1. Prescription Drug Abuse Kyle M. Kampman MD University of Pennsylvania kampman_k@mail.trc.upenn.edu

2. Outline Sedative abuse Sedative abuse Sleepers Sleepers Stimulant abuse Stimulant abuse Oral pain reliever abuse Oral pain reliever abuse

3. Teaching Points The ability to competently manage prescription drug abuse in clinical practice is rare Major issue – learning when to prescribe, what drug at what dose – and when not to, i.e., the management of substance abuse/addiction This lecture is focused on getting across the basics of management of: 1) sedative abuse, 2) use of sleeping medication, 3) stimulant abuse, and 4) oral pain reliever medication

4. Pre-Lecture Exam Question 1 The mechanism of action of benzodiazepine: a.Inhibits Gaba A b. Potentiates Gaba A c.Inhibits SER d.Stimulates Alpha 1 e.A and D

5. Pre-Lecture Exam Question 2 Stimulant drugs can be effective for: a. ADHD b. ADD c. Schizophrenia d. Weight reduction e. Narcolepsy

6. Pre-Lecture Exam Question 3 Physical dependence is: a. A normal response b. An abnormal response c. Does not cause tolerance d. Does not cause dependence e. Is all of the above

7. Pre-Lecture Exam Question 4 Writing prescriptions for pain medication involves all but: a. Write like a check b. Specify pharmacy name c. Get to know pharmacist d. Usually no refills e. Avoiding contact with family

8. Benzodiazepines High potency short half life alprazolam (Xanax) lorazepam (Ativan) triazolam (Halcion) long half-life long half-life clonazepam (Klonopin)

9. Benzodiazepines Low potency Low potency short half-life oxazepam (serax) temazepam (Restoril) long half-life chlordiazepoxide (Librium) Chlorazepate (Tranxene) diazepam (Valium) flurazepam (Dalmane)

10. Benzodiazepines Mechanism of action Mechanism of action – Potentiate GABA A receptor activity – Similar mechanism of action Barbiturates Barbiturates Alcohol Alcohol – Tolerance – Withdrawal

11. BZ Withdrawal Anxiety Anxiety Agitation Agitation Increased sensitivity to lights, sound Increased sensitivity to lights, sound Paresthesias, strange sensations Paresthesias, strange sensations Muscle cramps Muscle cramps Myocolonic jerks Myocolonic jerks Insomnia Insomnia Dizziness Dizziness Seizures, delirium Seizures, delirium

12. E R Mentions of Benzodiazepines

13. Rationale Benzodiazepine Use Consider other alternatives Consider other alternatives Avoid benzos for drug abusers Avoid benzos for drug abusers Avoid writing large scripts Avoid writing large scripts Avoid refills Avoid refills Avoid the most abusable Avoid the most abusable

14. Treating Insomnia Look for an underlying cause Look for an underlying cause Start with sleep hygiene Start with sleep hygiene Medication options Medication options Antihistamine Antihistamine Non - benzodiazepine hypnotic Non - benzodiazepine hypnotic Sedating antidepressant Sedating antidepressant benzodiazepine benzodiazepine

15. Stimulant drugs Amphetamines Amphetamines Dextroamphetamine (Dexadrine) Dextroamphetamine (Dexadrine) Mixed (Adderall) Mixed (Adderall) Diet Pills - Phentermine et al. Diet Pills - Phentermine et al. Methylphenidate (Ritalin) Methylphenidate (Ritalin)

16. Stimulant drug abuse

18. Use of prescription pain relievers ages 12-17

19. Favorite Narcotics Hydrocodone Hydrocodone Oxycontin Oxycontin Combo meds are schedule III Combo meds are schedule III Oxycontin can be snorted or chewed Oxycontin can be snorted or chewed

20. Sources of Narcotics Deceived physicians Deceived physicians Dishonest physicians Dishonest physicians Genuine pain patients Genuine pain patients Thefts or diversion from pharmacies Thefts or diversion from pharmacies Internet Internet

21. The Availability of Opiates over the Internet Robert F. Forman, Ph.D Treatment Research Institute University of Pennsylvania

25. Pain and Addiction Can the treatment of pain cause addiction? Can the treatment of pain cause addiction? How is pain managed in the addicted? How is pain managed in the addicted?

