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Policies & Programs in the Age of 21 st Century Drugs Greenagel Counseling Services
Policies & Programs in the Age of 21st Century
Drugs
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Frank L. Greenagel Jr. LCSW, LCADC, ACSW, CJC, ICADC MPAP Candidate, CCS Candidate
Recovery Counselor - Rutgers
NJ Governor's Council on Alcoholism & Drug Abuse
Adjunct Professor - School of Social Work, Rutgers
Chairman – NJ Task Force on Heroin & Other Opiates
Instructor – Center of Alcohol Studies
ADAP - 2011 NAADAC Organization Achievement Award
Greenagel Counseling Services, LLC
Recovery Inc
www.greenagel.com
www.schoolrecovery.com
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Disclosure Statement
• I have no financial relationship with any pharmaceutical or health care company
•I am supportive of MAT’s, and I am in favor of using MAT’s in treatment and correction settings
•I get paid to present on RX Drugs and 21st Century drugs around the country
•I have never been paid by a pharmaceutical company or insurance company to talk
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Tell ‘Em What You’re Going to Tell’Em
• Adderall & Oxycotin Review
• New Opiate Treatments
• Recovery High Schools
• Education Programs for Middle & High Schools
• Recovery College Programs
• PMP’s and Operation Medicine Cabinet
• NJ Task Force on Heroin & Other Opiates
• Improving Pharmacies
• Macro Level Policy Changes Greenag
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RX Drugs of Abuse
• Adderall
• Soma
• Benzodiazapines
• Hydrocodone
• The Ascension of Oxycodone
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What does “rebound effect” mean?
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Adderall • Drugforum
• Introduced in 1996
• schedule II drug
• Amphetamine/dextroamphetamine salts
• Ritalin, Concerta, Vyvanse, Focalin also abused
• overly prescribed for ADHD
• Sometimes prescribed for narcolepsy
• Higher potency than Ritalin
• Adderall IR(immediate release)
• Adderall XR (extended release)
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Adderall
• “study drug” for staying awake, increased energy and improved concentration
• $5 to $40 at Rutgers
• increased blood pressure
• insomnia
• chronic use can cause depression
• chronic use can cause delusions
• high level of dependence
• hurts natural ability to concentrate
• banned by NFL, UFC & NCAA w/o a prescription
• banned in Japan, Korea & Thailand
• ADHD in the NYTimes: deaths, overprescribing, college counseling centers “opting out,” young athletes abusing it, a doctor using it to “fight educational inequality”
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What is the most prescribed drug in America?
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Hydrocodone • Schedule III drug
• Germany, 1920
• Semi-synthetic opiate, used to treat pain
• Tablet, capsule or syrup
• Usually paired with acetominapine or ibuprofen
• Vicodin, Hycodan, Norco, Lorcet
• Respiratory depression when combined with alcohol
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Oxycodone • Opiate – painkiller • Schedule II Drug • Germany, 1916 • overly prescribed for pain management • Purdue Pharma in 1996. • Oxycontin 10, 15, 20, 30, 40, 60, 80 mg $1/mg at Rutgers • Oxycontin 160 mg discontinued in 2001 • Percodan 4.8355 mg w/ 325 mg aspirin • Percocet 2.5, 5, 7.5 & 10 mg w/ acetaminophen • Roxicodone, “Blues” 15 & 30 mg, immediate release • oral, intranasal, intravenous, intramuscular • Adverse interactions with numerous other drugs • high level of dependence • More than 50% of RX in USA come from FLA • Oxycontin Express documentary
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Oxycodone • memory loss, constipation, diarrhea, loss of appetite,
stomach pain, fatigue, nausea, lightheadedness, dizziness, headache, dry mouth, anxiety
• withdrawal symptoms: anxiety, nausea, insomnia, muscle aches, weakness, fever, panic attacks, and vomiting
• gateway to heroin • Far more young people are abusing opiates due to Oxycodone • opiates were #1 for DMHAS funded facilities in NJ in 2011.
