Pharmageddon: The Rx Drug Abuse Crisis National 800 Phone Number Works just like 911 Program your cell phone! Linda B. Kalin, RN, BS, CSPI Director Linda.Kalin@unitypoint.org Hotline: 800-222-1222 Office: 712-279-3710 www.iowapoison.org 24 hours a day- 7 days a week Federally funded by HRSA iphone app is available Iowa s PCC What is Misuse? >50,000 incoming calls Over 25% of IPCC cases come from health care providers (primarily hospital ERs) 48% of IPCC cases involve children under age 6 Over 20,000 drug ID calls Staffed by RNs specially trained in toxicology Full-time MD; board-certified medical toxicologist Misuse is non-medical use or any use that is outside of a medically prescribed regimen Examples can include: Taking for psychoactive high effects Taking in extreme doses Mixing pills Using with alcohol or other illicit substances Obtaining from non-medical sources www.iowapoison.org Commonly Misused Rx Drugs Opioids: pain-killers Hydrocodone (Vicodin) Oxycodone (Oxycontin) Sedatives/Tranquilizers: treat anxiety and sleep disorders Xanax, Ativan, Valium, Soma Stimulants: ADHD, weight loss Adderall, Ritalin, Concerta Many deaths are a result of polypharmacy Combining Rx & OTC medications Taking Rx and OTC meds with alcohol Using Rx and OTC with other illicit drugs 04/07/14 1
Not Just Celebrities Generation Rx 1 in 5 students abuse Rx drugs* Most common among white students (23%) and 12 th graders (26%); no difference by gender Risk perception plays important role Deaths by Rx drugs now exceed those caused by cocaine, heroin, and methamphetamine combined and exceed deaths by MVAs 2009 National Youth Risk Behavior Survey (YRBS), CDC 4 billion U.S. prescriptions written in 2010 Today's teens are more likely to abuse Rx and OTC drugs than most illicit drugs Rx drugs are the 2 nd most abused drugs next to marijuana (3 rd is cough medicine) Legal, widely available, easily accessible and affordable Safe prescribed by MD Consumerism Two Wrongs Make an Epidemic Social Slang Teens and parents believe that Rx drugs are safe because a doctor prescribes them. Teens think their parents aren t as concerned about Rx drugs as illicit drugs. 16% of parents said they think Rx drugs are safer than street drugs. Parents don t realize that some Rx meds are a synthetic, equally potent version of the street drugs they fear. 2012 Partnership Attitude Tracking Study; Partnership at Drugfree.org Xbrs or Xanabars: Xanax Vic: Vicodin Skittles, Dex, Robo, Tussin (any OTC cold pill containing DXM) Triple Cs or CCC: Coricidin Cough & Cold medicine SIZ zurp: cough syrup & ETOH Trail Mix or Salad Bowl: Pharm Party UNDER PARENTS RADAR Warnings Signs What are opioids? Pills in medicine cabinet disappearing Continually losing prescriptions Seeking prescriptions from >1 doctor Taking higher doses despite warnings Stealing, forging or selling prescriptions Excessive mood swings Sudden drop in performance (school or work) Weight loss, agitation, insomnia (stimulants) Opiate: derivative of opium poppy (naturally occurring from plants) Includes morphine and codeine Opioid: a compound that binds to opiate receptors Semi-synthetic: created from natural opiates Fully synthetic: drugs made in a laboratory which cause the same effect as opium Endogenous opioids: naturally produced in the body (endorphins) Narcotic: legal designation 04/07/14 2
Semi-synthetic Opioids Synthetic Opioids Hydrocodone with Tylenol: Lortab, Vicodin, Lorcet Hydrocodone with ibuprofen: Vicoprofen Hydromorphone: Dilaudid Oxycodone with Tylenol: Percocet Oxycodone with aspirin: Percodan OxyContin Buprenorphine Heroin is also semi-synthetic Methadone Meperidine (Demerol) Fentanyl Suboxone/Subutex (buprenorphine) Tramadol Complex mechanism of action Nonscheduled, less abuse potential Opioids Adequate sensitivity for detecting morphine, codeine Unable to detect synthetic or semi-synthetic opioids Do NOT metabolize to codeine, morphine, or 6-acetylmorphine May result in a false-negative Oxymorphone Oxycodone Fentanyl Hydromorphone Propoxyphene Pentazocine Hydrocodone Methadone Buprenorphine Dihydrocodeine Meperidine Tramadol Opiates: Special Considerations Sustained Release or Long Half-Life Oxycontin, methadone Opiates Containing Acetaminophen Hydrocodone: Vicodin, Lorcet, Lortab Oxycodone: Percocet, Roxicet, Tylox Propoxyphene: Darvocet, Wygesic Seizures Propoxyphene, demerol, tramadol, dextromethorphan EKG Changes Propoxyphene (QRS widening) Hydrocodone (Vicodin) Contains hydrocodone plus acetaminophen #1 most prescribed drug in U.S. 131M prescriptions written in 2011 Zohydro approved 10/25/13 First hydrocodone-only opioid Pure and stronger form of HC Available in 10, 15, 20, 30, 40, 50 mg HC designed to be released over 12 hr Abusers will be able to crush it, chew or mix it with alcohol FDA Urging Tighter Controls Oct 24, 2013 FDA recommends tighter controls on drugs containing hydrocodone (Vicodin, Lortab) Involves rescheduling from Schedule III to II # of drug deaths from opioids quadrupling since 1999 Changes how doctors prescribe these drugs and imposes storage and record-keeping changes Debate: Will this reduce Rx drug abuse? Will this affect patient s access to meds for patients with legitimate chronic pain? 04/07/14 3
