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Prescription Drug Abuse

Prescription Drug Abuse. Larissa Mooney, M.D. Assistant Professor of Psychiatry UCLA Integrated Substance Abuse Programs David Geffen School of Medicine at UCLA. Overview. Three classes of commonly abused Rx drugs (opioids, sedatives, stimulants) What are they?

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Prescription Drug Abuse

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  1. Prescription Drug Abuse Larissa Mooney, M.D. Assistant Professor of Psychiatry UCLA Integrated Substance Abuse Programs David Geffen School of Medicine at UCLA

  2. Overview • Three classes of commonly abused Rx drugs (opioids, sedatives, stimulants) • What are they? • How do they act in the brain and body? • What are their effects? • Neurobiology

  3. What are opioids? • Opiate: derivative of opium poppy • Morphine • Codeine • Opioid: any compound that binds to opiate receptors • Semisynthetic (including heroin) • Synthetic • Oral, transdermal and intravenous formulations • Narcotic: legal designation

  4. Opioid Receptors • Receptor types • mu, delta, kappa • Receptors located throughout body • Pain relief: central and peripheral nervous system • Reward and reinforcement: deep brain structures • Side effects: constipation, sedation, itch, mental status changes • Receptor interactions • Full agonists • Partial agonists • Antagonists

  5. SOURCE: National Institute on Drug Abuse, www.nida.nih.gov.

  6. Endogenous Opioids • Produced naturally in body • Act on opioid receptors • Examples: endorphins, enkephalins, dynorphins, endomorphins • Produce euphoria and pain relief; naturally increased when one feels pain or experiences pleasure

  7. Pain: the Fifth Vital Sign • JACHO Guidelines 2000: • Mandated pain assessment and treatment • Nurse and physician education required • When opioids prescribed properly for pain, addiction rare in patients without underlying risk factors • Vulnerabilities same as for other addictions: genetic, peer and social influences, trauma and abuse history

  8. Pain Pathway www.ccac.ca

  9. Pain Control and Addiction • “Pseudoaddiction”: • Presence of drug-seeking behavior in context of inadequate pain control • Behavior stops with adequate pain relief • Description of a clinical interaction (not a true diagnosis) • “Hyperalgesia”: exaggerated sense of pain with increasing opioid doses

  10. How Opioid Use Escalates • Short duration of action • Exceptions: methadone and buprenorphine • Has necessitated development of new delivery systems • Tolerance • Definition: with continued use, progressively higher doses necessary to produce the same effect • Physical dependence • Definition: with continued use, withdrawal syndrome produced by abrupt cessation, rapid dose reduction, and/or administration of an antagonist; occurs via neuroadaptation • Not synonymous with tolerance or addiction

  11. Opioid Withdrawal • Dysphoric mood • Nausea or vomiting • Diarrhea • Tearing or runny nose • Dilated pupils • Muscle aches • Goosebumps • Sweating • Yawning • Fever • Insomnia

  12. Protracted Withdrawal • Low energy • Anhedonia • Sleep disturbance • Emotional lability/dysphoria • Anxiety • Craving • Can persist for months

  13. Morphine • Routes: oral, intramuscular, intravenous, rectal • Sustained release preparations: • MS Contin • Oramorph • Kadian • Avinza

  14. Codeine • Opiate (naturally occurring in poppy) • Low potency • Pain relief via 10% conversion to morphine • Most commonly prescribed opioid in the world • Probably the most widely used analgesic • (Excluding aspirin)

  15. Semisynthetic Opioids • Hydrocodone with Tylenol: • Norco • Lortab • Vicodin • Lorcet • Hydrocodone with ibuprofen: Vicoprofen • Hydromorphone: Dilaudid • Oxycodone with Tylenol: Percocet • Oxycodone with aspirin: Percodan • OxyContin

  16. OxyContin • Used to treat pain associated with arthritis, lower back injuries, and cancer • Most commonly in tablet form: 10mg, 20mg, 40mg, 60mg, and 80mg tablets • Dosed every 12 hours, half-life 4.5 hours • Abuse: may be chewed, crushed, snorted or injected • Eliminates time-release coating • Enhances euphoria, “rush” • Increases risk for serious medical consequences

  17. Synthetic Opioids • Methadone • Demerol (meperidine) • Fentanyl • Suboxone (buprenorphine) • Tramadol • Complex mechanism of action • Nonscheduled, less abuse potential

  18. Opiates and Reward • Opiates bind to opiate receptors in the nucleus accumbens: increased dopamine release

  19. Sedative-Hypnotics • Used to treat anxiety and sleep disorders • Mechanism: enhances GABA • act to slow normal brain function • Barbiturates • Phenobarbital • Pentobarbital • Fioricet (butalbital/acetaminophen/caffeine)

  20. Sedative-Hypnotics Cont’d • Benzodiazepines • Librium (chlordiazepoxide HCL) • Valium (diazepam) • Restoril (tempazepam) • Klonopin (clonazepam) • Ativan (lorazepam) • Xanax (alprazolam) • Non-benzo hypnotics • Ambien (zolpidem) • Sonata (zaleplon) • Lunesta (eszopiclone) • Soma • Cross-tolerance with alcohol (GABA related)

  21. Sedative-Hypnotic Effects • Sedation • Slurred speech • Incoordination • Unsteady gait • Impaired attention or memory • Stupor or coma • Overdose risk increased with barbiturates or in combination with other sedatives, including opioids and alcohol

