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The Face of Addiction

The Face of Addiction. Kenneth L. Kirsh , Ph.D. Assistant Professor Pharmacy Practice and Science University of Kentucky Clinical Psychologist, Researcher The Pain Treatment Center of the Bluegrass Lexington, KY. The Faces. Rising painkiller abuse damages lives. Concern for Youth.

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The Face of Addiction

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  1. The Face of Addiction Kenneth L. Kirsh, Ph.D. Assistant Professor Pharmacy Practice and Science University of Kentucky Clinical Psychologist, Researcher The Pain Treatment Center of the Bluegrass Lexington, KY

  2. The Faces

  3. Rising painkiller abuse damages lives

  4. Concern for Youth

  5. Prescription opiates and kids: One pill can kill Glut of drugs fuels reports of poisonings among very young children Nine-month-old Shayla Davidson was a sick little girl, and her mother had no idea why. Pale, listless and barely breathing, the baby wouldn’t wake up one day last month, even when 25-year-old Nicolle Jones rushed her to an emergency room near Cincinnati. Medical crews were stumped, too, until they noted that Shayla’s pupils were constricted, a tell-tale sign of opiate poisoning. “They kept asking me, ‘Did she get a hold of any medicine?’” Jones recalled. “I said, ‘No.’” In fact, Shayla had ingested medication, a single 60-milligram tablet of OxyContin, a powerful prescription painkiller. Shayla Davidson is recovering at her Independence, Ky., home a month after accidentally ingesting a single prescription painkiller dropped by her grandfather, Michael C. Jones. Mother Nicolle Jones, left, said the 9-month-old baby required five doses of an antidote to save her life. By JoNelAleccia Health writer msnbc.com

  6. Pain Facts • Dichotomy: Rx drug abuse increasing, but pain still undertreated • 50 million people in USA have chronic pain 1-3 • 40-60% have difficulty getting pain adequately treated 4-6 • Dembe AE, Himmelstein JS, Stevens BA, Beachler MP. 1998 • Osterweis M, Kleinman A, Mechanic D. 1987. • Verhaak PFM, Kerssens JJ, Dekker J, et al. 1998 • Glajchen M, Fitzmartin RD, Blum D, et al. 1995 • Ramer L, Richardson JL, Cohen MZ, et al. 1999 • Ward SE, Goldberg N, Miller-McCoulry V, et al. 1993

  7. Pain Treatment Today • Wherever pain is treated, a market can be expected to grow vying for access to controlled substances for misuse • All pain management in our society goes on against a backdrop of addiction, diversion and misuse • All stakeholders (practitioners, patients, regulators, insurance companies, pharmaceutical companies) need to develop realistic strategies for the use of pain medicines in a drug abusing world (including use of PMP systems where available)

  8. New* Illicit Drug Use in the US: 2006 *Past-yr initiates for specific illicit drugs among persons aged ≥12 yrs SAMHSA. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series: H-32, DHHS Publication No. SMA 07-4293). Rockville, MD

  9. Source of Pain Relievers for Nonmedical Use: 2006 *Past-yr use among persons aged ≥12 yrs SAMHSA. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series: H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.

  10. Embracing Common Definitions Opioid versus Narcotic Tolerance Physical Dependence Pseudoaddiction Substance Abuse Addiction

  11. The Core Question Freud famously asked: “Was will das Weib?” (“What does a woman want?”) I ask: “What do addicts want?”

