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Prevention and Treatment of Prescription Drug Abuse on the College Campus

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Prevention and Treatment of Prescription Drug Abuse on the College Campus Minimal Abuse Maximum Care Josh Hersh M.D. Staff Psychiatrist Miami University – PowerPoint PPT presentation

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Title: Prevention and Treatment of Prescription Drug Abuse on the College Campus


1
Prevention and Treatment of Prescription Drug
Abuse on the College Campus
Minimal Abuse Maximum Care
  • Josh Hersh M.D.
  • Staff Psychiatrist
  • Miami University

2
Disclosures
  • Dr. Hersh serves as a Treatment Advocate for
    Reckitt-Benckiser Pharmaceutical
  • Generic drug names are listed with Trade names
    with the exception of Pill Identification

3
Multiple articles on scope of the problem
  • Prescription Drug Abuse Rises on CampusesABC
    News
  • Report Prescription Drug Deaths
    SkyrocketFoxnews.com
  • Stimulant Abuse Rises on the College CampusThe
    Columbus Dispatch
  • Prescription Drug Abuse on the Rise in
    AmericaChicago Tribune

4
Drug Overdoses
  • Drug induced death now outnumbers suicide, injury
    by fire arms, and homicide
  • Emergency room visits from prescription drug
    overdoses doubled from 2004 to 2009
  • Overdose deaths from painkillers have risen from
    less than 2,901 in 1999 to 11,499 in 2007
  • By 2007, more teenagers used opioid analgesics
    recreationally than used marijuana1
    1Center for Disease Control

5
Famous Celebrity Deaths
  • Marilyn Monroe
  • Health Ledger
  • Michael Jackson
  • Anna Nicole Smith
  • Elvis Presley
  • Whitney Houston?

6
Prescription Opioid Drugs
Vicodin
Percocet
OxyContin
Tylenol 4 w/codeine
Lortab
Opana
7
Prescription Stimulant Drugs
  • Adderall Concerta Vyvanse

Ritalin Adderall XR
8
Prescription Sedative Hypnotics
  • Xanax Klonopin Ativan

Ambien
9
What is Prescription Drug Abuse?
  • Taking prescription medication without a
    prescription
  • Taking more prescription medication than
    prescribed (also called misuse)
  • Taking prescription medication with unintended
    routes of administration (intranasal or I.V.)

10
What is Prescription Drug Abuse, continued
  • Diverting prescription medication (selling it,
    trading it, or giving it away)
  • Harmful consequences from a controlled substance
    (DSM-IV)
  • Obtaining controlled substances from different
    doctors (Doctor Shopping)

11
What is Dependency?
  • Tolerance and withdrawal symptoms
  • Decline in normal activities
  • Unsuccessful attempts to cut down or control
    use
  • Use for longer period or larger amounts than
    intended
  • Use consumes lot of time to acquire and/or
    recover from effects
  • Continued use despite physical
  • and/or psychological problems

12
How Common is Abuse on the College Campus?
  • Ohio State University surveyed 5000
  • students in 2008 General Survey
  • Opiates--9.2 at least once per year
  • (higher in intramural sports participants)
  • Sedatives--5.1 at least once per year
  • Stimulants--4.4 at least once per year

13
How Common is Misuse?
  • World Health Association estimates about 50 of
    people do not take prescription drugs as
    prescribed
  • Maryland study found 35.8 of college students
    reported that they had diverted a drug at least
    once in their lifetime.1
  • Prescription stimulants--61.7 diversion
  • Prescription opiates--35.1 diversion
  • 9.3 of students sold medication
  • 1 J Clin Psychiatry. 2010 March 71(3)
    262269

14
Reasons for Prescription Drug Abuse
  • Stimulantscramming, delaying sleep, weight loss,
    Sleep Disorders, ADHD symptoms, recreational,
    dependency
  • Opiatespain (especially athletes), anxiety,
    insomnia, recreational, dependency
  • Benzodiazepinesanxiety, insomnia, recreational,
    dependency

15
Reasons for Co-Administration/Co-Abuse
  • Combining stimulants with alcohol to drink longer
    and counteract sedation
  • Combining opiates or benzodiazepines with alcohol
    to increase intoxication (dramatically increases
    rate of overdose)
  • Combining benzodiazepines with stimulants to
    decrease anxiety from stimulants

