1. PRESCRIPTION DRUG DIVERSION Christian J. Teter, Pharm.D., BCPP Associate Professor, Psychopharmacology College Of Pharmacy, University Of New England Portland, ME E-Mail: cteter@une.edu Maine Pharmacy Association, Spring Conference &Trade Show, Freeport, Maine (March 20 – 22, 2015)

2. 1. Identify which category of prescription medications demonstrates the highest rates of diversion. 2. Recognize sources of diversion for prescription opioids and stimulants. 3. Describe other problem behaviors that are associated with prescription drug diversion. LEARNING OBJECTIVES 2

3. DISCLOSURES  Christian J. Teter has no real or potential conflicts of interest to report.  The use of prescription medications for ‘off-label’ use will be discussed during this presentation: Example: among ‘healthy students’ without Attention- Deficit/Hyperactivity Disorder (ADHD) Acknowledgement: this work supported by NIDA research grants R01DA024678 and R01DA031160. Additional support provided by an Emily Jane Etherton Charitable Lead Trust Student Research Fellowship to one of the student authors (CGD). 3

4. INTRODUCTION 4

5. Key Definitions  “Medical misuse of prescription medications”  Refers to use of a prescribed psychotherapeutic medication in a manner not intended by the prescribing clinician (e.g., taking too much, intentionally using to get high)  “Diversion of prescription medications”  Refers to exchange of prescription medications that leads to use of these medications by people other than for whom the prescribing clinician intended  “Nonmedical use of prescription medications”  Refers to the non-prescribed use of a controlled, psychotherapeutic medication  Example: nonmedical use of prescription stimulants (NMUPS) 5

6. 6 1) Sleeping medication (e.g., Ambien®, Halcion®, Restoril®, temazepam, triazolam) 2) Sedative/anxiety medication (e.g., Ativan®, Xanax®, Valium®, Klonopin®, diazepam, lorazepam) 3) Stimulant medication (e.g., Ritalin®, Dexedrine®, Adderall®, Concerta®, methlyphenidate) 4) Pain medication (i.e., opioids such as Vicodin®, OxyContin®, Tylenol 3 with codeine®, Percocet®, Darvocet®, morphine, hydrocodone, oxycodone) Background Significant therapeutic overlap between these categories. Focus of this lecture (i.e., prescription stimulants and prescription opioids).

7. Why should we be concerned? 7

8. Considerations: Potential for Addiction Source: Volkow et al, 1995 (Arch Gen Psych) Note: both cocaine and MPH inhibit dopamine transporter; similar brain regions.

9. NMUPM PREVALENCE RATES & TRENDS (brief overview) DIVERSION vs. NMUPM 9

10. 10 Distribution of Past Year Nonmedical Use of Prescription Medications: 119 U.S. Colleges Source: McCabe et al 2011

11. Past Year Medical Use and Nonmedical Use of Prescription Medications (College Undergraduates) Sedative medication Opioid medication Stimulant medication Sleeping medication % reporting prescription medication use Source: McCabe SE. Arch Pediatr Adolesc Med 2008 11 By definition…Rx DRUG DIVERSION is taking place!

12. 12 Student Life Survey (SLS): 20-Year Trends from 1993 – 2013

13. 13 Trends in Past-Year Nonmedical Use of Prescription Medications by UM Undergraduate Students (2003, 2005, 2007, 2009, 2011, and 2013 SLS) Note: 1993-2001 results were not included because the measure was worded differently. Source: McCabe et al. Addictive Behaviors 2014

14. Past-Year Drug Use among UM and U.S. Undergraduate Students (Sources: 2013 SLS and 2012 MTF) Note: Past-year prevalence rates for inhalants, heroin, crystal methamphetamine use were 1% or less and not shown in this figure. 14

15. DIVERSION 15

16. 16 % approached to divert their medication Approached to Divert Medications in Lifetime (Adolescent medical users approached to divert) Source: McCabe et al. Drug Alc Depend 2011 Percentages much larger among college students!

17. 17 Prevalence of Actual Diversion among College Students Prescribed Stimulant Medication for ADHD Sources: Garnier et al., 2010; Rabiner et al., 2009; Sepulveda et al., 2011

18. 18 Past Year Diversion of Specific Prescription Stimulants by College Students Prescribed Stimulant Medication for ADHD Source: Sepulveda et al. J Pharm Practice 2011 Lower diversion rates with extended release formulations

19. 19 Sources of Lifetime Nonmedical Use of Prescription Stimulants [College] The following sources were less than 1%: aunt/uncle, other family, abroad, and internet.

20. 20 Sources of Lifetime Nonmedical Use of Prescription Opioids [College] *** ***p<.001 *** The following sources were 2% or less: aunt/uncle (2%), abroad (1%), and internet (0.2%).

21. 21 Sources of Prescription Opioids among Past Year Nonmedical Users [High School Seniors 2007-10] The following source was 2% or less: internet. Source: McCabe et al. JAH 2013

22. National Survey on Drug Use & Health (NSDUH; 2013; Public domain) 22 Example: pain reliever sources for nonmedical use past-year users aged 12(+) 2012-2013 Friends/relatives!