Replaces alcohol, which had been #1 forever before that • Older adults are also abusing and becoming addicted in high
numbers • OxyNeo – released in 2012 due to lawsuits & criticisms
– Too sticky to chew – Can’t crush – Turns to thick gel when put in water Gree
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What are the most common ways that people get introduced to
opiates?
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Oxycodone – Where To Get It • Medicine Cabinets • Grandparents • Pain management clinics • Emergency Rooms • Online Pharmacies • Dentists
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NJ Other Opiate Treatment Admits SAMHSA Data
Other
opiates 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
0-11 yrs 0 1 0 0 0 0 0 0 0 0 0 0
12-17 yrs 7 11 13 21 19 20 27 59 74 74 80 95
18-20 yrs 18 29 63 58 100 144 210 271 451 610 956 993
21-25 yrs 47 63 144 158 290 471 550 783 1080 1488 2304 2790
Other
Opiates
Total 0-
25 yrs 72 103 220 237 409 635 787 1113 1605 2172 3339 3878
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Treatments For Opiate Problems
• Buprenorphine
– Suboxone
– Subutex
• Naltrexone
– Naltrexone pill
– Vivitrol
• Naloxone
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Buprenorphine
Subutex - Schedule III drug - DATA 2000 – allowed for detox, short-term and long-term
maintenance as a form of medical treatment - FDA approval 2002 - MD’s must take a 3-day training, can treat 100 patients at a
time; law suggests MD recommends weekly therapy - Semi-synthetic opiate
- Helps physical withdrawal, helps with cravings - Used for pregnant women - White, oval shaped, bitter - Transdermal patches available
- Butrans, 7 day patch: 5, 10, 20 mcg (Purdu Pharma) Greenag
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Buprenorphine
Suboxone - Schedule III drug
- DATA 2000; FDA 2002 - Semi-synthetic opiate - Orange color, hexagon shape, Lime or Orange taste - Also has Naloxone in it (4 B/1 N ratio) - 1, 2, 4, 8, 16 & 32 mg tablets - Helps physical withdrawal, helps with cravings - Ceiling effect regular users can’t OD, above 32 mgs does
nothing - Suboxone film 16/4 mgs, 8/2, 4/.5 - Better than methadone easier to withdraw, more
convenient, much less euphoric effect - Irony: Off-label use for pain management - Negatives: Can mask opiate use; expensive Gree
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Naltrexone • Naltrexone (Revia or Depade)
• Standard is 50 mg tablet
• Works for alcohol & opiate dependence
• Reduces cravings; blocks opiate euphoria
• Vivitrol (injectable Naltrexone)
• Muscle injection every 4 weeks
• Should accompany therapy
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Naloxone • Opiate antagonist
• Used in case of opiate overdose
• Available in generic form
• Takes 1 minute to take effect
• Stop Opiate Overdose in Washington State, as a result of Good Samaritan law 6/10/10
• Used in the movie Pulp Fiction (6:45 in clip)
• Some parents and public health officials pushing for more widespread availability
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Naloxone • Narcan, Nalone, and Narcanti • Signed into NJ law 5/2/2013 • Injection or nasal spray • Widely available by prescription • Need training – must be able to: • opioid overdose prevention and recognition; • how to perform rescue breathing and resuscitation; • opioid antidote dosage and administration; • the importance of calling 911 emergency telephone service
for assistance with an opioid overdose; • and care for an overdose victim after administration of the
opioid antidote.
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Opiates – Some Facts
• Most widely prescribed class of drugs in the USA • Sales of RX Opioids 2001 $3.97B 2012 $8.34B +110%
• Opioid RX’s 2001 181.7M 2012 240.4M +33%
• Emergency Room Visits (non-H) 2001 299,498 2011 885, 348 +295%
• Overdose Deaths RX Opiates 1999 4,030 2010 16,651 +413%
• RX for Opioid TX 2002 >100K 2012 8M +8000%
• Adolescents in TX at Hazleton 2001 15% 2011 41% +26%
* Source: New York Times, June 23, 2013
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Opiates – Some Facts
• Workplace Costs – (workers’ comp, treatment cost, lost wages)
– Avg. claim w/o opioids $13K
– Avg. claim w/short-acting opioids $39K
– Avg. claim w/long-acting opioids $137K
• Drug Screen Industry 2000 $800M 2013 $2B +250%
• PMP’s in States 2002 16 states 2012 46 states • NH, MD, GA are developing programs. None in DC or MO.
