Prescription

1
Prescription OTC Drug Abuse What You Dont
Know Can Hurt You

• Laura G. Leahy
• MSN, APN, CNS, FNP, BC

2
Objectives

• The purpose of this presentation is to provide
  information regarding the abuse of prescription
  and over-the-counter medications and offer
  solutions for treatment and prevention

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By the end of the presentation, the
audience should be able to

• Discuss the most widely abused OTC prescription
  medications
• Identify the most vulnerable populations
• Identify solutions for prevention and treatment
  of prescription OTC drug abuse

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Profile of a Prescription Drug Abuser

• Joey the 14 year old on Adderall for ADHD whose
  friends encourage him to share
• Linda the 47 year old home maker who has been
  stressed and not sleeping

5

• Pete the 32 year old roofer who complains of
  chronic back pain
• Mr. Jones the 70 year old retiree whose physician
  recommended he take aspirin to decrease the risk
  of heart attack

6

• Janie the 20 year old college student who feels
  uncomfortable in social settings
• Frank the 23 year old med student who is getting
  behind in his work

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Commonly Abused Prescription Drugs

• Depressants
• Dissociative Anesthetics
• Opioids Morphine Derivatives
• Stimulants
• Anabolic Steroids

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Depressants

• Barbiturates
• Amytal, Nembutal, Seconal, Phenobarbital
• Schedule II III
• Typically injected or swallowed
• Benzodiazepines
• Ativan, Klonopin, Xanax, Valium, Halcion
• Schedule IV
• swallowed
• Flunitrazepam
• Rohypnol
• Schedule IV
• Swallowed, snorted

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Effects of Depressants

• Decrease pain anxiety
• Lowered inhibitions
• Slowed pulse breathing
• Poor concentration, confusion
• Respiratory depression, arrest
• Drowsiness, dizziness, depression
• Unusual excitement
• Memory loss, amnesia

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Depressants In the Brain

• Slow brain activity
• Act on GABA Benzodiazepine receptors
• Produce calming effect
• Potential for physical dependence
• Potential for addiction

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• Severe Withdrawal Effects
• Seizures following rebound in brain activity with
  reduced dose or discontinuation
• Do not use with
• Alcohol
• Opioids
• Some OTC cold allergy preps

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Dissociative Anesthetics

• Ketamine
• Vitamin K, Special K
• Schedule III
• Typically snorted or smoked

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Effects of Ketamine

• Increased heart rate
• Increased blood pressure
• Memory loss
• Impaired motor function
• Numbness
• Delirium
• Depression
• Respiratory depression, arrest

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Opioids Morphine Derivatives

• Codeine
• Empirin, Fiorinal, Fioricet, Robitussin A-C,
  Tylenol w/ Codeine
• Schedules II, III, IV
• Injected and swallowed
• Fentanyl
• Actiq pops, Duragesic, Sublimaze
• Schedule II
• Injected, smoked, snorted, lollipops
• Morphine
• Roxanol, Duramorph
• Schedule II III
• Injected, swallowed, smoked

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• Opium
• Laudanum, Paregoric
• Schedule II III
• Swallowed smoked
• Other opioid pain relievers
• Oxycodone, Oxycontin, Percocet, Hydrocodone,
  Darvocet, Dilaudid, Viocodin, Lortab, Lorcet,
  Demerol
• Schedule II, III, IV
• Swallowed, chewed, injected, suppositories,
  crushed, snorted

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Effects of Opioids

• Pain relief
• Euphoria
• Drowsiness, sedation
• Respiratory depression, arrest
• Confusion
• Unconsciousness, coma
• High tolerance addiction

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Opioids in the Brain

• Attach to opioid receptors in the brain and
  spinal cord
• Block perception of pain
• High potential for tolerance
• High potential for addiction

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• Severe respiratory depression or death following
  single large dose
• Severe withdrawal symptoms
• Do not use with
• Alcohol
• Antihistamines
• Barbiturates
• Benzodiazepines
• General anesthetics

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Stimulants

• Amphetamines (all Schedule II)
• Dexedrine, Adderall
• Swallowed, smoked, snorted
• Cocaine (including crack cocaine)
• Injected, smoked, snorted
• Methamphetamine
• Desoxyn
• Injected, swallowed, smoked, snorted
• Methylphenidate
• Ritalin, Concerta
• Injected, swallowed, snorted

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Effects of Stimulants

• Increased heart rate blood pressure
• Increased metabolism
• Exhilaration
• Increased energy
• Increased mental alertness/concentration
• Decreased appetite, weight loss
• Hallucinations, paranoia, delirium, psychosis
• Aggression, irritability, impulsivity