23. 23 “My friends need these drugs for ADD/ADHD and they give them out to myself and other friends.” (Hispanic, senior) “From friends with prescriptions, or from those who have bought large quantities from people with prescriptions.” (White, junior) “I was given them by a friend at a party.” (White, freshmen) “A friend has a prescription and sells the pills to me.” (White, senior) WOMENMEN Image source: Scientific American. The Quest for a Smart Pill. Qualitative Quotations

24. 24 Amount Paid for One Prescription Stimulant Pill: Undergraduate Students (n=225) Source: Arria et al., 2008

25. PROBLEMATIC BEHAVIORS 25

26. 26 n=1901 n=48 n=140 n=131n=1936 n=78 n=122 n=121 Drug Abuse Screening Test Results based on Source of Prescription Opioids [College] *** % positive screening for drug abuse ***p<.001 based on logistic regression using “no medical use” as reference group and adjusting for race/ethnicity, class year and living arrangement Source: McCabe et al. Addict Behav 2007

27. 27 Diversion x Medical Misuse among Past-Year Medical Users of Prescription Stimulants for ADHD (n=50 undergraduates) % reporting diverting their medication Source: Sepúlveda et al. J Pharm Practice 2011

28. 28 Diversion by Medical Misuse among Past-Year Medical Users of Controlled Medications [Secondary (grades 7-12)] % reporting diverting their medication Source: McCabe et al. Arch Pediatr Adolesc Med 2011

29. 29 Conclusions  Nonmedical use of prescription medications has been a relatively recent public health issue among many populations  Secondary and college students  Residents of Maine  General population  Much of this nonmedical use of prescription medications is driven by diversion

30. 30  Diversion: Peer sources  Most individuals obtain diverted prescription medications from friends and family No strong evidence that individuals obtain prescription medications directly via the internet Evidence suggests that a majority of individuals (specifically students) obtain prescription medications for free (e.g., from peers)  Diversion: Medication misuse  Strong relationship between misusing a prescribed medication and diverting prescribed medication Conclusions

31.  Need to reduce nonmedical use and diversion of prescription medications must be balanced against the need for clinicians and patients to have access to medications for legitimate medical purposes  Example: prescription stimulants are highly effective at treating core symptoms of ADHD; large effect sizes Treatment Considerations 31

32.  When prescribing controlled medications to adolescents and young adults:  Designate gatekeeper at home/school  Educate regarding secure location for storage  Discuss diversion (more in depth w/ ADHD meds)  Screen for SUDs, especially those with a history of nonmedical use and/or medical misuse  Consider medications with less risk for abuse/diversion  Limit/monitor medication quantity and refills  Educate regarding proper disposal of medications Treatment Recommendations 32

33. For More Information (Selected References): 33 1. Johnston, L. D., O’Malley, P. M., Bachman, J. G., and Schulenberg, J. E., (2013). Monitoring the Future national survey results on drug use, 1975– 2012: Volume 2, College students and adults ages 19–50. Ann Arbor: Institute for Social Research, The University of Michigan. 2. McCabe, S.E., Cranford, J.A., Boyd, C.J., Teter, C.J. (2007). Motives, diversion and routes of administration associated with nonmedical use of prescription opioids. Addictive Behaviors, 32(3):562-575. 3. McCabe, S.E. (2008). Screening for drug abuse among medical and nonmedical users of prescription drugs in a probability sample of college students. Archives of Pediatrics & Adolescent Medicine, 162(3):225-231. 4. McCabe, S.E., Cranford, J.A., Teter, C.J., Rabiner, D., Boyd, C.J. (2011). Use, misuse and diversion of scheduled controlled prescription medications by college students. In H.R. White, D. Rabiner (Eds.), College Substance Use: Etiology, Consequences and Prevention. Thousand Oaks, CA: Sage. 5. McCabe, S.E., West, B.T., Teter, C.J., Ross-Durow, P., Young, A., Boyd, C.J. (2011). Characteristics associated with the diversion of controlled medications among adolescents. Drug and Alcohol Dependence, 118(2-3):452-458. 6. McCabe, S.E., West, B.T., Boyd, C.J. (2013). Leftover prescription opioids and nonmedical use among high school seniors: A multi-cohort national study. J Adolescent Health, 52(4):480-485. 7. McCabe, S.E., West, B.T., Teter, C.J., Boyd, C.J. (2014). Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 2003 to 2013: Connecting the dots. Addictive Behaviors 39(7):1176-1182. 8. Sepúlveda, D.R., Thomas, L.M., McCabe, S.E., Cranford, J.A., Boyd, C.J., Teter, C.J. (2011). Misuse of prescribed stimulant medication for ADHD and associated patterns of substance use. Journal of Pharmacy Practice, 24(6):551-560. 9. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

34. Assessment Questions 34 QUESTION #1: Which of the following characteristics is consistently associated with individuals who divert their prescription medications? a. Gender b. Medication misuse c. Polypharmacy d. Race/Ethnicity

35. Assessment Questions 35 QUESTION #2: The most common source for obtaining prescription drugs to use nonmedically is which of the following: a. Friends/Relatives b. Altered prescriptions c. Drug Dealers d. Internet Websites

36. Assessment Questions 36 QUESTION #3: Which of the following methods is the most common pathway for obtaining prescription drugs to use nonmedically? a. Doctor shopping b. Theft/take without asking c. Purchase from someone d. Obtain for free

37. QUESTIONS (?)