ED Mentions and Prescriptions of Fentanyl

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Prescription Drug Abuse An Emerging Public
Health Threat
Nora D. Volkow, M.D. Director National Institute
on Drug Abuse
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Millions of Americans Abuse Prescription Drugs
Current (Past Month) Use of Prescription
Drugs for Non-Medical Purposes 2004 National
Survey on Drug Use and Health
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Annual Numbers of New Nonmedical Usersof Pain
Relievers 1965-2004
4
Numbers of Past Year Initiates (In Thousands)
2,422
2,500
2,142
2,000
1,500
1,180
Numbers of Past Year Initiates (in Thousands)
998
1,000
857
793
607
500
240
235
118
106
0
Marijuana
Cocaine
Stimulants
Sedatives
Heroin
Pain Relievers
Tranquilizers
Inhalants
Ecstasy
LSD
PCP
Source SAMHSA, 2004 NSDUH
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Drug Abuse-Related ED Visits Involving Narcotic
Analgesics 1995-2002
Emergency Department Visits
1995 1996 1997 1998 1999 2000
2001 2002
Source SAMHSA, The DAWN Report Narcotic
Analgesics, 2002 Update, September 2004.
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Issues of Concern
Percent of 12th Graders Reporting Nonmedical Use
of OxyContin and Vicodin in the Past Year
Remained High
12.0
10.5
9.5
9.6
9.3
10.0
8.0
Percent
6.0
5.5
5.0
4.5
4.0
4.0
2.0
0.0
OxyContin
Vicodin
2002
2003
2004
2005
No year-to-year differences are statistically
significant.
Between 2002 and 2005 the abuse of OxyContin by
12th graders increased significantly.
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Why Do People Abuse Prescription Drugs?
These prescription drugs, like other drugs of
abuse (cocaine, heroin, marijuana) raise brain
dopamine levels
Dopamine Neurotransmission
BUT dopamine is also elevated by natural
reinforcers
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Source Nestler, EJ and Malenka, RC, Scientific
American, pp. 78-85, March 2004.
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Stimulants (Ritalin, Adderall) Act like
Cocaine Directly in the Dopamine
Cells Distribution in the Human Brain of Cocaine
and Ritalin
Cocaine
Ritalin
Cocaine and Ritalin Act on the Same Sites in Brain
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Rate of Drug Uptake Into the Brain
iv cocaine
iv Ritalin
oral Ritalin
0.06
0.06
0.0035
0.003
0.05
0.05
0.0025
0.04
0.04
0.002
Uptake in Striatum (/cc)
0.03
0.03
Uptake in Striatum (nCi/cc)
Uptake in Striatum (/cc)
Slow!!
Fast!!
Fast!!
0.0015
0.02
0.02
0.001
0.01
0.01
0.0005
0
0
0
0
20
40
60
80
100
120
0
20
40
60
80
100
120
0
20
40
60
80
100
120
Time (minutes)
Time (minutes)
Time (minutes)
Cocaine (iv) and Ritalin (iv) produce a high
but Ritalin (oral) does not. The slow brain
uptake of oral Ritalin permits effective
treatment without a high.
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What is the Difference Between Therapeutic Use
and Abuse?

• Dose and Frequency of Dosing
• Lower, fixed regimes vs higher, escalating use
• Route of Administration
• Oral vs injection, smoking, snorting

• Expectation of Drug Effects
• Expectation of clinical benefits vs euphoria
  high
• Context of Administration
• School, clinic, home vs bar,
• discotheque

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Glucose Metabolism Was Greatly Increased By the
Expectation of the Drug
Unexpected MP
70
Change
Expected MP
Expected MP
Unexpected MP
Expected MP Got Placebo
Increases in Metabolism Were About 50 Larger
When MP Was Expected Than Unexpected
0
µmol/100g/min
Source Volkow, ND et al., Journal of
Neuroscience, 23, pp. 11461-11468, December 2003.
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Why Has the Abuseof Prescription Drugs Been
Increasing?
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As Prescriptions Increase Emergency Room Visits
ForNon-Medical Abuse Have Also Increased
24000
80000
.
Hydrocodone
70000
prescriptions
18000
emergency
60000
50000
Number of Prescriptions (in 1000s)
ED Mentions
12000
40000
Oxycodone
30000
prescriptions
emergency
6000
20000
10000
0
0
1994
1995
1996
1997
1998
1999
2000
2001
Source SAMHSA, DAWN, 2002
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Increased Media Attention
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Availability on the Internet Delivered in the
Privacy of your Home
Some reasons why you should consider using this
pharmacy No prescription required!
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NIDA
What Are We Doing About All of This?
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Development of Alternative Medications with no
Drug Abuse Potential
Activation of CB2 Cannabinoid Receptors by
AM1241Inhibits Experimental Neuropathic Pain
Suboxone Buprenorphine monotherapy
product Subutex Buprenorphine naloxone
combination product (addition of opioid
antagonist reduces abuse liability)
Source Ibrahim et al., PNAS, September 2, 2003.
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Medications to Treat Those Addicted
94 to 98
85 to 92
100
90
80
70
27 to 47
60
Receptor Occupancy
50
40
30
20
10
0
2 mg
16 mg
32 mg
Dose
Source Greenwald, MK et al, Neuropsychopharmacol
ogy 28, 2000-2009, 2003.
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National Drug Abuse Treatment Clinical Trials
Network (CTN)
Appalachian Tri-State Node
Washington Node
Northern New England Node
Oregon/ Hawaii Node
New York Node
New England Node
Ohio Valley Node
Long Island Node
Delaware Valley Node
California/ Arizona Node
Mid-Atlantic Node
North Carolina Node
Pacific Node
Southwest Node
Southern Consortium
Texas Node
Florida Node
NIDA Has Launched New Clinical Trials On

• Treatment of addiction to opiate analgesics
• Treatment of ADHD in substance abusers

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Expanded Research Efforts
Prescription Drug Abuse Program
Announcement (PA-04-110) Prescription Opioid
Use and Abuse in the Treatment of Pain
(RFA-DA-06-005) (with NIA NIDCR)
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Weve Developed and Widely Disseminated
Materials Detailing the Facts About
Prescription Drug Abuse
NIDA PRESCRIPTION DRUG RESEARCH DISSEMINATION
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Visit Our Website _at_
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We Are Working to Increase Awareness About Drug
Abuse in Primary Health Care Providers and to
Engage Them As Our Partners In Recognizing,
Preventing Treating Drug Abuse
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The FRIENDS OF NIDA
Partnerships Are Essential In Advancing the
Science of Addiction in Translating Prevention
Treatment Strategies into Practice