16
Consequences of Abuse/Dependence
  • Medical risks (cardiac and stroke risks, liver
    damage, nasal perforation, blood-borne diseases,
    overdose)
  • Psychiatric illness (depression, anxiety,
    psychosis, sleep disturbance)
  • Inability to attend classes/do schoolwork
  • Inability to work and financial problems
  • Relationship problems
  • Criminal behavior

17
Prevention of Prescription Drug Abuse
MAXIMUM CARE
MINIMAL ABUSE
  • Interdisciplinary treatment protocols to treat
    ADHD, Anxiety Disorders, Sleep Disorders, and
    pain (Minimal Abuse/Maximum Care)
  • Help physicians say NO!
  • Student education on scope of problem
  • and how to care for controlled substances
  • Legal consequences for criminal behavior (e.g.
    selling meds, forging scripts, etc.)
  • Enforcement of medical standards

18
Interdisciplinary Treatment of ADHD
MINIMAL ABUSE
MAXIMUM CARE
  • Initial Phone Screening
  • Attention Problem Evaluation (APE)
  • ADHD Workshop
  • Behavioral Interventions
  • Miami University Learning Center Planner
  • Medication
  • Academic Coaching and Therapy

19
Initial Phone Screening
  • Front desk staff refers all students with ADHD
    symptoms to phone screening
  • Counselor does brief phone screening to refer
    students to proper treatment setting
  • Students may be sent for an Attention Problem
    Evaluation, to the Learning Center, to the ADHD
    workshop, or for a complete initial evaluation

20
Attention Problem Evaluation (APE)
  • Semi-structured interview to
  • gather basic information
  • Includes diagnostic criteria for ADHD
  • Includes screening out other causes of
    inattention such as medical causes, Sleep
    Disorders, Substance Use Disorders, and other
    psychiatric disorders
  • Includes comprehensive treatment plan

21
ADHD Workshop
  • One hour psychoeducational workshop required
    prior to ADHD treatment for ALL students seeking
    medication
  • Includes education about ADHD, behavioral
    interventions, use of the Miami University
    Planner, sleep hygiene, and procedures for taking
    medication
  • Education about risks and benefits of medication
    including suggestions for avoiding misuse and
    diversion

22
Behavioral interventions for ADHD
  • How to keep a planner
  • How to use cell phone to keep
  • track of appointments
  • How to improve sleep hygiene
  • Treating college like a full time job
  • Minimizing distractions

23
The Miami University Learning Center Planner
  • The planner is an essential part of this approach
  • Every student being treated for ADHD has this
    planner
  • Teaches block scheduling, grade tracking, and
    syllabus tracking
  • Provides list of resources including workshops at
    the learning center
  • Helps students with study skills and
    procrastination

24
Medication
  • Stimulants are used according to the weekly
    planner
  • The effective dose is found and used throughout
    the remainder of treatment
  • The prescriber delineates times the student will
    take the medication and gives only amount needed
    for the month
  • Techniques are implemented to prevent tolerance
    to stimulants (i.e. drug holidays, discontinuing
    caffeine)

25
Academic Coaching and Therapy
  • Coaching and/or therapy can be required for
    medication use
  • Academic Coaching
  • Weekly Sessions
  • Utilizes the Miami University Planner
  • Provides accountability
  • Therapy
  • Address Comorbities (anxiety, substance
  • use, eating disorders, etc.)

26
MINIMAL ABUSE
MAXIMUM CARE
27
InterdisciplinaryTreatment of Anxiety Disorders
MAXIMUM CARE
MINIMAL ABUSE
  • Refer to anxiety management workshops and/or
    individual therapy
  • Try non-addictive substances first (SSRIs,
    buspirone, and beta blockers)
  • If benzodiazepines are needed, limit amount of
    benzodiazepines (i.e. 10 per month)
  • Monitor frequently for signs of misuse and
    diversion

28
MAXIMUM CARE
MINIMAL ABUSE
29
interdisciplinary treatment of Sleep Disorders
MAXIMUM CARE
MINIMAL ABUSE
  • Refer to anxiety management workshops and/or
    individual therapy
  • Referral to sleep disorders clinic for concerns
    about narcolepsy or sleep apnea
  • Try behavioral techniques (sleep hygiene, white
    noise, etc.)
  • Consider non-controlled substances
  • Limit amounts of controlled substance such as
    zolpidem (10 per month)

