Chronic Pain and Addiction April 10-12, 2012

Walt Disney World Swan Resort

Dr. Barbara Krantz Medical Director/Corporate Director of Research Fellow of the American Society of Addiction Medicine Diplomat of the American Board of Addiction Medicine

Accepted Learning Objectives: 1.  Overview on Drug Abuse in US, focusing on

national Statistics on nonmedical psychotherapeutics including older adult trends with chronic pain diagnosis.

2.  Describe the effects and consequences of prescription pain abuse as it progresses over time.

3.  Advocate the importance of continuing education on addiction for pain management providers.

What is Prescription Drug Abuse?

•  Prescription drug abuse is the intentional use of a medication without a prescription; or in a way other than as prescribed; or for the experience or feeling its causes.

•  The three classes of prescription drugs that are most commonly abused are: –  Opioids, which are most often prescribed to treat pain –  Central nervous system (CNS) depressants, which are used to

treat anxiety and sleep disorders –  Stimulants, which are prescribed to treat the sleep disorder

narcolepsy and attention-deficit hyperactivity disorder (ADHD).

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Media Attention

Prescription Drug Abuse

What is driving the high prevalence?

- misperceptions about their safety - increasing environmental availability - varied motivations for their abuse - consumer culture amenable to “quick fix”

Among those who abuse prescription drugs, high rates of other behaviors, including abuse of other drugs and alcohol, have also been reported.

Highlights - Global •  Globally, it is estimated that 13.5 million people take opioids, including 9.2 million

who use heroin. WHO, 2010

•  In many countries (notably those from Europe), the majority of heavy drug users seeking treatment are primarily addicted to opiates UNDCP, 2009

•  Worldwide abuse of prescription drugs will soon exceed illicit drug use, warned a United Nations panel charged with monitoring global patterns of drug abuse.

•  In its 2006 report, the International Narcotics Control Board (INCB), based in Vienna, Austria, noted that medications containing narcotic or psychotropic drugs are becoming the drugs of choice for many abusers, and that drug traffickers are responding to the demand through increased diversion and the production of counterfeit drugs.

•  The problem is particularly acute in the United States, where cannabis is the only illicit drug that is more widely abused than prescription drugs, including analgesics, stimulants, sedatives, and tranquilizers, according to the INCB. Between 1992 and 2003, the number of US individuals abusing prescription drugs increased from 7.8 million to 15.1 million.

National Key Points

•  The non-medical use or abuse of prescription drugs is a serious and growing public health problem in this country. It is the nation’s fastest growing drug problem.

•  Approximately 48 million people ages 12 and older have used prescription drugs for non-medical reasons in their lifetime.

•  The percentage of unintentional drug poisoning deaths involving opioid analgesics has been increasing since 1999, while those involving cocaine and heroin have been steadily decreasing.

•  Opioid analgesics (i.e. hydrocodone, oxycodone, and methadone) are more likely than cocaine or heroin to be the cause of unintentional drug poisoning deaths in U.S.

National Key Points From the CDC (2010) Report

2010 CDC Report:

•  It stated that there were 27,658 annual fatal unintentional drug poisonings as of 2008.

•  Drug overdose deaths are second only to car crashes for unintentional injury deaths.

•  Overdose is the number one injury-related killer among adults aged 35-54.

•  Rates of unintentional drug overdose deaths have increased 5-fold since 1990.

National Key Points

•  In 2000, retail pharmacies dispensed 174 million prescriptions for opiods. By 2009, 257 million were dispensed, an increase of 48%.

•  Opiate overdoses once almost always due to heroin, are now increasingly due to abuse of prescription painkillers.

•  Parents, patients, healthcare providers and manufacturers play a critical role in preventing prescription drug abuse.

•  The potent medications science has developed have great potential for relieving suffering as well as great potential for abuse.

•  Increasing need to minimize abuse of prescription drugs and ensure access for their legitimate use.

National Key Points

•  1/3 of people aged 12 and over who used drugs for the first time in 2009 began by using a prescription drug non-medically.

•  70% of people who abused prescription pain relievers got them from friends or relatives, while approximately 5% received them from a drug dealer or the internet.

•  In our military, illicit drug use increased from 5% to 12% among active duty service members over a 3 year period from 2005 – 2008, primarily attributed to prescription drug abuse.

•  From 1997 to 2007, the milligram per person use of prescription opioids in the United States increased from 74 mg to 369 mg, an increase of 402%!

