Prescription Drug Abuse Flashcards
3 National Epidemics Related to PDA
- Chronic pain: causes additional problems (decreased sleep/QoL, increased anxiety/depression)
- Depression/Anxiety: 60% of white adults received no treatment for mental illness (increase in % of A, AA, H)
- Prescription Drug Abuse (ie opioid epidemic)
3 Classes of Medications Commonly Misused
- Opioids: used to treat pain
- Central nervous system (CNS) depressants: used to treat anxiety and sleep
- Stimulants: most often used to treat attention-deficit hyperactivity disorder (ADHD)
How Did We End Up with 3 Epidemics?
• Unimodal treatment
- Usually medication therapy
- Reimbursement on non-medication therapy??
• Single discipline
- Usually a physician (or a medical provider)
- +/- Pharmacist involvement (optimizing pharmacology of medications and non-pharmacological approaches?)
Pain and Prescription Pain Relievers
• Pain is how our bodies warn us something is wrong
- It can alert us to an illness, injury or impending injury
- Sometimes when pain is chronic and persistent, it can be debilitating and impact daily functions
• The goal of pain medications in the setting of chronic pain is to enable individuals to function
Opioids
• Opioids are one class of pain relieving medications (vicodin/norco, percocet, oxycontin, morphine)
• Please do not call opioids “narcotics”
• Studies have shown that when opioids are (1) prescribed for the appropriate indication; (2) taken exactly as prescribed AND (3) monitored appropriately
- They are safe to use
- Manage pain effectively
- Less likely to lead to misuse/abuse
- Especially if they are take for short-term
• Appropriate medical reasons?
- Physical pain? Yes
- Emotional pain? No
- Sleep? Only if physical pain is contributing to insomnia
Prescription Pain Relievers and Misuse
• When “misused” (aberrant drug seeking behaviors):
- Taken by someone other than the patient for whom the medication was prescribed
- Or taken in a manner of dosage other than what was prescribed (e.g. taking more than prescribed)
- Or taking it for an indication other than what was prescribed
- When taken aberrantly then prescription pain medication can produce serious adverse health effects
- And can lead to substance use disorder
How are Opioids Abused?
- Pills can be crushed and the powders snorted or injected
- Some slow release formulation (previous Oxycontin formulation) when injected or snorted cause rapid release in bloodstream, exposing patient to high doses resulting in overdose
What Occurs in Opioid Overdose?
- Overdose reactions: excessive drowsiness, including breathing difficulties, and sometimes death
- Naloxone (Narcan) (opioid antagonist) should be given in the setting respiratory depressions
How do Opioids Affect the Brain?
- Opioids can change a way a person experiences physical pain
- It can also impact parts of the brain where you feel pleasure, a sense of feeling “high” and well-being
What Adverse Effects Can Be Associated with Opioids? What Happens When You Stop Taking Opioids?
• Opioids can cause
- Constipation, drowsiness, nausea or stomach upset, pruritus and if taking too high of doses can affect breathing
• Monitoring, prevention and education are important
• Also be aware of drug-drug interactions
- Especially with other medications that can cause drowsiness
• You can experience symptoms of withdrawal
Opioid Abstinence (Withdrawal) Syndrome
- Insomnia (take sleep med)
- Fever/chills (acetaminophen)
- Runny nose (clonidine)
- Nausea/vomiting (prochlorperazine)
- Dilated pupils
- Goose bumps
- Yawning
- Anxiety (clonidine)
- Agitation (clonidine)
- Muscle aches (clonidine)
- Increased tearing
- Sweating (clonidine)
- Abdominal cramping (clonidine)
- Diarrhea (loperamide, hydration)
Are There Treatments for Opioid Use Disorder?