* Source: New York Times, June 23, 2013
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High School Recovery Programs Archway Academy, Houston, TX
Central Freedom Recovery School, Mankato, MN City West Academy, Eden Prairie, MN CRES Academy, Janesville, WI Day top Preparatory School Mendham, NJ Hardin Community School, Kenton, OH Hope Academy, Indianapolis, IN INSIGHT Program, White Bear, MN Lakes Recovery School, Detroit Lakes, MN Minnesota Transitions Charter School Mission Academy, Oklahoma City, OK New Day Charter High School, Newark, NJ (denied 2012)
Northshore Recovery High School, Beverly, MA PEASE Academy, Minneapolis, MN Project Change: A Charter Recovery High School, Waukesha, WI Recovery School of Southern Minnesota Serenity High, McKinney ISD, McKinney, TX Sobriety High School(Alliance Academy West), Burnsville, MN Sobriety High School (Arona Academy North Summit), Coon Rapids, MN Springfield Recovery High School, Springfield, MA Summit High School, Santa Barbara, CA Transitions High School (Grace Youth and Family Foundation), Butler, PA Visions Scholastic Academy, Los Angeles, CA William J. Ostiguy High School, Boston, MA
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Recovery High Schools
• 30+ in America
• 85% of students returning to high school from tx relapse within 30 days
• HOPE Academy in Indianapolis
• teachers, staff & administrators all understand addiction & recovery
• New Day Charter HS rejected in NJ
• cost effective Greenag
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Quality Programming for Middle & High Schools
• get rid of DARE & Scared Straight
• teach students, teachers & parents about denial
• strong RX drug education
• peer education is very impactful
• be very wary of who you select to be a peer leader
• reduce stigma associated with therapy Gree
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Helping People with Substance Disorders
• Ask about alcohol & drug use (repeatedly)
• Convey positive attitude about recovery
• Get more training
• Don’t be offended when they lie
• Consult and/or refer to experts
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Reasons To Go To Therapy
• Concerns About Future
• Romantic Relationships
• Sexual Identity
• Grief/Loss
• Academic Stress
• Interpersonal Stress
• Adjusting to Life Changes
• Alcohol & Drug Abuse
• Mental Health Disorder Greenag
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The Alcohol Problem
• Approximately 1,800 student deaths
• 600,000 unintentional injuries
• 700,000 assaults (100,000 sexual assaults)
• Lower grade point average
• 31% met criteria for alcohol abuse or dependence
• $53 billion social cost for underage drinking
• 100,000 students report having been too intoxicated to know they consented to having sex
* source: NIAAA (National Institute on Alcoholism & Alcohol Abuse)
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A Brief History of Alcohol Prevention on Campuses
• Pre-1977 it was a Dean, Judicial or Family Issue
– Education & Awareness Programming
– Individual Interventions
– Substance Free Events
– Peer Health Advocates and Peer Counselors
• 1990’s – Social Norms Marketing – Policy Creation – Residence Life, Judicial Affairs, Campus Police – Little collaboration
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1st Generation Recovery
Schools • Brown University
– Bruce Donovan, Classics Professor, got sober in 1972
– Dean of Chemical Dependency in 1977 - 2003
– Chair still exists (is an endowed position)
– No housing. Off campus meetings. Non-clinical individual support and academic counseling.
– Does not identify as a Recovery School
– Serves about a dozen students per year
• Small NY college in 1980’s Gree
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1st Generation Recovery
Schools • Rutgers
– Rutgers Center of Alcohol Studies (moved from Yale 1960’s)
– President Bloustein formed Alcohol Policy Committee in 1979
– Lisa Laitman hired in 1983 to cover Newark, Camden & NB
– Students in Laitman’s Recovery Group discussed housing issues
– Recovery Housing started in 1988
– Trouble selling administrators
– Housing reportedly said, “All housing is substance free”
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Rutgers • 1988 – 2008
– Apartment Housing from 1988 – 2000. House after that.
