1. Prevention and Treatment of Prescription Drug Abuse on the College Campus Josh Hersh M.D. Staff Psychiatrist Miami University Minimal Abuse Maximum Care

2. DISCLOSURES Dr. Hersh serves as a Treatment Advocate for Reckitt-Benckiser Pharmaceutical Generic drug names are listed with Trade names with the exception of Pill Identification

3. MULTIPLE ARTICLES ON SCOPE OF THE PROBLEM “Prescription Drug Abuse Rises on Campuses”—ABC News “Report: Prescription Drug Deaths Skyrocket”—Foxnews.com “Stimulant Abuse Rises on the College Campus”—The Columbus Dispatch “Prescription Drug Abuse on the Rise in America”—Chicago Tribune

4. DRUG OVERDOSES Drug induced death now outnumbers suicide, injury by fire arms, and homicide Emergency room visits from prescription drug overdoses doubled from 2004 to 2009 Overdose deaths from painkillers have risen from less than 2,901 in 1999 to 11,499 in 2007 By 2007, more teenagers used opioid analgesics recreationally than used marijuana 1 1 Center for Disease Control

5. FAMOUS CELEBRITY DEATHS Marilyn Monroe Health Ledger Michael Jackson Anna Nicole Smith Elvis Presley Whitney Houston ?

6. PRESCRIPTION OPIOID DRUGS PercocetOxyContin Vicodin Tylenol #4 w/codeineLortab Opana

7. PRESCRIPTION STIMULANT DRUGS Adderall Concerta Vyvanse Ritalin Adderall XR

8. PRESCRIPTION SEDATIVE HYPNOTICS Xanax KlonopinAtivan Ambien

9. WHAT IS PRESCRIPTION DRUG ABUSE? Taking prescription medication without a prescription Taking more prescription medication than prescribed (also called misuse) Taking prescription medication with unintended routes of administration (intranasal or I.V.)

10. WHAT IS PRESCRIPTION DRUG ABUSE, CONTINUED Diverting prescription medication (selling it, trading it, or giving it away) Harmful consequences from a controlled substance (DSM-IV) Obtaining controlled substances from different doctors (Doctor Shopping)

11. WHAT IS DEPENDENCY? Tolerance and withdrawal symptoms Decline in normal activities Unsuccessful attempts to cut down or control use Use for longer period or larger amounts than intended Use consumes lot of time to acquire and/or recover from effects Continued use despite physical and/or psychological problems

12. HOW COMMON IS ABUSE ON THE COLLEGE CAMPUS? Ohio State University surveyed 5000 students in 2008 General Survey Opiates--9.2% at least once per year (higher in intramural sports participants) Sedatives--5.1% at least once per year Stimulants--4.4% at least once per year

13. HOW COMMON IS MISUSE? World Health Association estimates about 50% of people do not take prescription drugs as prescribed Maryland study found 35.8% of college students reported that they had diverted a drug at least once in their lifetime. 1 Prescription stimulants--61.7% diversion Prescription opiates--35.1% diversion 9.3% of students sold medication 1 J Clin Psychiatry. 2010 March; 71(3): 262–269

14. REASONS FOR PRESCRIPTION DRUG ABUSE Stimulants—cramming, delaying sleep, weight loss, Sleep Disorders, ADHD symptoms, recreational, dependency Opiates—pain (especially athletes), anxiety, insomnia, recreational, dependency Benzodiazepines—anxiety, insomnia, recreational, dependency

15. REASONS FOR CO- ADMINISTRATION/CO-ABUSE Combining stimulants with alcohol to drink longer and counteract sedation Combining opiates or benzodiazepines with alcohol to increase intoxication (dramatically increases rate of overdose) Combining benzodiazepines with stimulants to decrease anxiety from stimulants

16. CONSEQUENCES OF ABUSE/DEPENDENCE Medical risks (cardiac and stroke risks, liver damage, nasal perforation, blood- borne diseases, overdose) Psychiatric illness (depression, anxiety, psychosis, sleep disturbance) Inability to attend classes/do schoolwork Inability to work and financial problems Relationship problems Criminal behavior

17. PREVENTION OF PRESCRIPTION DRUG ABUSE Interdisciplinary treatment protocols to treat ADHD, Anxiety Disorders, Sleep Disorders, and pain (Minimal Abuse/Maximum Care) Help physicians say “NO!” Student education on scope of problem and how to care for controlled substances Legal consequences for criminal behavior (e.g. selling meds, forging scripts, etc.) Enforcement of medical standards MINIMAL ABUSE MAXIMUM CARE

18. INTERDISCIPLINARY TREATMENT OF ADHD Initial Phone Screening Attention Problem Evaluation (APE) ADHD Workshop Behavioral Interventions Miami University Learning Center Planner Medication Academic Coaching and Therapy MINIMAL ABUSE MAXIMUM CARE

19. INITIAL PHONE SCREENING Front desk staff refers all students with ADHD symptoms to phone screening Counselor does brief phone screening to refer students to proper treatment setting Students may be sent for an Attention Problem Evaluation, to the Learning Center, to the ADHD workshop, or for a complete initial evaluation

20. ATTENTION PROBLEM EVALUATION (APE) Semi-structured interview to gather basic information Includes diagnostic criteria for ADHD Includes screening out other causes of inattention such as medical causes, Sleep Disorders, Substance Use Disorders, and other psychiatric disorders Includes comprehensive treatment plan

21. ADHD WORKSHOP One hour psychoeducational workshop required prior to ADHD treatment for ALL students seeking medication Includes education about ADHD, behavioral interventions, use of the Miami University Planner, sleep hygiene, and procedures for taking medication Education about risks and benefits of medication including suggestions for avoiding misuse and diversion

