Prescription Drug Abuse: Prevalence and Prevention

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Prescription Drug Abuse Prevalence and
Prevention

• Robert Pack, PhD, MPH
• Community Medicine

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Outline

• Overview
• Prevalence
• Prevention
• What NIDA says
• Other thoughts
• Our own research study on predictors
• Discussion

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Sam

• Close friend
• Charming, funny, fit, good looking
• In 2004 married father of two BS in
  horticulture worked as a pharmacy tech (10 hrs a
  week)
• Addicted for 12 years starting with Xanax Soma

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Sams addiction

• Carefully regimented sequence
• Ate set amounts of food at set times
• Certain drugs before food and after
• Slept three hours a night
• Up to 40-50 Lorcet 10/325s a day
• 4 Xanax 2 mg (plus a valium 10, an ativan 2mg and
  a Clonipin 1mg) and 40-60 Soma (Carisoprodol) at
  set times during the day plus all manner of
  other stuff
• ODd twice but was not hospitalized friends took
  care of him
• Day job prescription drug seeker and a
  stay-at-home dad to his young daughter

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Sam the dealer

• Sold Ambien and Xanax to neighborhood housewives
• Sold Adderall to students and young professionals
• Sold Vicodin and Lortab to everyone
• 40-50,000 pills in his garage (on the floor, in
  tupperware)
• Half dozen pistols (on the floor, in tupperware)
• 50,000 in cash (on the floor in a small toy
  safe)
• Cameras on every corner of the house that fed
  into a central security system in the garage
  (command and control)
• Attack dogs in the backyard
• The wrong people were starting to know who he was
• Claims to have never stolen from the pharmacy

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Sams wife

• Caught him once in 2000 and threatened divorce if
  it happened again
• Forced counselor visits
• Stayed away from the command center in the garage
  because of the mice
• Naïve until
• Sam fell asleep at dinner and would not wake up
• More about Sam later.

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Epidemiology
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NHSDUH

• Household computerized (ACASI) survey of
  incidence and prevalence of non-medical use of
  licit drugs and use of illicit drugs
• Licit (i.e., psychotherapeutic, mind-altering)
  drugs
• Pain relievers (opioids)
• Tranquilizers (barbiturates)
• Stimulants (amphetamines)
• Sedatives (benzodiazepines)
• Illicit drugs
• Such as marijuana or hashish, Cocaine, Heroin etc.

SOURCE Zacny (2004). Trends in abuse of
prescription drugs. http//www.painandchemicaldep
endency.org
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Prescription Opioids Ranked on Non-Medical
Lifetime Use

• 1,2. Darvon, Darvocet, or Tylenol with Codeine
  19 million people
• 3. Vicodin, Lorcet, or Lortab 13 million people
• 4. Percocet, Percodan, or Tylox 9.5 million
  people
• 5. Demerol 3 million people
• 6. Morphine 2 million people
• 7. OxyContin 2 million people
• 8. Dilaudid 1 million people

SOURCE Zacny (2004). Trends in abuse of
prescription drugs. http//www.painandchemicaldep
endency.org
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More than 6.3 Million Americans Reported Current
Use of Prescription Drugs for Nonmedical
Purposes in 2003
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Dependence NSDUH data

• About 259,000 people are dependent on
  prescription stimulants
• About 900,000 people in the US are dependent on
  opioids
• About 1,100,000 cocaine
• About 8,000,000 marijuana
• About 70,000,000 tobacco

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Annual Numbers of New Nonmedical Users of
Psychotherapeutics 19652001
SOURCE http//www.oas.samhsa.gov/nhsda/
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Dependence or Abuse of Specific Substances among
Past Year Users of Substances 2002
SOURCE http//www.oas.samhsa.gov/nhsda/
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Substances for Which Persons Aged 12 or Older
Received Treatment in the Past Year 2002
SOURCE http//www.oas.samhsa.gov/nhsda/
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Past Month Use of Selected Illicit Drugs among
Persons Aged 12 or Older 2002
SOURCE http//www.oas.samhsa.gov/nhsda/
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What about youth?
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Percent of Students Reporting Past Month Use of
Any Illicit Drug Has Decreased

17 Decline 2001 to 2004
Percent

P 18
Issues of Concern
Percent of 12th Graders Reporting Nonmedical Use
of OxyContin and Vicodin in the Past Year
Remained High
12.0
10.5
9.6
9.3
10.0
8.0
Percent
6.0
5.0
4.5
4.0
4.0
2.0
0.0
OxyContin
Vicodin
2002
2003
2004
No year-to-year differences are statistically
significant.
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Past Month Use of Selected Illicit Drugs Among
Youths, by Age 2003
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NIDA estimates