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Stimulants in the Brain

• Enhance brain activity through dopamine
  norepinepherine pathways
• Increase alertness, attention, energy
• Potential for physical dependence
• Potential for addiction

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• Cardiovascular failure
• Lethal seizures
• No significant withdrawal
• Rebound depression upon withdrawal
• Do not use with
• OTC decongestants
• Antidepressants (unless monitored closely)
• Some asthma medications

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Anabolic Steroids

• Steroids
• Anadrol, Equipoise, Durabolin
• Depo-Testosterone, Oxandrin
• Schedule III
• Swallowed, injected, topical

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Effects of Steroids

• Increased Blood Pressure
• Hostility, aggression
• Acne
• Growth suppression
• Reduced sperm production (males)
• Gynecomastia (males)
• Beard growth, facial hair (females)
• Menstrual irregularities (females)

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Over-the-Counter Drugs

• Sleep aids
• Cough suppressants
• Pain relievers

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Sleep Aids

• Psychoactive effects in large doses
• Antihistamines
• The PMs, Benadryl, Sominex
• Doxylamine
• Unisom
• Dimenhydrinate
• Gravol, Dramamine

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Cough Suppressants

• Dextromethorphan Based Products
• Over 125 available
• Caplets, liquid form
• Doses 360mg
• Hallucinations, dissociation, amnesia, numbness
• effects similar to ketamine PCP
• May last 6-8 hours
• Found under various other names
• Cold flu prep
• Cough cold prep

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Pain Relievers

• Aspirin
• Increased risk of bleeding, ulcers
• NSAIDs
• Ibuprofen, Motrin, Alleve
• Increased risk of bleeding, ulcers, GI issues
• Increases Lithium levels
• Acetominophen
• Tylenol, the PMs
• Risk of liver damage, failure with over use
• Avoid with Hepatitis C patients

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Vulnerable Populations

• Teens
• Ages 12-18
• College Students
• Ages 18 to 25
• Elderly
• Over 65

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Generation Rx

• 2004 Teen Studies
• 1 in 5 teens have abused Vicodin
• 1 in 5 teens have abused Oxycontin
• 1 in 10 teens have abused Ritalin or Adderall
• 1 in 11 teens have abused OTC Cough Preps

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• Teens view prescription OTC drugs as much
  safer than illicit street drugs
• Ease of access is major factor
• More sophisticated familiar

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• Use of MJ down since 1998
• Use of MDMA (Ecstasy) among teens is down 25
  since 2001
• In 2001 12 of teens reported abuse
• In 2004 9 reported abuse of Ecstasy

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Generation Rx Drugs of Abuse

• Marijuana 8.7 million 37
• Inhalants 4.4 million 19
• Vicodin 4.3 million 18
• Oxycontin 2.3 million 10
• Ritalin/Adderall 2.3 million 10
• Cough Suppressants 2.2 million 9
• Cocaine/Crack 2.2 million 9

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• Ecstasy 2 million 9
• Methamphetamine 1.5 million 8
• LSD 1.4 million 6
• Ketamine 1.1 million 5
• Heroin 1 million 4
• GHB 1million 4

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College Students

• Increased abuse of Vicodin, Opioids, Stimulants,
  and Sedatives

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• Highest Abuse Rates for College Students
• Whites 4.9
• 1.6 Blacks, 1.3 Asians
• Fraternity/Sorority Members
• 8.6 members vs 3.5 non-members
• Lower grade earners
• 5.2 GPA 3.0
• Northeastern Universities

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Campus Stimulant Abuse

• Admission Criteria
• More competitive 5.9
• Competitive 4.5
• Less Competitive 1.3
• Geographical Region
• Northeast 6.3 South 4.6
• West 3.2 North Central 2.8
• Commuter Status
• Residing on campus 4.6
• Commuting to school 1.2

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Elderly

• High risk for prescription OTC abuse
• Polypharmacy
• Multiple providers
• Decreased metabolism, nutrition
• Discontinued medications not disposed of
• Changes in memory, cognition
• Account for 1/3rd of all prescriptions in US

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Consequences of Abuse in Elderly

• Increased hospitalizations
• Risk of falls
• Cardiac and/or respiratory failure
• Dehydration
• Change of mental status
• Coma
• Death

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Recognizing Abuse

• Multiple participants
• Practitioners
• 70 visit PCP at least 1x every 2 years
• Screen for abuse, ask the questions
• Monitor usage refill requests
• Adequately treat symptoms (especially pain)
• Pharmacists
• Monitor multiple rxs from multiple practitioners
• Patients
• Take meds as prescribed (
• Be honest with your practitioner about ALL drugs
• Families
• Monitor rxs in home including OTCs
• Friends

