1. June 20, 2005 Pharmaceutical Misuse & Abuse: from National to Local What the Data Say and Mean for Montgomery County Public Schools Presenter: Kenneth Hoffman, MD, MPH

2. Objectives u Define the problem u Review the National Data u Licit and illicit drug use u Review the Maryland State Department of Education Maryland Adolescent Survey u Licit and illicit drug use u Discuss next steps

3. Desired: Appropriate Drug Use u Over the Counter (OTC) u High margin of safety (but surprises happen) u Through prescription by licensed provider u For Indicated Use u Listed on the FDA regulated package insert u For Off-Label Use u By regulated prescription (with DEA number) u for known drugs of potential abuse

4. Desired: Monitor Use of Potentially Abused Drugs u Licensed Provider Application Process for Drug Enforcement Agency (DEA) Number u Drugs of potential abuse placed into a DEA/FDA controlled substance schedule: u I: never medically indicated u II: medical indications, high abuse, non-refillable u III-IV: medical indications, high abuse, refillable u V: medical indications, some abuse concern u Prescription Drug Monitoring Act (proposed)

5. Desired: Shared Decision Making u Provider-patient shared decision for drug use u Provider believes drug useful for treatment u Explains rationale to patient u Benefits outweigh the risks u Patient agrees that drug will be useful u Understands rationale u Accepts the risks for the desired benefit u Patient takes the drug as directed u Provider gets patient feedback

6. Problem: Drug misuse u Drugs not taken as intended u Provider prescribes for wrong reason u Patient does not take drug as directed u Unintentional: forgetfulness, too many drugs, mind- altering drug interactions u Intentional: patient doesnt feel need or believes drug not working and doesnt discuss with the provider u Drugs diverted to another person u Potential problem & illegal (with prescribed drugs)

7. Problem: Drug Abuse u Interactions affecting decision-making u Individual - a voluntary decision to use u Psychologically pleasurable u Physically enhancing for specific outcomes u Environmental – friends & groups affect decision u Drug is available at a reasonable price u Drug enhances group bonding u Drug connected to desired group activities u Drug abuse more common than dependence

8. Problem: Drug Dependence u Physical dependence: tolerance or withdrawal u Addiction: Involuntary once use begins u Out of control, obsessive-compulsive use u Predisposing factor: Genetics u Psychological hedonistic pleasure u Metabolism of specific drugs u Precipitating factor: Environment u Drug available u Initial use encouraged, by social group or prescription

9. March 2004 Prescription Drug Abuse in the United States

10. Nonmedical use of prescription drugs, reported by 6.2 million persons in 2002, is second only to marijuana use. (incl. crack) Past Month Users, Ages 12 and Older (in Millions) Source: SAMHSA, 2002 National Survey on Drug Use and Health. 2/2004

11. Pain relievers account for the largest portion of nonmedical use of prescription drugs. Past Month Users, Ages 12 and Older (Thousands) Source: SAMHSA, 2002 National Survey on Drug Use and Health. 2/2004

12. Nonmedical use of prescription drugs is most prevalent among young adults and youth. Users (Percentage) Source: SAMHSA, 2002 National Survey on Drug Use and Health. 2/2004

13. Over 2 million are estimated to be dependent on or abusing prescription drugs in the past year. Past Year Dependent/Abusers, Ages 12 or Older (in Thousands) Source: SAMHSA, 2002 National Survey on Drug Use and Health. 1/2004

14. Past Year Users (Percent) Source: University of Michigan, 2003 Monitoring the Future study. 2/2004 The rate of Vicodin ® use in the past year ranks second to marijuana use among 12th graders in 2003.

15. Number of mentions Emergency department mentions of narcotic analgesics (pain relievers) rose steadily and have overtaken benzodiazepines (sedatives) in 2002. Source: SAMHSA, Drug Abuse Warning Network. 2/2004

16. DAWN ED Mention of Narcotics Mentions Source: Drug Abuse Warning Network

17. Number of mentions Oxycodone and hydrocodone both registered substantial increases in emergency department mentions in the last 5 years. Source: SAMHSA, Drug Abuse Warning Network. 2/2004

18. 1994-2002 Drug Abuse in the Montgomery County Public Schools (MCPS) Source: Maryland Department of Education Maryland Adolescent Survey Data specific to Montgomery County

19. MCPS Beer, Wine, Coolers Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

20. MCPS Hard Liquor Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

21. MCPS 5+ Drinks/Same Occasion Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

22. MCPS Cigarette Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

23. MCPS Smokeless Tobacco Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

24. MCPS Steroids for Body Building Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

25. MCPS Marijuana or Hashish Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

26. MCPS LSD Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

27. MCPS Mescaline, shroom Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

28. MCPS PCP Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

29. MCPS Amphetamine Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

30. MCPS Methamphetamine Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

31. MCPS Cocaine (not crack) Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

32. MCPS MDMA, Ecstasy Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

33. MCPS Narcotic (not Heroin) Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

34. MCPS Barbit. or Tranquilizer Use Source: 1994, 1996, 1998, 2001, 2002 Maryland Adolescent Survey

35. Discussion u Montgomery County has a drug use problem u Misuse, abuse, and dependence u Who chooses to become an addict? (rhetorical question) u What can we do? (prevention strategies) u Primary – healthy community, social norms u Secondary – identify high risk, early intervention, prescription drug monitoring u Tertiary – effective treatment easily accessed u Next steps?

36. Contact Information Kenneth Hoffman, MD, MPH Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Division of Pharmacologic Therapies 1 Choke Cherry Road, Rockville, MD 20857 Telephone: (240) 276-2701 Email: kenneth.hoffman@samhsa.hhs.gov