  12. Identifying Addiction – The 4 C’s • Continued use of drug despite harm • Loss of Control re: taking the drug • Compulsive use of the drug • Cravings for the drug Note: Tolerance and physical dependence do not play a defining role

  13. Setting the Stage Challenges of Treating Pain in Kentucky: Cultural Influence

  14. Any NASCAR fans?

  15. Kentucky Facts Cottage Industry #1: Moonshine

  16. Kentucky Facts • Kentucky runs 3rd or 4th in marijuana production • Daniel Boone National Forest is often target for growing crops (690,000 acres of public property to avoid personal loss or responsibility) • KY forests are deemed to be the “marijuana belt” – good soil and climate conditions • 206,908 plants eradicated by DEA in 2003 (“drop in the bucket”) Cottage Industry #2: Marijuana

  17. Kentucky Facts • 19,366 doses of diverted pharmaceuticals were captured in Kentucky in 2003 (another “drop in the bucket”) • Eastern KY leads the nation in grams of narcotic pain medications distributed on a per capita basis • DEA: “Anecdotal information suggests that OxyContin abusers may switch to heroin and/or methadone in response to a diminished availability of OxyContin in a given region “ Cottage Industry #3: Prescription Drugs

  18. Newsweek (Sept, 2004)“Kentucky's Pain” • Three years into the war on OxyContin abuse, the casualties continue. But there's hope where it all began… • Police raids, like this one in Hazard, Ky., have led to the arrest of hundreds, including teenagers and even grandmothers

  19. Kentucky Facts • Sources: • “Hillbilly” meth – cheaper, lower quality, homemade goods • Mexican/Hispanic organizations – higher quality, more expensive Cottage Industry #4: Methamphetamine production and use is on the rise on Kentucky

  20. Prescription Drug Abuse KY Data • Used chart review to study abusers entering drug treatment • Set the stage for the prospective study that followed

  21. Seeking Treatment for OxyContin Abuse: A Chart Review of Consecutive Admissions to a Substance Abuse Treatment Facility(Commentary: What Oncologists Should Know About Prescription Opioid Abuse and Diversion)Lon Hays, MDKenneth L. Kirsh, PhDSteven D. Passik, PhDJNCCN, 2003; 1 (3): 423-428.(Journal of the National Comprehensive Cancer Network)

  22. JNCCN Article - Results • 491 admissions to Addictive Disease Unit in 15-month period • 258 (52.5%) admitted for abuse with prescription opioids • 169 men, 89 women • 219 rural, 39 urban • Mean age – 34 (SD 10.6) • 162 (62.8%) for OxyContin, 96 (37.2%) for any other opioid Hays, Kirsh Passik. JNCCN, 2003; 1 (3): 423-428

  23. JNCCN Article –OxyContin Specific Results(n = 162) • Profile: • 117 men, 45 women • mostly rural (n = 148, 91.4%) • Majority admitted to buying on the street (n = 160, 98.8%) • Only 48 (29.6%) had ever obtained it through legitimate rx • 78 (48.1%) also used other opioids (either hydrocodone products or methadone) • Mean dose: 181.3mg for average of 19.7 months • Administration (initial): oral (82%), snorting (16%), IV (1%) • Administration (admission): snorting (58%), IV (21%), oral (21%) Hays, Kirsh Passik. JNCCN, 2003; 1 (3): 423-428

  24. Street Value Vicodin $6-8 Darvocet N-100 $ 0.50 Demerol 100mg $10 Tylenol #3 $ 2-3 Percocet 5/500 $ 6-8 Morphine 30mg $15 Dilaudid 4mg $48 OxyContin $0.50-1.00/mg Methadone $ 0.50-1.00/mg Duragesic $ 1-2/mcg Actiq 200/400 µg $20 Ativan 2mg $ 2-3 Xanax 1mg $ 5-7 Valium 10mg $ 4-6 Ritalin 10mg $10-12 Fiorinal $ 3-5 Soma $ 3-4 Diversion and Abuse