Oxycodone (Oxycontin, Percocet) Abuse-Proof OxyContin Used to treat moderate to severe pain Oxycontin (AKA Pharmaceutical heroin ): Produced in a 12-hr timed-release tablet Tabs: 10 mg, 20 mg, 40 mg, 60 mg and 80 mg Abusers crush the pill to bypass the timerelease mechanism-then chew, snort or inject Enhances the rush This was the ultimate score until reformulated August 15, 2010 new formulation of controlled-release Oxycontin available Drug is coated in a plastic-like polymer Designed to discourage abuse by preventing medicine from being cut, broken, chewed, crushed or dissolved Internet shows how to tamper with tamper-proof Oxy *Tablets changed from OC to OP. The number on each tablet corresponds to the milligram dosage. Unintended Consequences Iowa Opioid and Heroin OD Deaths As OxyContin abuse dropped with the new formulation, heroin abuse rose 1. Heroin is easier to use, much cheaper and easily available. Small bag of heroin can cost $5 and an 80 mg dose of Oxy may cost up to $80 (U.S. DEA) 1 Effect of Abuse-Deterrent Formulation of OxyContin, N Engl J Med 2012; 367:187-189 July 12, 2012 70 60 50 40 30 20 10 0 4 1 Rx Opioid Deaths +1,450% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 62 Heroin OD Deaths +900% 10 IDPH, 2012 Heroin (Schedule I drug) Speedball black tar heroin Teen heroin use is growing Initiations to heroin have increased 80% among 12-17 year olds since 2002 90% of teen heroin addicts are white Most users started with Rx opioids (SAMSHA) Fastest-acting opioid; extremely high potential for abuse Powder is usually cut with other chemicals Unknown dose and purity Heroin + cocaine in same syringe Produces intense rush of euphoria Combines the effects of both drugs while negating less desirable effects Heroin cancels out anxiety & paranoia created by cocaine Cocaine negates sedation of heroin use Cocaine wears off far more quickly Potentially fatal overdose 04/07/14 4
Tramadol (Ultram, Ultracet) Unique synthetic opioid analgesic Originally thought to have weak opiate effects and little potential for abuse (1995) Only available non-scheduled opiate Drug-drug interactions can occur (when combined with other serotoninergic drugs) High doses can cause seizures Fentanyl Ex. Duragesic, Actiq, Sublimaze, Abstral Synthetic heroin - 80 x stronger than morphine, faster acting than high grade heroin, lasts twice as long Manufactured illicitly as powder or tablets; often sold or mixed with heroin Not detected in routine drug screens Methadone Developed to treat heroin dependence; now widely prescribed for long-lasting pain relief Available as a low-cost generic drug Causes 30% of Rx painkiller deaths; accounts for only 2% of painkiller Rxs (CDC, 2009) Much longer half-life than other opiates; can build up in a person s body and cause toxicity Added risk when taken with sedatives or other Rx painkillers Morphine Opiate derived from the poppy plant Available in tablet, syrup, injection, suppository Sustained release preparations: MS Contin, Oramorph, Kadian, Avinza Taking a large single dose can cause severe respiratory depression, coma or death Oxymorphone (Opana) Buprenorphine Becoming much more popular with abusers (especially with Oxycontin s new formulation) Euphoria exceeds that of oxycodone and some say heroin as well Person with low tolerance will get a powerful high from ~1/8 of a high dose (40 mg ER) through snorting Used for opioid dependence Office-based, expands availability Ceiling effect Lower abuse potential; safer in overdose Sublingual administration (AKA Bupe strips ) Subutex (Bup) and Suboxone (Bup + Naloxone) Tablets withdrawn in 2012 due to accidental pediatric risks Zubsolv released 2013 (Bup + Naloxone) 04/07/14 5