• Annual abuse of Vicodin was 9.5 percent among
  12th-graders in 2005, ranking it among the most
  commonly abused drugs for 12th-graders in the
  annual use category.
• From 2002 to 2005, annual prevalence of OxyContin
  use significantly increased among 12th-graders.
• Likely due to increased availability during that
  time
• Since 2001, there has been a 25 percent increase
  in annual abuse of sedatives/barbiturates among
  12th-graders

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2003 Monitoring the Future

• Among twelfth graders in the US, annual
  prevalence of Vicodin use was second only to
  marijuana use.
• Young people frequently mix prescription drugs
  with other drugs of abuse, such as marijuana and
  alcohol, putting them at risk for drug
  interactions and overdose.
• Prescription of methylphenidate and other
  stimulants to treat attention-deficit
  hyperactivity disorder (ADHD) has also increased
  in recent years.

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The situation in WV?

• No denominator based epidemiologic studies
• Anecdotes abound in the press in local lore

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Data-based WV indicators

• According to West Virginias Department of Health
  and Human Resources (DHHR 2003), in 2000,
  pharmaceutical-related treatment admissions were
  more common than admissions for any other drug
  except for marijuana.
• The DHHR also reports that West Virginias
  problem is growing over time with the number of
  prescription treatment admissions increasing by
  approximately 42 percent between 1998 and 2003
  (DHHR 2003).

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Data-based WV indicators

• Specific characteristics in West Virginia.
• Nationally, only 2.8 of admissions were for
  treatment of dependence on opiate-like drugs, but
  in West Virginia they accounted for 12.2 of
  admissions.
• Also, on average, West Virginia admissions are
  younger and more likely to be white and female
  (SAMHSA 2004).

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Data-based WV indicators

• In terms of crime, in 2002, West Virginia had
  more arrests for prescription-based opiates than
  for cocaine (Turley and Hutzel 2003).
• About half (49.2) of these arrests were for
  sales and distribution (more than cocaine,
  methamphetamine, or marijuana)

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Some media
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Some peer reviewed literature
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Gender differences

• Women are up to 48 more likely to be prescribed
  an abusable prescription drug
• However, men and women are about equally likely
  to abuse
• Except in 12-17 year olds
• Females are more likely than males to abuse
  psychotherapeutic drugs
• Men and women are also equally likely to become
  addicted

NIDA Research Report, (2005) Prescription Drugs
Abuse and Addiction
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College students stimulants

• Cross sectional study of 10,904 college students
  across the nation
• Lifetime prevalence of non-medical prescription
  stimulant abuse was 6.9
• Past year prevalence was 4.1
• Past month was 2.1
• Predictors
• Male, white, Greek affiliated, and lower GPA

Esteban McCabe, Knight, et al 2005. Addiction,
99, 96-106.
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College students pain meds

• Cross-sectional web-based survey of 9161 college
  students at one university in the midwest US
• Men lifetime 17.4 past year 10.1
• Women lifetime 15.7 past year 8.7
• Predictors previously prescribed pain meds,
  living in a house or apt., lower GPA

Esteban McCabe, Teter Boyd (2004) Drug
Alcohol Depend. 77, 37-47.
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PDA Youth in Europe

• Cross-sectional survey of 3,021 youth (12-24 yrs)
  in Europe
• Lifetime prevalence of illicit use of PD was 4.5
• Young women have higher rates of use
• Young men have higher rates of abuse

Lieb, Pfister, et al (1998), Eur Addict Res 4,
67-74.
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Opioids as gateway?

• Qualitative study of 10 heroin detox pts
• Oxycontin abuse was linked to experimentation and
  use of heroin
• Half of the ten addicts reported abusing
  prescription opioids, most notably Oxycontin,
  before initiating heroin use.
• Most reported that heroin was more readily
  available and less expensive than Oxycontin and
  that they would never have tried heroin had they
  not become addicted to opioids
• Severe limitations to this study
• Useful for discussion only

Siegal, et al (2003) American Family Physician
67(5) p. 939
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Risk perception

• Inverse correlation between risk perception and
  use of illicit substances by youth

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12th Graders Past Year Marijuana Use vs.
Perceived Risk of Occasional Marijuana Use
Percent
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Youth Risk Perception for Prescription Drugs