  25. Opioid Exposure and Abuse Passik, Hays, Eisner, Kirsh. J Pain Pall Care Pharmacotherapy, 2006

  26. Opioid Preference and Cost Passik, Hays, Eisner, Kirsh. J Pain Pall Care Pharmacotherapy, 2006

  27. Preferred Modes of Alteration Passik, Hays, Eisner, Kirsh. J Pain Pall Care Pharmacotherapy, 2006

  28. Conclusions – Profile of Addiction • Those entering treatment for prescription drug abuse were most likely to be young, rural, Caucasian men • Most were smokers and approximately half also drank alcohol on occasion • They tended to be polysubstance abusers with multiple additional psychiatric complications such as anxiety, depression, or PTSD • This profile sheds light on the complex drug abuse problems inherent in this region of the country • The pain management offered these complex patients is often in settings where adequate pre-screening is often limited Passik, Hays, Eisner, Kirsh. J Pain Pall Care Pharmacotherapy, 2006

  29. Conclusions – Drug Preferences • Hydrocodone class abused most often overall;OxyContinsingle most preferred drug for abuse • likely a mixture of a regional effect combined with availability issues • OxyContin abuse nearly always entailed alteration of delivery system to create a more rapid, short-acting effect • thus, the top three medications preferred for abuse (OxyContin, Lortab and Percocet) were all short-acting medications in the way they were abused Passik, Hays, Eisner, Kirsh. J Pain Pall Care Pharmacotherapy, 2006; 20(2):5-13.

  30. Conclusions – Drug Preferences • Drug abusers do not seek out long-acting medications with an intact delivery system • prefer bolus doses with rapid onset and rapid offset action • schedule of an opioid is less important than the ease of rapid administration • Considering schedule III medications “safer” than schedule II medications is a gross oversimplification, and a miscalculation often made by physicians Passik, Hays, Eisner, Kirsh. J Pain Pall Care Pharmacotherapy, 2006; 20(2):5-13.

  31. What Should Prescribers Be Doing Better?And, Why Can’t They Just Look at Patients and Identify The Addicts?

  32. Physician-Ranking of Ab. Behs.(Passik, Kirsh, et al, J Pain Pall Care Pharm, 2002)

  33. Documentation: The 4 A’s • Analgesia (pain relief) • Activities of Daily Living (psychosocial functioning) • Adverse effects (side effects) • Aberrant drug taking (addiction related outcomes) Passik and Weinreb, 1998; Passik, Kirsh et al, 2004; 2005

  34. Population of Rx Opioid Users Is Heterogeneous “Self-Treaters” “Adherent” “Chemical copers” “Recreational users” “Substance abusers” “Substance abusers” “Addicted” (SUD) “Addicted” (SUD) Nonmedical Users Pain Patients

  35. Differential Diagnosis of Aberrant Drug-Taking Attitudes and Behavior • Addiction • Pseudoaddiction (inadequate analgesia) • Chemical Copers • Other psychiatric diagnosis • Encephalopathy • Borderline personality disorder • Depression • Anxiety • Criminal Intent (Passik & Portenoy 1996)

  36. Management of Risk Is a “Package Deal” • Screening & risk stratification • Use of PMP data • Compliance monitoring • Urine screening • Pill/patch counts • Education regarding drug storage & sharing • Psychotherapy & highly “structured” approaches • Abuse-deterrent formulations

  37. Future Horizons Can Pain Management Be Made ‘Safer’?

  38. Abuse Deterrent Formulation: Questions • Requirements for “reduced abuse liability” label claim • Bioequivalence to existing product? • Short-term evaluation of therapeutic efficacy? • Long-term studies in susceptible populations? • Acceptable risk? • How much does the barrier approach deter the determined? • How much do agonist/antagonist compounds retain efficacy & pose serious adversity? • Will it be possible to retain titratable or rapid onset properties required for some analgesic needs?

  39. Conclusion • Pain management is complicated and under intense scrutiny • Controlled substances are being diverted, abused, and illegally sold in growing numbers • We are all in this together and everyone can play a role!

  40. Resources • Websites of interest: • http://www.emergingsolutionsinpain.com • http://www.painknowledge.org • http://www.npecweb.org • http://www.painedu.org

  41. Contact Kenneth L. Kirsh, PhD The Pain Treatment Center of the Bluegrass 2416 Regency Rd Lexington, KY 40503 doctorken@windstream.net (859) 323-3849

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