– Individual & Group Counseling
– Five on-campus 12-step meetings
– No additional cost
• 2009 – Present
– State Grant
– 9+ on-campus 12-step meetings
– Rigorous data collection. 3.18 GPA 95% 98%
– 150+ activities per year Scholarships offered
– 90 day minimum
– 2 12-step meetings per week, sponsor with first 30 days
– Increased community outreach and government presence
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RH Requirements (1) At least 90 days of sobriety at move-in
(2) 2+ Interviews at Counseling Center by ADAP
(3) Accepted by Rutgers (Admissions)
(4) Full-time student
(5) Sponsor in the area by September 30th
(6) Attend 2+ area 12-step meetings a week
(7) 8+ individual counseling sessions 1st semester (Additional requirements for less than one year of sobriety)
(8) Weekly attendance at Early Recovery Group for the 1st year
(9) Looking for those with “the fierce urgency of now”
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Activities in 2011-2012 School Year
• 6 BBQ’s 3 Breakfasts • 16 lunches 14 dinners • 6 coffee talks 3 Hikes • 2 Bike Trips 4 Matinees • 6 High School Speaking Events 1 Dinner for 4.0 students • 1 night of Female Superbonding • 2 Recovery Therapist Events • 2 Social Justice Presentations • 2 Move-in Events • Alumni vs. Student Softball game
• Recovery Karaoke Night • Trip to the Hamilton Sculpture Garden
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Activities in the 2011-12 School Year
• Trivia Bowl • Jimmy D 5K Race RU Telescope • 2 days of Recovery House Clean-out • 3 RA meetings & meals Tubing the Delaware • Intramural soccer & flag football • 2nd Greatest Mets Comeback Ever Nets vs. Clippers • 3 NJ Devils Games Cory Booker’s Talk • Peter Maas’s Talk 1 Play • Observed services at a Mosque • Spiritual Retreat to Ender’s Island Big Fun Madden League • Croquet Tutelage Rutgers Croquet Match • Great Adventure Graduation • NYC Comic Con 2 RU Basketball Games
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School yr, divided
by semesters
Students
Living in
the RH
Yearly*
Relapse
Number
Yearly
Avg. Yearly
Abstinence
Rate
Avg.
Relapse
Rate GPA
Graduated
or
Returned
Graduated or
Return %
Alumni
Participation Graduated
2008, Fall 12 1.0 91.60% 8.40% 2.61 11 91.66% N/A 9
2009, Spring &
Summer 13 1.0 92.30% 7.70% 2.79 13 100.00% 6 11
2009, Fall 21 0.0 100.00% 0.00% 3.09 20 95.24% 23 18 2010, Spring &
Summer 21 0.0 100.00% 0.00% 3.08 20 95.24% 17 18
2010, Fall 23 0.0 100.00% 0.00% 3.08 22 95.65% 29 13
2011, Spring &
Summer 24 4.0 83.33%
16.67
% 3.05 22 91.66% 33 13
2011, Fall 30 1 96.66% 3.44% 3.25 29 96.66% 33 11
2012, Spring &
Summer 31 1 96.77% 3.66% 3.23 28 90.00% 33 11
2012 Fall 32 0 100.00% 0.00% 3.34 32 100.00% 35 7
2013 Spring &
Summer 32 2 93.75% 6.25% 3.13 32 100.00% 29 7
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2nd Generation Recovery
Schools • Case Western Reserve University
– Long-standing counseling & recovery support
– Opened Recovery Housing in 2004
– Open to many Cleveland Colleges
– On campus meetings. Academic supports. Activities
• Augsburg College
– Step Up 1997
– Housing Opens 1999
– 3.02 GPA, 95% Abstinence Rate last 5 years
– Largest College Recovery Housing Program
– Academic support. Activities. Outreach opportunities
– No additional cost
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Augsburg College StepUp Program
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2nd Generation Recovery
Schools
• Texas Tech – CSAR opens in 1986
– Heavy contributions to data gathering and research
– Academic support
– Service opportunities
– Scholarships from $500 to $5000 a semester
– Collegiate Recovery Seminar (1 credit)
– Federal Grant 2004
– 2011 Replication Project Begins
– Over one dozen self-help groups per week at the center Greenag
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Lessons Learned
• Creating a safe space
• Recovery Housing?