Treatment of Opiate Overdose Opioid Withdrawal GOOD SUPPORTIVE CARE! NaHCO 3 for wide QRS from propoxyphene Narcotic Antagonist: Naloxone Effective at reversing respiratory depression CAUTIOUS use (if at all) with opioid-dependent May lead to pulmonary edema Duration of effect SHORTER than opioid effect Re-sedation and RR or apnea may reappear Dysphoric mood Nausea or vomiting Diarrhea Goosebumps Runny nose Dilated pupils Sweating Yawning Muscle aches Fever Insomnia Krokodil (Desomorphine) Sedative-Hypnotics Home-made opiate synthesized from codeine Toxic chemicals used in synthesis- flesh eating Iodine; strong alkalis, HCL acid, red phosphorus, lighter fluid, industrial cleaning oil Highly impure, contaminated with toxic byproducts Named for its crocodile appearance of skin More powerful and cheaper than heroin AKA poor man s heroin, dirty cousin of morphine No confirmed cases in U.S. Used to treat anxiety and sleep disorders Mechanism: enhances GABA Acts to slow normal brain function Benzodiazepines Non-benzo hypnotics Ambien (zolpidem) Sonata (zaleplon) Lunesta (eszopiclone) Barbiturates (ex. phenobarbital) Soma (skeletal muscle relaxant) Benzodiazepines (BDZ) Sedative-Hypnotic Effects Most benzo names end in "pam" or "am Xanax (alprazolam) Valium (diazepam) Klonopin (clonazepam) Ativan (lorazepam) Medically used for anxiety, insomnia, alcohol withdrawal, treat seizure disorders, inducing amnesia for uncomfortable procedures Rapid tolerance; highly addictive Withdrawal may be severe (similar to alcohol) Sedation Slurred speech Incoordination Unsteady gait Impaired attention or memory Stupor or coma Overdose risk increased with opioids or in combination with other sedatives, including alcohol 04/07/14 6
Sedative-Hypnotic Withdrawal heart rate blood pressure sweating Hand tremor Nausea/vomiting Transient hallucinations or illusions Anxiety and agitation Seizures Attention Deficit Disorder (ADD) AD/Hyperactivity Disorder Drugs Short term effects: Euphoria energy/productivity concentration and alertness appetite libido wakefuless, sleep High potential for abuse; may cause dependence and addiction Adderall Abuse (aka Addys ) Powerful combination of four time-released amphetamines AKA: Study Pill, Ivy League Crack Abused for its energetic, stimulating and euphoric effects Snorted and taken IV (more direct routes to the bloodstream and likely more dangerous) Schedule II drug Lots of Medical Risks Norepinephrine release causes constriction of blood vessels, elevated blood pressure and rapid heart rate Increased activity levels Dangerously high body temperatures Increased risk of seizures Potentially fatal arrhythmias, heart attack, or stroke Psychiatric Symptoms Psychiatric symptoms associated with use of larger doses of amphetamines include depression, anxiety, psychosis, and suicidal ideation Symptoms may depend on differences in sensitivity, frequency and quantity of use, and method of administration Abstinence syndrome may occur (dysphoria, anhedonia, irritability, insomnia, anxiety, low energy) Dextromethorphan (DXM) Over-the-counter cough suppressant >120 products contain DXM or DM Structurally related to morphine Excess doses can cause symptoms similar to PCP and ketamine Effects vary with the amount taken >Large doses of cough syrup taken (8-12 oz); often causes vomiting 04/07/14 7
Coricidin HBP Cough & Cold* 4 Plateaus* of Skittling AKA: Triple C, Red Devils, Skittles Contains 30 mg DM per tab Therapeutic dose= 30 mg q 6-8 hr Abusers: 250-1500 mg in one dose #1 stolen product from pharmacies OTC meds are perceived as no risk * Coricidin HBP Cold and Flu is commonly mistaken for the Cold and Cough and contains acetaminophen! 1. Mild inebriation 2. Described as being stoned and drunk : slurred speech, mild hallucinations, impaired short-term memory 3. Extremely strong hallucinations, confused thinking, double or blurred vision 4. Out of body dissociative sensation and loss of motor control; effects like PCP and Ketamine *May also cause N/V, difficulty breathing, heart rate, seizures, coma Other OTC highs Which contains more alcohol? Diphenhydramine (Benadryl and Dimenhydrinate (Dramamine ) Large doses can cause hallucinations and delirium Used as a cheap high Effects: somnolence, anticholinergic effects (large pupils, flushing, fever, dry mouth), tachycardia (common), N/V Overdose can lead to serious cardiac dysrhythmias, coma and death First Responders Never leave the person alone! GET HELP! Better safe than sorry! Turn the person on his/her side and monitor breathing until help arrives. Remember, a person s BAC can continue to rise even while he or she is passed out: Don t try to guess the level of drunkenness! Don t assume a person is going to be fine just by sleeping it off! 04/07/14 8