22. BEHAVIORAL INTERVENTIONS FOR ADHD How to keep a planner How to use cell phone to keep track of appointments How to improve sleep hygiene Treating college like a full time job Minimizing distractions

23. THE MIAMI UNIVERSITY LEARNING CENTER PLANNER The planner is an essential part of this approach Every student being treated for ADHD has this planner Teaches block scheduling, grade tracking, and syllabus tracking Provides list of resources including workshops at the learning center Helps students with study skills and procrastination

24. MEDICATION Stimulants are used according to the weekly planner The effective dose is found and used throughout the remainder of treatment The prescriber delineates times the student will take the medication and gives only amount needed for the month Techniques are implemented to prevent tolerance to stimulants (i.e. drug holidays, discontinuing caffeine)

25. ACADEMIC COACHING AND THERAPY Coaching and/or therapy can be required for medication use Academic Coaching Weekly Sessions Utilizes the Miami University Planner Provides accountability Therapy Address Comorbities (anxiety, substance use, eating disorders, etc.)

26. MINIMAL ABUSE MAXIMUM CARE

27. INTERDISCIPLINARY TREATMENT OF ANXIETY DISORDERS Refer to anxiety management workshops and/or individual therapy Try non-addictive substances first (SSRI’s, buspirone, and beta blockers) If benzodiazepines are needed, limit amount of benzodiazepines (i.e. 10 per month) Monitor frequently for signs of misuse and diversion MINIMAL ABUSE MAXIMUM CARE

28. MINIMAL ABUSE MAXIMUM CARE

29. INTERDISCIPLINARY TREATMENT OF SLEEP DISORDERS Refer to anxiety management workshops and/or individual therapy Referral to sleep disorders clinic for concerns about narcolepsy or sleep apnea Try behavioral techniques (sleep hygiene, white noise, etc.) Consider non-controlled substances Limit amounts of controlled substance such as zolpidem (10 per month) MINIMAL ABUSE MAXIMUM CARE

30. MINIMAL ABUSE MAXIMUM CARE

31. INTERDISCIPLINARY TREATMENT OF PAIN Referrals and communication with surgeons, PCP’s, physical therapy, and/or counselors Preference for non-controlled substances such as NSAID’s Limit supply of opiates for severe, acute pain Meet frequently and monitor for signs of misuse and diversion MINIMAL ABUSE MAXIMUM CARE

32. PREVENTION DOESN’T ALWAYS WORK!

33. DIAGNOSIS OF PRESCRIPTION DRUG ABUSE/DEPENDENCE History (non-judgmental stance, admission of problems, wanting help) Pain, Anxiety Disorders, Sleep Disorders, and ADHD (ask about self-medicating) DSM-IV criteria (abuse vs. dependence) Drug seeking behavior) Signs of intoxication or withdrawal Prescription drug monitoring system Urine drug tests

34. SCREENING TOOLS Comprehensive Drug Use Screening and Assessment: NIDA-Modified ASSIST Interactive online screening tool, includes tobacco, alcohol, prescription, and illicit drugs Generates a numeric Substance Involvement Score that suggests the level of medical intervention necessary Http://www.drugabuse.gov/nidamed/screening

35. MANAGEMENT OF PRESCRIPTION DRUG ABUSE AND DEPENDENCE Identify “Stage of Change” Pre-contemplation—Security if needed Don’t enable the problem--Contact all physicians prescribing to the student and make them aware of problem Contemplation and Action Non-judgemental stance—disease model Let student know options for treatment Inpatient vs. outpatient treatment

36. WHY TREAT OPIATE DEPENDENCE ON THE COLLEGE CAMPUS? Shortage of community providers Inpatient treatment not very effective Improves retention of students Prevents overdose Decrease criminal behavior Decrease the spread of infectious disease (e.g. HIV, HCV/HBV, STI) Treatment is effective and rewarding

37. QUALIFICATIONS FOR PRESCRIBING BUPRENORPHINE/NALOXONE Be licensed to practice medicine Have the capacity to refer patients for psychosocial treatment Limit their practice to 100 patients receiving buprenorphine at any given time Be qualified to provide buprenorphineBe qualified to provide buprenorphine Certification in addiction specialty or Certification in addiction specialty or completion of an 8 hour training course completion of an 8 hour training course Receive a DEA license waiverReceive a DEA license waiver

38. CHEMICAL PROPERTIES OF BUPRENORPHINE/NALOXONE Partial opioid agonist; ceiling effect at higher doses (safer than most opioids in overdose) Blocks effects of other agonists (can’t get high off opioids while on buprenorphine) buprenorphine) Binds strongly to opioid receptor, long acting (once daily dosing)

39. BUPRENORPHINE/NALOXONE TREATMENT PROTOCOL Pretreatment Screening Can be over phone or in person Make sure student is appropriate Intake Complete history and physical Check for other drug use (i.e. benzo’s) Induction Dose and monitor with COWS Watch for precipitated withdrawal

40. BUPRENORPHINE/NALOXONE TREATMENT PROTOCOL Stabilization Follow up the next day and 1 week Consider initial supervised administration Maintenance Monthly appointments, weekly therapy, and regular urine screens Medically Supervised Withdrawal Wait until ready Taper over the course of several months

41. BUPRENORPHINE/NALOXONE IN COLLEGE HEALTH PRACTICE DeMaria et. al. J Am Coll Health. 2008 Jan-Feb;56(4):391-3. The implementation of buprenorphine/naloxone in college health practice

42. CONCLUSIONS Prescription Drug Abuse is a growing problem on the college campus Creating interdisciplinary treatment protocols may help in prevention When prevention is not effective it is important to not enable the problem and help those receptive to treatment Buprenorphine/Naloxone is a safe and effective treatment for opiate dependence that can be given on the college campus