National Prevalence of Prescription Drug Abuse

•  In 2009, 7 million Americans reported current (past month) nonmedical use of prescription drugs – more that the number using cocaine, heroin, hallucinogens, and inhalants combined.

•  National surveys show that the number of new abusers of several classes of prescription drugs increased markedly in the United States in the 1990’s.

•  Continuing at high rates during the past decade, abuse of prescription drugs now ranks second (after marijuana) among illicit drug users.

•  Perhaps even more disturbing, approximately 2.2 million Americans used pain relievers non-medically for the first time in 2009 (initiates of marijuana use were 2.4 million).

Indicators of Prescription Drug Abuse Epidemic in this Country

Treatment admissions for opiates other than heroin rose from 19,870 in 1998 to 111,251 in 2008, over a 450% increase.

The number of fatal poisonings involving prescription opioid analgesics more than tripled from through 2006, outnumbering total deaths involving heroin and cocaine.

The Drug Abuse Warning Network (DAWN), which monitors emergency department (ED) visits in selected areas across the Nation, estimates that in 2008, roughly 305,000 ED visits involved nonmedical use of Prescription pain relievers; 19,000 involved CNS stimulants; and 325,000 involved CNS depressants (anxyiolytics, sedatives, and hypnotics). Over half involved more than one drug. These numbers have more than doubled for pain relievers, and nearly doubled for stimulants, and CNS depressants since 2004.

ED visits related to zolpidem (Ambien) – one of the most popular prescribed non- Benzodiazepine hypnotics in the United States – also more than doubled during this

period, from about 13,000 in 2004 to about 28,000 in 2008.

National Prevalence of Prescription Drug Abuse

More law enforcement agencies are reporting that pharmaceutical diversion and abuse pose the greatest drug threat to their areas, in part because of increases in associated crime and gang involvement, which put additional strain on agency budgets and assets.

Percentage of State and Local Law Enforcement Agencies Reporting CPD’s as their Greatest Drug

Threat 2005-2009

2008 2009

Street Gang Involvement 44.2% 48.0%

Property Crime 6.0% 8.4%

Violent Crime 3.5% 4.8%

National Drug Threat Survey

Percentage of State and Local Law Enforcement Agencies Reporting Street Gang Involvement in Pharmaceutical Distribution and an

Association Between Pharmaceutical Diversion and Crime, 2008-2009

National Key Elements Among adolescents, prescription and over-the-counter medications account for most of the frequently abused drugs by high school seniors (including tobacco and alcohol).

- Nearly 1 in 12 high school senior reported non-medical use of Vicodin; 1 in 20 reported abuse of Oxycontin.

- When asked how prescription pain relievers were obtained for non-medical use, 59% of 12 graders said they were given

to them by a friend or a relative. The number obtaining them over the internet was negligible.

Older Adults

Changing Substance Abuse Patterns Among Older Admissions

•  Older substance abuse treatment admissions (aged 50 or older) increased from 6.6% of all admissions 12 years of age or older in 1992 to 12.2 % in 2008.

•  Between 1992 and 2008, the proportion of older admissions that reported primary alcohol abuse decreased from 84.6% to 59.9%,

•  The proportion of older admissions that reported multiple substances of abuse nearly tripled, increasing from 13.7% in 1992 to 39.7% in 2008.

•  In 2008, older admissions who initiated use of their primary substance of abuse within the past 5 years were more likely than those in 1992 to have reported prescription pain relievers as their primary substance (25.8% vs. 5.4%).

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Source: Florida Agency for Health Care Administration ED data sets and Inpatient data sets.

Health Effects of the Prescription Drug Abuse

•  The abuse of opiods can produce drowsiness, constipation and depending on the amount taken, can cause respiratory depression and ultimately death. Repeated use can lead to physical dependence and addiction.

•  The abuse of the central nervous system depressants can result in seizures, respiratory depression and decreased heart rate.

•  Stimulant abuse can lead to high body temperature, irregular heart rate, cardiovascular system failure and seizures. Taken repeatedly, it can cause paranoia and anxiety.

Effects on the Brain and Body

Opioids act on the brain and body at attaching to specific cell surface proteins called opioid receptors, which are found in the brain, spinal cord, gastrointestinal tract and other organs. When these drugs attach to certain opioid receptors, they alleviate the perception of pain.

These drugs can induce euphoria by indirectly boosting dopamine levels in the brain regions that influence our perception of pleasure.

Abusers may snort or inject the drug amplifying its euphoric affects and increasing medical risk such as respiratory arrest, coma and addiction.