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Treating Addiction

• Abuse is a Behavioral Issue
• Addiction is a BRAIN DISEASE

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Treatment Components

• Detoxification
• Counseling/Behavioral Therapies
• Pharmacological Therapies

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Detoxification

• Medical Intervention to safely withdrawal from
  addictive medications
• May require inpatient hospitalization
• With Benzos it may take months to fully detox
  from the drugs
• May require pharmacologic interventions

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Counseling

• Multiple Modalities
• Individual
• Group such as NA or AA
• Family therapy
• Cognitive Behavioral Therapy
• Contingency management

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Pharmacotherapies

• Counter effects of the abused drug on the brain
  and behavior
• Used to relieve withdrawal symptoms
• Used to treat overdose
• Used to overcome drug cravings

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Treating Opioid Addiction

• Combination Treatment
• Detoxification
• First line to treatment
• Behavioral Interventions
• Pharmacotherapy
• Naltrexone
• Blocks effects of opioids
• Methadone
• Synthetic opioid, blocks the effects, relieves
  cravings
• Buprenorphine
• Decreased side effects, both agonist antagonist
  at opioid receptor site in brain

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Treating CNS Depressant Addiction

• Medically Supervised Withdrawal
• Very slow taper of drugs
• Abrupt withdrawal can be life threatening
• Risk of seizures
• CBT
• Modifying thinking, expectations, behaviors while
  increasing skills to cope with lifes stressors

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Treating Stimulant Addiction

• Taper of drug dosage to ease withdrawal symptoms
• Behavioral Therapies
• CBT Group Therapy
• Contingency management
• Earn vouchers for drug free urine tests that can
  be exchanged for items that promote healthy living

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Prevention of Drug Abuse

• Talk, Talk, Talk

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• Parents talk with your kids
• Educators talk with your students
• Couples talk with one another
• Patients talk with your practitioner
• Seek out friends and family

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• Dispel the myths
• Prescription drug abuse is NOT safer than
  illicit/street drug abuse
• More is not better
• Your kids/spouse/loved one will not hate you for
  intervening

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• Monitor the drug cabinet
• More kids, friends, and family obtain the
  prescription drugs they abuse right from your own
  medicine cabinet

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• Dispose of unused, unneeded, expired prescription
  and OTC drugs per the new federal guidelines

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Drug Disposal Guidelines

• Take out of original container
• Mix with undesirable substance
• Coffee grounds, sand, kitty litter
• Put in impermeable, nondescript containers
• Empty cans, sealable bags
• Throw containers in the trash
• Only flush down the toilet if patient info
  instructs it is safe to do so
• Return unused, unneeded, expired prescription
  drugs to pharmaceutical take-back locations for
  safe disposal

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• Set an example
• Be aware
• Offer Support
• Offer Encouragement

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Conclusions

• Prescription and Over-the-Counter Drug Abuse is
  on the rise
• Youth are among the highest abusers today,
  choosing whats at home to whats on the street

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• Commonly prescribed medications are frequently
  the target of abuse and misuse
• Common OTCs such as cough suppressants, cold
  preps, and pain relievers can contribute to
  serious adverse events when abused

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• Prevention of Prescription and OTC drug abuse
  starts at home by monitoring the medicine cabinet
• Observation and Awareness can be the best
  preventative medicine

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• Addiction is a Brain Disease in need of treatment
• The most effective treatments include therapies
  and occasionally pharmacotherapy

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• Keep an eye out for the elderly
• They are at high risk for prescription and OTC
  drug abuse and complications

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Questions Comments
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References

• Generation Rx (11-16-05) retrieved from
  www.drugfree.org
• Legal but Lethal retrieved from
  http//www.family.samhsa.gov/get/otcdrugs.aspx?pri
  ntid1
• Selected Prescription Drugs with Potential for
  Abuse (4-05) retrieved from www.drugabuse.gov
• National Institute on Drug Abuse Research Report
  Series (8-05) retrieved from NIDA website
  www.drugabuse.gov

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• Community Drug Alert Bulletin (8-05) retrieved
  from NIDA website www.drugabuse.gov
• Over the Counter Drug Facts (2006) retrieved from
  http//www.justthinktwice.com/drugfacts/otc.cfm.
• Getting High on Prescription and Over-the-Counter
  Drugs is Dangerous brochure retrieved from
  www.drugfree.org
• What Every American can do to Prevent Misuse of
  Prescription Drugs (2-20-07) retrieved from
  http//www.whitehousedrugpolicy.gov/news/press07/0
  22007.html