Yes
• Needs to be done under medical supervision
• By a provider with special training
Medication-Assisted Therapy (MAT)
• Methadone- opioid agonist; daily liquid
• Naltrexone- opioid antagonist; daily pill or monthly injection
• Buprenorphine- mix of opioid agonist/antagonist; daily dissolving tablet, cheek film, or 6-month implant under the skin
Ways to Dispose of Controlled Substances
• Prescription Drug Drop Boxes
- Sheriff locations
- UC San Diego Health (2 different locations)
- Some participating pharmacies
• DisposeRx
• TakeAway Medication Recovery System
- Mix with cat liter, coffee grind, or in bleach container and then throw it away
• Flush it down the toilet
Oxycontin (Oxycodone CR)
- Strong opioid
- Common medication of abuse in those seeking help for heroin use disorder
- Purdue Pharmaceutical pleaded guilty to misleading the public about Oxycontin’s risk of opioid use disorder, and agreed to pay $600 million (2007)
- Reformulated Oxycontin(2010) -> abuse deterrent formulation
Ultram (Tramadol)
- Opioid (acts on the opioid receptor)
- Mistaken by prescribers and patients as the “safe alternative” to an opioid
- “chill pills”, “ultras”, “OxyContin lite”
- Can cause euphoria even at low doses
- Scheduled CIV (vs. CII of other opioids)
- Rise in tramadol prescriptions -> misuse/abuse and overdose deaths
- Tramadol claiming more lives than any other drug – including heroin and cocaine
Lomotil (Diphenoxylate/Atropine)
- Prescribed for the treatment of diarrhea
- Diphenoxylate acts on the opioid receptor
- Atropine can produce nausea and weakness, and is combined with opioid products as a way to discourage misuse and abuse
- 30 or 40 pills will cause euphoria
Cough Syrups
• Phenergan (promethazine) with codeine
- Codeine is an opioid, promethazine antihistamine which increases the euphoria of opioids
- Drinking promethazine-codeine cough syrup mixed with soda plus a jolly rancher.
- “sizzurp”, “purple drank”
• Dextromethorphan
- At high doses, dextromethorphan is classified as a dissociative general anesthetic and hallucinogen
- Common drug of abuse amongst teenagers
- California: SB-514 Dextromethorphan: sale to minors prohibited
- “robo-tripping”
Benzodiazepines (CNS Depressant)
Xanax (alprazolam), Ativan (lorazepam)
• Benzos, downers, tranks, roofies, xannies, and roches
• Enhances the effect of the neurotransmitter gamma- aminobutyric acid (GABA)
- Sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties
- Over time the sedation reduces and you need to take higher doses to obtain the same effects
• Risk of death significantly increased with concurrent alcohol use
CNS Stimulants and Pseudoephedrine
Ritalin (methylphenidate) and Adderall (mixed amphetamines)
• Used for ADHD and sleep disorders
• “performance enhancement,” study aid, increased concentration
Pseudoephedrine
• Behind the counter
• Used to make methamphetamine
Gabapentin/Pregabalin
- Neurontin (gabapentin), Lyrica (pregabalin)
- Used to treat neuropathic pain
- GABA-mimetic properties
- Abuse can cause euphoria, improved sociability, a marijuana-like ‘high’, relaxation and sense of calm
- Other patients report feeling “zombie-like”
Cannabis/Marijuana
Marijuana = Cannabis Cannabis = THC + CAnnabidiol
• Plant Cannabis sativa (60-70 cannabinoids) with two main components
- Delta-9-tetrahydrocannabinol (THC): May contain more of the CNS depressant effect (causing sedation, dizziness) and causing euphoria or dysphoria
- Cannabidiol (CB) compound that may have more of the therapeutic effects
How is it used?
• Smoked (hand-rolled joints, pipes, cigars)
• Ingested via teas, edibles, topical oils
State and Federal Medical Marijuana Laws
STATE
• State laws differ: Legalized, medical and decriminalized, medical, decriminalized, fully illegal
• 17 states & D.C : Legalized
FEDERAL
• Schedule I substance
• Definition: illegal drug that has high potential for abuse and no established medical use
FDA Approved Medications
- Marinol (schedule III) is a synthetic form of THC FDA approved for chemotherapy-induced nausea and vomiting, and anorexia from AIDS
- Epidiolex (not scheduled) is a cannabidiol oral solution FDA approved for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients 2 years of age and older
Medicinal Marijuana: Your Approach as a Pharmacist
- Ask if the patient if they are using marijuana, cannabis, cannabidiol during your assessment of the patient’s social history
- Separate your personal opinion versus your professional responsibility to make sure patients are using medication therapies safely
Cannabis Counseling
• Cannabis, as a CNS depressant, can cause sedation and impair judgment with any activity that requires alertness
- Caution when marijuana is combined with other medications that cause sedation
- May be taken with other pain medications with carefully monitoring by pain provider/marijuana provider
• Eachproductmayhavedifferentvariationsof cannabinoids and different potency -> use caution when using a product for the first time
• Avoid smoking it as it may cause lung infections
- Some known drug-drug interactions with cannabis
Cannabis Withdrawal Symptoms
- Restlessness
- Insomnia
- Fatigue
- Irritability
- Anxiety
- Depression
- Stomach discomfort
- Sweating
- Tremor
- Fever and chills
- Headache
- Diminished appetite
Complications with Cannabis
• Associations between cannabis may worsen symptoms of mental illness in some patients - Schizophrenia/psychotic disorders - Depression - Suicide ideations - Anxiety disorders • Cannabis Use Disorder (CUD)