  22. Sedating Drugs and Overdose

  23. Other Sedative-Hypnotic Risks • No significant adverse medical consequences of long-term use • Amnesia • Difficulty with recent memory • Tolerance, physiological dependence, addiction • Addiction risk factors same as for other drugs of abuse

  24. Sedative-Hypnotic Withdrawal • Increased pulse, blood pressure, or sweating • Hand tremor • Nausea or vomiting • Transient hallucinations or illusions • Agitation • Anxiety • Seizures (grand mal)

  25. Protracted Withdrawal • Abstinence syndrome • Anxiety • Muscle twitching • Low mood • Sweating • Headache • Derealization • Rebound insomnia • Especially with short-acting benzodiazepines

  26. Sedative-Hypnotic Neurobiology Source: www.ccforum.com

  27. Prescription Stimulants Amphetamines enhance alertness. Stimulant medications (e.g., amphetamines) are often prescribed to treat individuals diagnosed with attention-deficit hyperactivity disorder (ADHD). Substantial amounts of pharmaceutical amphetamines are diverted from medical use to non-prescription use. Amphetamines increase wakefulness and have been used by: The military, by pilots, truck drivers, and other workers to keep functioning past their normal limits Source: Erowid.org

  28. Street Names for Stimulants Dex Dexamphetamine Bennies, Minibennies Dexies Copilots Crank Eye Openers Uppers Wake Ups Black Beauties Whizz Ups Pep Pills Lid Poppers Source:Erowid.org

  29. Short-Term Effects • Euphoria • Increased energy/productivity • Increased concentration • Decreased appetite • Increased libido • Decreased sleep

  30. Ritalin When this medication is used to treat ADHD, patients may find they have increased attention, decreased impulsiveness, and decreased hyperactivity. Milder stimulant that works by affecting the levels of chemicals (neurotransmitters) in the nervous system. May also be used in the treatment of depression in certain cases. Long-acting form: Concerta * WebMD

  31. Adderall Adderall is used to treat attention deficit hyperactivity disorder (ADHD). Adderall is a combination of stimulants (amphetamine and dextroamphetamine). It increases the ability to pay attention, focus, and control behavior problems. This drug may also be used to treat certain sleeping disorders (narcolepsy).

  32. 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

  33. Psychiatric Symptoms and Stimulants • 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/hypersomnia, anxiety, low energy)

  34. Neurobiology of Stimulants

  35. Overview • Introduction to medication treatment approaches for addictive disorders • Medication treatment options within Rx drug classes: • Opioids • Sedative-hypnotics • Stimulants • Clinical implications of co-occurring psychiatric disorders

  36. Medications to Treat Addiction • Addiction is a chronic, relapsing brain disease characterized by compulsive use despite harmful consequences • Medications as part of comprehensive treatment plan • Treatment approaches: • Medications (Bio) • Therapy, lifestyle changes (Psycho-Social) • Thorough evaluation and diagnosis essential

  37. Pharmacotherapy in Substance Use Disorders • Treatment of withdrawal (“detox”) • Treatment of psychiatric symptoms or co-occurring disorders • Reduction of cravings and urges • Substitution therapy

  38. Treating Opioid Dependence: Aims • Detoxification: • Opioid-based (methadone, buprenorphine) • Non-opioid based (clonidine, supportive meds) • Relapse prevention: • Agonist maintenance (methadone) • Partial agonist maintenance (buprenorphine) • Antagonist maintenance (naltrexone) • Lifestyle and behavior change

  39. Opioid Detoxification • Medications used to alleviate withdrawal symptoms: - Opioid agnonists (methadone, buprenorphine) - Clonidine (alpha-2 agonist) - Other supportive meds • anti-diarrheals, anti-emetics, ibuprofen, muscle relaxants, BDZs

  40. Opioid Substitution Goals • Reduce symptoms & signs of withdrawal • Reduce or eliminate craving • Block effects of illicit opioids • Restore normal physiology • Promote psychosocial rehabilitation and non-drug lifestyle

  41. Methadone: Clinical Properties • Synthetic opioid agonist • Analgesic • Quick absorption, slow elimination • Effects last 24 hours; once-daily dosing maintains constant blood level • Prevents withdrawal, reduces craving and use • Facilitates rehabilitation • Clinic dispensing limits availability

  42. Buprenorphine for Opioid Dependence • FDA approved 2002, age 16+ • Mandatory certification from DEA • Mechanism: partial opioid agonist • Office-based, expands availability • Analgesic properties • Ceiling effect • Lower abuse potential • Safer in overdose

  43. Buprenorphine Formulations • Sublingual administration • Subutex (Buprenorphine) • Suboxone (4:1 Bup:naloxone) • Dose: 2mg-32mg/day • Once-daily dosing

  44. MYTH: Patients are still addicted FACT: Addiction is pathologic use of a substance and may or may not include physical dependence. • Physical dependence on a medication for treatment of a medical problem does not mean the person is engaging in pathologic use and other behaviors.

  45. Case Vignette #1 • 34 y.o. African American female with 3-year history of Vicodin use • Using 10-12 pills/day for back pain suffered in an automobile accident • No history of heroin or other opiate use • Sometimes takes more than prescribed by her physician, but would like to stop taking all medications. • Employed, lives with her husband and two children, and has private insurance

  46. Medications for Sedative-Hypnotic Dependence • Taper: slowly decrease dose to minimize withdrawal symptoms • May first convert to longer-acting agent • Role for anticonvulsants • Use non-addictive medications for residual anxiety symptoms • SSRIs and other antidepressants • Other anti-anxiety agents

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