Prescription Drug Abuse

2. Prescription Drug Abuse Walter Ling MD Integrated Substance Abuse Programs Semel Institute for Neuroscience and Human Behavior UCLA Western Conference on Addiction Universal City, California Sunday November 13, 2005 lwalter@ucla.edu www.uclaisap.org

3. Prescription Drug Abuse: Scope of the Talk • What and which drugs? • Why now? • Who abuse prescription drugs? • What can we do?

4. Definitions: What’s “abuse behavior” to us? Any non-prescribed use of a drug (NIDA, 2002 & DEA, 1970) Non-medical use of a substance for psychic effect, dependence, or suicide attempt or gesture (SAMHSA, 2002) Any harmful use, irrespective of whether the behavior constitutes a “disorder” in the DSM-IVdiagnostic nomenclature (IOM, 1996) A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one or more behaviorally-based criteria (APA, 1994)

5. Drugs of Abuse: Not Just Opioids • Opioids and other pain killers • Stimulants • Anti-anxiety drugs • Sedative/hypnotics • Feel good drugs (antidepressants) • Look good drugs (steroids) • Feeling goofy drugs (psychedelics)

6. Number of new non-medical users of therapeutics

7. Pain Prescription Abuse • In 2002, nearly 30 million people over 12 used prescribed pain relievers non-medically • 1.5 million dependent/abused prescribed pain relievers; 2nd. only to marijuana

8. Under the CounterJuly 7, 2005 CASA • “More than 15 million American abuse Opioids, Depressants & Stimulants in 2003 • Rx abuse among teens triple in 10 years • From 1992 to 2003, abuse of controlled Rx drugs grew at the rate 2x that of marijuana; 5x that of cocaine; 60x that of heroin • In 2003, 2.3 million teens 12-17 y.o. (1/10) abused a controlled Rx, 83% opioids • ER visits related to opioid medication more than doubled between 1994 and 2001 (DAWN 2002)

9. Commonly Abused Opioids Diacetylmorphine Heroin Hydromorphone Dilaudid Meperidine Demerol Hydrocodone Lortab, Vicodin Oxycodone OxyContin, Percodan, Percocet, Tylox

10. Oxycodone and Oxycodone CR • Oxycodone: OxyIR, Roxycodone • Acute pain • 4-6 hrs duration of action • Tabs, caps, liquid • Oxycodone CR: Oxycontin • Chronic pain; already tolerant to opioids • 12 hrs duration of action • Not for prn use • Tablets only

11. Emergency Dept. MentionsOf Single-Entity Oxycodone 2002 National Survey on Drug Use and Health (NSDUH), SAMHSA, Sept 5, 2003

12. Increased Media Attention

13. Oxycodone

14. “Some reasons why you should consider using this pharmacy” No prescription required! Easy Access: Role of the Internet? “Delivered in the Privacy of your Home”

16. Prescription Abusing Populations • Prescription drug abusers • Youths, elderly, women, minorities • Pain patients who abuse opiate medication • Users with comorbid psychiatric conditions • Substance abusers • Prescription drugs only • Prescription drugs plus other substances such as heroin (polydrug abusers)

17. Youth Prescription Abuse • Youth obtain prescription opioids from peers family and friends • Fastest growing prescription abuse group • Females users out number males • Prevention programs don’t work • Not reached by treatment programs • Largely unknown later consequences

18. The Elderly Prescription Opioid Abuser • Multiple medical problems • Higher incidence of chronic pain • Misunderstand directions: misuse vs abuse • Multiple prescribers • Rationalization and denial among family members, peers or care providers • Deficits presumed to be due to age • Interaction with alcohol or other drugs • Over representation of females

19. Women and Prescription Drug Abuse • Similar rates as men • More likely to use abusable prescription drugs, especially opioids and anxiolytics • 2-3 x more inclined to be diagnosed with depression and given more psychotherapeutics • Twice more prone to be addicted to drugs • Combine with alcohol more often • More elderly women, more prescriptions

20. Women and Prescription Drug Abuse • 4 million women abuse prescription drugs • Among 12-17 year olds female surpass males in use of cigarettes, cocaine, inhalants and prescription drugs • Women account for 60% of ER visits for prescription drug abuse

21. Prescription Drug Abuse in Pain Patients • Complex relationship between drug abuse and use of opioids in pain management • Overlapping vulnerability and psychopathology • Somatoform pain disorders • Consumption of other substances • Iatrogenic factors • Uncritical prescribing, inadequate monitoring, • absence of functional improvement • Inadequately treated pain • J Jage Euro J Pain 2005 9:157-162

22. Odds Ratio Source: NESARC Study Is pain associated with opioid disorders? Opioid Disorders According to Different Levels of Past 4 Week Interference Due to Pain Nearly Linear Relationship of Pain and Opioid Use Disorder

23. 24000 80000 . Hydrocodone 70000 prescriptions 18000 emergency 60000 50000 ED Mentions Number of Prescriptions (in 1000s) 12000 40000 Oxycodone 30000 prescriptions 6000 emergency 20000 10000 0 0 1994 1995 1996 1997 1998 1999 2000 2001 Source: IMS Health for Prescriptions and SAMHSA (DAWN) for Emergency Department Mentions As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster rate