26. Inadequate treatment of cancer pain 40-60% oncology patients--inadequate medication 40-60% oncology patients--inadequate medication Minorities -3 times more likely Minorities -3 times more likely Women Women Elderly Elderly Fears: respiratory depression, tolerance, addiction Fears: respiratory depression, tolerance, addiction Confusion between “Dependence” and “Addiction” Confusion between “Dependence” and “Addiction”

27. Physical Dependence (Normal response) Tolerance - reduced effect from level dose, may begin with 1st dose Tolerance - reduced effect from level dose, may begin with 1st dose Withdrawal - Characteristic symptoms when drug abruptly stopped, may continue for days, weeks, months Withdrawal - Characteristic symptoms when drug abruptly stopped, may continue for days, weeks, months

28. Dependence (Addiction) Tolerance Tolerance Withdrawal Withdrawal More use than intended More use than intended Unsuccessful efforts to cut down Unsuccessful efforts to cut down Spends excessive time in acquisition Spends excessive time in acquisition Activities given up because of use Activities given up because of use Uses despite negative effects Uses despite negative effects DSM-IV

29. Pseudo-addiction Focus on obtaining opioids for pain relief Focus on obtaining opioids for pain relief Looks like addiction Looks like addiction manipulation, manipulation, doctor shopping, doctor shopping, multiple ED visits multiple ED visits But it disappears with adequate meds But it disappears with adequate meds

30. Pseudo-addiction Opioid Renewal Clinic at PVAMC 170 consecutive chronic pain patients 170 consecutive chronic pain patients Referred by primary care providers Referred by primary care providers All identified with “aberrant behavior” All identified with “aberrant behavior” Followed in special clinic (ORC) Followed in special clinic (ORC) Nurse practitioner, pharmacist Nurse practitioner, pharmacist Clinical algorhythms, treatment agreements Clinical algorhythms, treatment agreements Close follow up and monitoring Close follow up and monitoring 58 patients (34%) behavior resolved 58 patients (34%) behavior resolved 22 patients (13%) addicted 22 patients (13%) addicted

31. Chronic pain Headache (various types) Headache (various types) Backache (various etiologies) Backache (various etiologies) Reflex sympathetic dystrophy Reflex sympathetic dystrophy Diabetic Neuropathy Diabetic Neuropathy Fibromyalgia Fibromyalgia Tic douloureux Tic douloureux Post-herpetic (Shingles) Post-herpetic (Shingles) Ulcerative colitis Ulcerative colitis

32. Chronic Pain and Addiction Few trials conducted Few trials conducted Some say addiction not increased Some say addiction not increased Others show high rates drug abuse Others show high rates drug abuse Often addiction precedes pain Often addiction precedes pain

33. Multi-disciplinary treatment approach Diagnosis of pain etiology Diagnosis of pain etiology Psychological evaluation Psychological evaluation Multimodal treatment Multimodal treatment

34. Non- opiate options Acetominophen Acetominophen Ibuprophen Ibuprophen Aspirin Aspirin Combinations - caffeine adjuvant Combinations - caffeine adjuvant Tramadol (low opiate receptor activity) Tramadol (low opiate receptor activity) Carbamazepine, Gabapentin Carbamazepine, Gabapentin Anti-depressants (amitryptiline et al) Anti-depressants (amitryptiline et al)

35. Non medication strategies Biofeedback Biofeedback Hypnosis Hypnosis Group and individual psychotherapy Group and individual psychotherapy Cognitive therapy Cognitive therapy Family therapy Family therapy Exercise Exercise Acupuncture Acupuncture TENS and related stimulation TENS and related stimulation Nerve blocks Nerve blocks

36. Patients with substance abuse history Substance abuse may be a risk factor Substance abuse may be a risk factor Extra care is necessary Extra care is necessary Specialty trained clinician Specialty trained clinician Signed contract Signed contract Close monitoring Close monitoring

37. Careful with prescriptions One prescriber only One prescriber only Write like a check Write like a check No pre-printed DEA no. No pre-printed DEA no. Specify pharmacy name Specify pharmacy name Get to know pharmacist Get to know pharmacist Usually no refills Usually no refills Stay in touch with family Stay in touch with family

38. kampman_k@mail.trc.upenn.edu

39. Post-Lecture Exam Question 1 The mechanism of action of benzodiazepine: a.Inhibits Gaba A b. Potentiates Gaba A c.Inhibits SER d.Stimulates Alpha 1 e.A and D

40. Post-Lecture Exam Question 2 Stimulant drugs can be effective for: a. ADHD b. ADD c. Schizophrenia d. Weight reduction e. Narcolepsy

41. Post-Lecture Exam Question 3 Physical dependence is: a. A normal response b. An abnormal response c. Does not cause tolerance d. Does not cause dependence e. Is all of the above

42. Post-Lecture Exam Question 4 Writing prescriptions for pain medication involves all but: a. Write like a check b. Specify pharmacy name c. Get to know pharmacist d. Usually no refills e. Avoiding contact with family

43. Answers to Pre and Post Lecture Exams 1. B 2. D 3. A 4. E