Effects on the Brain and Body

Stimulants elicit a gradual and sustained increase in dopamine, which produces the expected therapeutic effects seen in many patients with ADHD, calming and focusing.

Methylphenidate is similar to cocaine, in that it binds to similar molecular targets in The brain, thereby increasing dopamine in reward circuits.

When administered intravenously, both drugs cause a rapid and large increase in dopamine, which is experienced as a rush.

For those who abuse stimulants, the range of adverse health consequences Include hyperthermia, seizures and cardiovascular complications.

Effects on the Brain and Body CNS depressants, typically prescribed for the treatment of anxiety, sleep disorders,

acute stress reactions, and muscle spasms, include drugs such as benzodiazepines

(e.g., valium, xanax) and barbiturates (e.g., Phenobarbital) – which are sometimes

prescribed for seizure disorders. Most CNS depressants act on the brain by affecting

the neurotransmitter gamma – Aminobutyric acid (GABA), which works by decreasing

brain activity. CNS depressants enhance GABA’s effects and thereby produces a

drowsy or calming effect to help those suffering From anxiety or sleep disorders. These

drugs are also particularly dangerous when mixed with other medications or alcohol;

overdose can suppress respiration and lead to death. The newer non-benzodiazepine

sleep medications, such as zolpidem (Ambien), exzopicione (Lunesta), and zalepron

(Sonata), have a different chemical structure, but act on some of the same brain

receptors as benzodiazepines and so many share some of the risks - they are

thought, however, to have fewer side effects and less dependence potential.

Case History – M.P. -  63 Years of age, Caucasian female -  Opiates and benzodiazepines -  Current meds: Prempro -  Past surgical history -  Past medical history

Case History – M.P. -  Chronic Pain:

-  Fibromyalgia -  Chronic shoulder -  Chronic back

-  Psychiatry: major depressive disorder -  E & B -  Labs -  Detox

Case History – D.S. -  72 Years of age, Caucasian male -  Alcohol, opiates and benzodiazepines -  Current meds:

-  Hydralazine 30 mg -  Celebrex 200 mg -  Atenolol 50 mg -  Simvastatin 20 mg -  Omeprazole 20 mg -  Androgel 2.5/0

-  Past surgical history -  Past medical history

Case History – D.S. -  Chronic Pain:

-  Rheumatoid arthritis -  Osteoporosis -  Lumbar fracture -  Thoracic compression fractures

-  Psychiatry: depressive disorder NOS -  E & B -  Labs -  Detox

Prescription Drug Abuse Prevention Plan Goals

•  Have an approved and implemented Risk Evaluation and Mitigation Strategy for certain long-acting and extended release opioids within 12 months.

•  Write and disseminate a Model Pain Clinic Regulation Law within 12 months.

•  Engage and work with Federal agencies and stakeholders to develop and implement a national public education campaign on prescription drug abuse and safe and proper medication disposal within 24 months.

•  IHS will increase the number of collaborative practice agreements that involve pharmacists prescribing privileges and monitoring of pain medication prescribing within 18 months.

•  Complete rule-making and implement regulations for medication disposal within 24 months.

•  Have legislation passed that requires prescribers applying for DEA registration to complete training on the appropriate and safe use, and proper storage and disposal of schedule II and III opioids. Legislation to be passed within 24 months.

Prescription Drug Abuse Prevention Plan Goals

•  FDA intends to issue a guidance document on developing abuse deterrent drug formulations and on post-market assessment of their performance within 24 months.

•  Have DOD, VA, and HHS provide controlled substance prescription information electronically to PDMP’s in states in which they operate healthcare facilities and pharmacies within 24 months.

•  Increase by 25% the number of states reimbursing for SBIRT within 24 months. •  Increase by 25% the number of HIDTA’s involved in intelligence gathering and

investigation around prescription drug trafficking and participation on statewide and regional prescription drug task force within 24 months.

•  Have legislation in all 50 states establishing Prescription Drug Monitoring Programs within 36 months.

•  Expand by 10%, within 36 months, the available funding for treatment to increase access since only a small fraction of drug users currently undergo treatment.

•  Decrease by 15% the number of unintentional overdose deaths related to opioids within 60 months.

HANLEY CENTER 933 45th Street

West Palm Beach, FL 33407 (Office) 561-841-1106

(Fax) 561-841-1100 Email: bkrantz@hanleycenter.org

Website: hanleycenter.org Toll Free: 866-4HANLEY

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