provider) Anxiety Insomnia Depression Seizures

OPIOIDS

Opioids Relieve pain by reducing the intensity of pain signals reaching the brain and affect those brain areas controlling emotion, which diminishes the effects of a painful stimulus. Hydrocodone (Vicodin)- most commonly prescribed for a variety of painful conditions, including dental and injury-related pain. Oxycodone (OxyContin, Percocet) Morphine (Kadian, Avinza)- often used before and after surgical procedures to alleviate severe pain. Codeine- often prescribed for mild pain.

Opioids Attach to proteins called opioid receptors located in the brain, spinal cord, GI tract, and other organs in the body. When opioids attach to receptors, they reduce the perception of pain.

Short Term Effects Drowsiness Mental confusion Nausea Constipation Respiratory depression Euphoric response

Long term effects Addiction Severe lethargy Sleep apnea Falls and fractures in the elderly. As dose increases, pain patients also become susceptible to a condition known as hyperalgesia, in which they feel more, not less pain.

Opioids Withdrawal (Work with provider when weaning off of opioids) Restlessness Muscle and bone pain Insomnia Diarrhea Vomiting Cold flashes with goose bumps Involuntary leg movements

Tolerance to Opioids Tolerance develops rapidly to the sedating, and euphoric effects of opioids It develops more slowly to their analgesic effects Tolerance can be characterized as decreased sensitivity to opioids

Similarities between Illicit and Prescription medications

Opioid Induced Hyperalgesia Increased sensitivity to pain resulting from opioid use Hard for clinicians to know if pain increase due to opioids or if the condition has worsened

Pseudoaddiction Results from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction The relief seeking behaviors resolve upon institution of effective analgesic therapy SAMHSA, Tip 54, Managing Chronic Pain in Adults with or in Recovery From Substance Use Disorders, 2012

STIMULANTS

Stimulants Increase alertness, attention, and energy Elevate blood pressure, heart rate, and respirations Mainly used in the treatment of ADHD and narcolepsy

Schedule II Medication Stimulants Schedule II Medication High potential for abuse which may lead to severe psychological or physical dependence

Short term effects Stimulants increase the amount of norepinephrine and dopamine in the brain, which increases blood pressure and heart rate, constricts blood vessels, increases blood glucose, and increases breathing. Effects can feel like an increase alertness, attention, and energy along with a sense of euphoria. There is also the potential for cardiovascular failure (heart attack) or lethal seizures.

Long term effects Addiction Taking high doses of some stimulants repeatedly over a short time can lead to feelings of hostility or paranoia. Taking high doses of a stimulant may result in dangerously high body temperatures and an irregular heartbeat. Cardiovascular failure (heart attack) or lethal seizures.

Stimulants Withdrawal Fatigue Depression Disturbance of sleep patterns

Patient Responsibility Monitor all medications in their home Don’t stock pile Lock up or hide medications Do NOT store medications in the “medicine cabinet” Dispose of medications properly Talk to friends and family (even grandparents) about securing their medications Understand the dangers of mixing medications and alcohol Lead by example MONITOR: Count, know what types, expiration dates, etc. ALL: Include pet medications

Just because they are prescribed by a health professional does NOT mean they are safe Prescription medications are only safe for the prescribed patient for the prescribed reason for a prescribed time

Take Back Event April 26, 2014 10:00 – 2:00 www.dea.gov

Colorado 2013 39,608 lbs Nationally 2013 695 Tons Take Back Events Colorado 2013 39,608 lbs Nationally 2013 695 Tons

Thank You! Contact Us: www.peerassist.org 2170 S Parker Road #229 Denver, CO 80231 www.peerassist.org Facebook: PreventRxMedicineAbuse 303-369-0039 x 203 llovedale@peerassist.org