• Prerequisite time in recovery
• Reducing stigma
• Confidentiality
• Working with “missing out”
• Relapses
• Funding
• 12-Step Meetings
• Attracting students
• Us vs. Them
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Government Programs & Policies
• Prescription Monitoring Programs
• Prescription Drug Turn-In Programs
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NJ Task Force on Heroin & Other Opiates: Dates & Structure
•5/29 Statehouse Annex, Committee Room 4, Trenton
•7/10 Daytop, Mendham
•8/29 Monmouth County
•10/2 Cooper Hospital, Camden
• Public testimony by family members of the deceased
• State & national data trends
• Review of other states’ commissions and task forces
• Expert presentations -- Dr. Tom McClellan
• Review of current polices & programs
• Public testimony by young people in recovery
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Have PMP’s been effective? Why or why not?
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Pharmacy Security Best Practices
• All schedule II & III medications should be locked in a solid steel cabinet at all times. Only licensed pharmacists should have access to locked cabinet (or refrigerator).
•Video surveillance of all activity involving C-II & C-III activities. Should be kept for 3 months
•Security features: alarmed doors/windows, sensors, sufficient lighting, height markers at exit doors Gree
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Pharmacy Security Best Practices
•Advertise security to the public and employees
•Pharmacist should maintain perpetual inventory for C-II and C-III medications. Date, drug name, quantity received and invoice number for all medications received.
•Random monthly counts of at least 5 drugs that are top 10% risk for diversion
•Report prescribers that you have substantiated your concerns to licensing board and PMP
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Pharmacy Technician Strategies • Get driver’s license (fake script people often will turn
away at this point) • Where are they from? Far away? • Where is the prescriber from? Far away? • Have they been to your pharmacy before? If so, what
is their profile? If not, tell pharmacist to check PMP • Are they picking it up themselves, or did they send a
representative? If it isn’t the prescribee, who is it? What is their relationship? What is their profile?
• Get insurance information.
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Pharmacy Technician Strategies • Paying cash is a red flag • If someone calls on the phone asking if your
pharmacy has certain medications (Xanax 2 mgs, Oxy 15 or Oxy 30), don’t say “yes.” Take down name and number, discuss with pharmacist and then call back
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Pharmacist Strategies
• Check PMP • Is their physician reachable by phone to verify the
prescription? • What specialty does the physician practice? • Is the dosing appropriate based on the patient
information that you are able to gather? Acute pain vs. chronic pain
• Do the prescriptions follow current pain management guidelines?
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Pharmacist Strategies
• Is the customer “really talkative?” Do they seem like they are trying to distract you, or are they closely watching what you are doing?
• Call authorities if concerned….or say “I don’t have the meds”
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Macro-Level Suggestions
• Drug testing for those that are getting RX opiate painkillers and ADHD drugs
• Education programs for tweens, teens, parents and teachers
• Peer education of high school and college students
• Train future professionals (law, nursing, pharmacy, social work, student affairs & medicine)
• More Recovery Support Programs. Especially at colleges
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Macro-Level Suggestions
• 911 Good Samaritan Bill • RX Drug Turn-In Day 2 – 4 a year • RX Drug Drop Box One in each town • Stronger prescription monitoring programs • More professional access to PMP’s • More and cheaper opiate maintenance and
withdrawal programs • Increase training of professionals who can prescribe
and distribute drugs • Reform insurance laws • More TX program in jails & prisons
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My English Teacher Thing…
• An American’s Resurrection
• Broken
• Beautiful Boy
• Trainspotting
• Night of the Gun
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