30
MINIMAL ABUSE
MAXIMUM CARE
31
interdisciplinary Treatment of Pain
MINIMAL ABUSE
MAXIMUM CARE
  • Referrals and communication with surgeons, PCPs,
    physical therapy, and/or counselors
  • Preference for non-controlled substances such as
    NSAIDs
  • Limit supply of opiates for severe, acute pain
  • Meet frequently and monitor for signs of misuse
    and diversion

32
Prevention Doesnt Always Work!
33
Diagnosis of Prescription Drug Abuse/Dependence
  • History (non-judgmental stance, admission of
    problems, wanting help)
  • Pain, Anxiety Disorders, Sleep Disorders, and
    ADHD (ask about self-medicating)
  • DSM-IV criteria (abuse vs. dependence)
  • Drug seeking behavior)
  • Signs of intoxication or withdrawal
  • Prescription drug monitoring system
  • Urine drug tests

34
Screening Tools
  • Comprehensive Drug Use Screening and Assessment
    NIDA-Modified ASSIST
  • Interactive online screening tool, includes
    tobacco, alcohol, prescription, and illicit drugs
  • Generates a numeric Substance Involvement Score
    that suggests the level of medical intervention
    necessary
  • Http//www.drugabuse.gov/nidamed/screening

35
Management of Prescription Drug Abuse and
Dependence
  • Identify Stage of Change
  • Pre-contemplationSecurity if needed
  • Dont enable the problem--Contact all
  • physicians prescribing to the student and
  • make them aware of problem
  • Contemplation and Action
  • Non-judgemental stancedisease model
  • Let student know options for treatment
  • Inpatient vs. outpatient treatment

36
Why Treat Opiate Dependence on the College Campus?
  • Shortage of community providers
  • Inpatient treatment not very effective
  • Improves retention of students
  • Prevents overdose
  • Decrease criminal behavior
  • Decrease the spread of infectious disease (e.g.
    HIV, HCV/HBV, STI)
  • Treatment is effective and rewarding

37
Qualifications for Prescribing Buprenorphine/Nalox
one
  • Be licensed to practice medicine
  • Have the capacity to refer patients for
    psychosocial treatment
  • Limit their practice to 100 patients receiving
    buprenorphine at any given time
  • Be qualified to provide buprenorphine
  • Certification in addiction specialty or
  • completion of an 8 hour training course
  • Receive a DEA license waiver

38
CHEMICAL Properties of Buprenorphine/Naloxone
  • Partial opioid agonist ceiling effect at
  • higher doses (safer than most opioids in
  • overdose)
  • Blocks effects of other agonists (cant
  • get high off opioids while on
  • buprenorphine)
  • Binds strongly to opioid receptor, long
  • acting (once daily dosing)

39
Buprenorphine/NaloxoneTreatment Protocol
  • Pretreatment Screening
  • Can be over phone or in person
  • Make sure student is appropriate
  • Intake
  • Complete history and physical
  • Check for other drug use (i.e. benzos)
  • Induction
  • Dose and monitor with COWS
  • Watch for precipitated withdrawal

40
Buprenorphine/NaloxoneTreatment Protocol
  • Stabilization
  • Follow up the next day and 1 week
  • Consider initial supervised administration
  • Maintenance
  • Monthly appointments, weekly therapy, and
    regular urine screens

  • Medically Supervised Withdrawal
  • Wait until ready
  • Taper over the course of several months

41
Buprenorphine/Naloxone in College Health
Practice
DeMaria et. al. J Am Coll Health. 2008
Jan-Feb56(4)391-3. The implementation of
buprenorphine/naloxone in college health practice
42
Conclusions
  • Prescription Drug Abuse is a growing problem on
    the college campus
  • Creating interdisciplinary treatment protocols
    may help in prevention
  • When prevention is not effective it is important
    to not enable the problem and help those
    receptive to treatment
  • Buprenorphine/Naloxone is a safe and effective
    treatment for opiate dependence that can be given
    on the college campus
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