24. The Fateful Triangle: Opioids Pain and Addiction • Under treatment of pain • Increasing availability of opioid analgesics • Increase in abuse of prescription opioids

25. Opium“…Lull all pain and anger, and bring forgetfulness of every sorrow.” - Odyssey “Among the remedies which it has pleased Almighty God to give to man to relieve his suffering, none is so universal and so efficacious as opium.” - Thomas Syndenham, 1680

26. Opium • “It banishes melancholy, begets confidence, converts fear into boldness, makes the silent eloquent and bastards brave” John Brown

27. Opium Opiate—an unlocked door in the prison of identity. It leads into the jail yard. - Ambrose Bierce, The Devil’s Dictionary The junk merchant does not sell his product to the consumer, he sells the consumer to the product. He does not improve and simplify his merchandise, he degrades and simplifies the client. - Burroughs

28. From Pain Relief to Addiction: Role of the Opiates • Relieve pain • Relieve pain and suffering • Relieve suffering and misery • Make you feel better • Make you feel good • Make you “high”

29. Characterizing Pain • Pain: An unpleasant sensory and emotional experience arising from the actual or potential tissue damage or described in terms of such damage. It is always subjective. Each individual learns the application of the word through experiences related to injury in early life.—IASP

30. Acute vs Chronic Pain • Acute pain is for survival • Chronic pain serves no purpose Sufferers of chronic pain suffer for nothing • Concern in acute pain: what pain does the patient have? • Concern in chronic pain: what patient does the pain have? .

31. Pain: More than a Feeling Feeling (sensory experience) : Pain Meaning (emotional & cognitive): Suffering --Historical—early life • Learned—experience • Private—subjective • Unique—individual Action– Expression of the “word”: Behavior Chronic pain is not having lots of pain; its having pain and behaving like a chronic pain patient

32. Chronic pain Early trauma Loss of mastery Loss of control Loss of sense of self Cognitive error “personalization” Over interpretation “catastrophy” Addiction Early trauma Loss of mastery Loss of control Loss of self efficacy Cognitive error “nirvana” Denial Chronic Pain and Addiction: Common Features

33. Addiction in Pain Patients • Published rates of abuse and/or addiction in chronic pain populations are ~ 10% (3-18%)* • Known risk factors in the general population also predict prescription opioid abuse in pain patients Fishbain, 1986, 1992; Kouyanou et al., 1997 *Adams et al., 2001; Brown, 1996;

34. Who’s at Risk and How to Tell? • Four ways to identify patients at risk: • History: personal history & family history • Screening instruments • Behavioral check lists • Therapeutic maneuver

35. History • What predicts addiction? • Personal history of drug abuse • Family history of drug abuse • Current addiction to alcohol or cigarettes • History of problems with prescriptions • Co-morbid psychiatric disorders Same predictors as in non-pain patients

36. Screening Instruments • CAGE • MAST • DAST • Nonspecific for pain patients

37. Ongoing Warning Signs • Altered/forged prescription • Theft of prescription pads • Frequent requests to move appointments up • Keep pain appointments; miss others • Grossly disheveled/impaired • Request early refills/frequent phone calls • Lost/stolen prescriptions • Frequent unauthorized dose escalations • Positive urine tests for illicit drugs

38. Is the pain patient addicted? (“Drug-seeking”  Addiction) Drug-seeking or increased requests for pain medication  pathology/pain of new source Detailed pain work-up No new pain pathology  opioid dose Improved functioning Absence of toxicity Unimproved functioning Presence of toxicity therapeuticdependence Addictive disease pseudoaddiction

39. Can Addicts be Treated with Opiates? • Yes, but with caution • Increase recovery activities • Provide support systems • Treat co-morbidity • Remember Non-opioid analgesics • Non-pharmacological treatments • Cognitive behavior therapies

40. Treating Pain with Opioids: What Can We Expect to Achieve? • Reduction in pain and suffering • Meaningful pain reduction • Improved functionality • Meaningful improvement in activities

41. Meaningful Pain Reduction: How Much? • Using a VAS or Numeric scale of 0-10 • (4-6= mod pain; 7-10= severe pain) • For Moderate pain ( mean=6) • Meaningful reduction=2.4 (40%) • Very much better=3.5 (45%) • For Severe pain (mean=8) • Meaningful reduction=4.0 (50%) • Very much better=5.2 (56%) M. Soledad Cepeda et al. Proc 10th world Cong on Pain vol 24; pp 601-609

42. Meaningful Functional Improvement: My Favorites • Patient perspective of “improvement” • Used to do, can’t do now, would like to do again • Could be physical, social, recreational • With friends, family, church • Achievable, enjoyable and meaningful • Hobbies • Volunteer work

43. Conclusion: Prescription Drug Abuse • Escalating problem • Heterogeneous population • Youth • Elderly • Women and minorities • Chronic pain patients • Pain and addiction – complex disorder

44. Acknowledgment and Thanks • Conference organizers • Friends and colleagues: • ISAP & elsewhere • NIDA • You the audience