• Two in five teens (40 percent or 9.4 million)
  agree that Rx medicines, even if they are not
  prescribed by a doctor, are much safer to use
  than illegal drugs
• Nearly one-third of teens (31 percent or 7.3
  million) believe theres nothing wrong with
  using Rx medicines without a prescription once
  in a while
• Nearly three out of 10 teens (29 percent or 6.8
  million) believe prescription pain relievers
  even if not prescribed by a doctor are not
  addictive and
• More than half of teens (55 percent or 13
  million) dont agree strongly that using cough
  medicines to get high is risky.
• Source Partnership for a Drug Free America

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Qualitative study of prescription drug abusers at
Chestnut Ridge Hospital
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Methods

• Identified 30 self-identified prescription drug
  addicted inpatients at CRH
• Primary DOC were prescription drugs
• Nominated by CRH staff
• Informed consent
• Took about 9 months in 2004
• Interviewed with a tape recorder
• Semi-structured interview

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Methods (cont.)

• Transcribed the interviews
• Coded the transcriptions using a preliminary
  coding dictionary
• Modified the dictionary over time
• Came up with a preliminary model to test in a
  quantitative study

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Preliminary model of prescription drug abuse
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Domains

• Physical
• Cognitive
• Social
• Behavioral

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Physical

• Back Pain (Rx)
• Other Pain (Rx)
• Accidents (orthopedic injury) (Rx)
• Headaches
• Cramping (Rx)
• Surgeries (Rx)
• Other forms of illness
• Other drug craving/addiction
• Self medication (pill addiction)
• Something is wrong with me

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Cognitive

• Depression (Rx)
• Boredom
• Curiosity
• Self-loathing
• Self-esteem (lack of)
• Anxiety (Rx)
• Loss and avoidance of
• responsibilities

• Fear of stepping into life
• Entitlement
• Fear of Discomfort
• Self-Control
• Thinking about using drugs
• When things get bad
• Self-efficacy

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Social

• Peer Influence
• Friends trying to influence you
• Your influence on others
• Accessibility
• Street
• Docs
• Unwitting
• Resigned to the fact
• Candyman"
• Family
• Childhood environment
• Present family life

• Education
• Pharmacy
• Community
• Chain
• Community acceptance of problem
• Legitimacy rationalization b/c of Rx
• Friends
• Trade, i.e. sex, money, for drugs
• Social compensation for staying sick
• Hidden/invisible network
• Observational Learning

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Behavior

• Reinforcers
• Really high - a search for a better high
• Numbness
• Peer acceptance
• Maintaining baseline - more consistent high
• Clean high
• Nurturing by others

• Consequences
• Loss of control
• Divorce
• Job loss
• Relationship destruction
• Doctor shopping
• Full-time occupation
• Networking
• Withdrawal
• Side effects

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Plans for the data

• Quantitative study
• Test prevalence in community
• Develop prevention programming

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Prevention best target are youth
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Present Study

• Prevention programming
• Aimed at 6th grade youth in school
• Mentored by Health Sciences and Technology
  Academy (HSTA) youth from the high schools
• Pre-post design
• Community focused
• Parent training
• Local media and community-supported
• Funded by WV State Oxycontin settlement dollars

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Diversion
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Nurses, Physicians Dentists

• Adequate and appropriate prescription
• Early detection of abuse
• Aid in the patient recognizing the problem
• History physical screen for substance abuse
  history
• Careful notation of increases in quantity

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Pharmacists

• Detection of prescription fraud or diversion by
  looking for falsified or altered forms
• Hotlines to other pharmacies
• Driving is common for addicts
• Five-state area within two hours of here
• Electronic systems

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Sam again
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Sam again

• After the OD his wife convinced him to go to
  treatment
• She filed for divorce while he was in detox (1
  wk)
• In November Sam fell off his ex-wifes roof
  (cleaning the gutters) and shattered his leg
• Walks with a cane
• Still on some meds for anxiety and pain

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Finally

• CTN-0030 A Two-Phase Randomized Controlled
  Clinical Trial of Buprenorphine/Naloxone
  Treatment Plus Individual Drug Counseling for
  Opioid Analgesic Dependence
• Enrolling patients now
• Conducted at Chestnut Ridge Hospital in
  conjunction with Harvard Medical School
• If you have patients that meet specific
  eligibility criteria, contact
• James Lyndon McCracken, MA Research and Protocol
  Manager Department of Behavioral Medicine and
  Psychiatry WVU School of Medicine Morgantown,
  WV 26505 Tel [phone] Fax [phone]
  lmccracken_at_hsc.wvu.edu