1

Legal Intoxication:

What prescriptions

are being abused now?

Nancy Balch, PharmD, BCCCP

July 13, 2018

Disclosure Statement

• I have no personal or financial conflicts of interest relating

to this presentation

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Objectives

• Determine the potential for abuse due to the

mechanism of action of prescription

medications.

• Outline methods to potentially decrease the

risk of illicit prescription medication abuse.

• Evaluate whether a patient is at risk of

medication abuse and/or abusing prescription

medications.

Question 1: Which One Is Not Abused?

A. Carbidopa/levodopa (Sinemet)

B. Gabapentin (Neurontin)

C. Buproprion (Wellbutrin)

D. Atenolol (Tenormin)

E. Fexofenadine (Allegra)

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Question 2: Which medication would you

choose?

I.V., a 38 yo male, presents with depression. He has a 15

year history of heroin abuse, currently in remission, on

methadone. The team asks your opinion on the best

option for initiation of treatment from the following

options:

A. Fluoxetine (Prozac)

B. Paroxetine (Paxil)

C. Phenelzine (Nardil)

D. Quetiapine (Seroquel)

Question 3: Which medication would you

choose?

U.S.E., a 23 yo female, has been admitted for an open left

tibia fracture. She requires a hydromorphone PCA; MGH

ACT will wean her off and put her back on Suboxone

after discharge. She complains of severe itching from

the opiates, the Team asks your assistance on

treatment:

A. Diphenhydramine 50 mg IV by rapid push

B. Famotidine 20 mg by mouth twice daily

C. Solumedrol 125 mg IV prior to opiates

D. Fexofenadine 180 mg by mouth twice daily

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For Another CE: Known Abusive Medications

• Amphetamines: alone or with other meds

• Benzodiazepines: alone or with other meds

• Dextromethorphan: alone or with other meds

• Diphenhydramine: all routes, ‘dirty high’, preferably

before other meds (increase high)

• Ketamine: alone or with other meds

• Nitrous oxide: from welding supply stores, etc

• Opiates: hydromorphone > fentanyl > morphine >

oxycodone > tramadol

• Pregabalin: alone or with other meds

• Promethazine: increase opiate high

How Do They Learn?

• Prisoners: Trickle down effect

• Accidentally: taking medications together

• Internet: what to use, how to use, what not to use, how

to obtain from your Provider, purchasing prescription

meds

• ‘Best’ sites cannot be accessed unless you create an

account

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Where Do They Learn?

• www.bluelight.org

• Wikipedia, treato.com

• Martindale, pmc, ncbi.gov, sci-hub.cc, nih.gov,

PubMed, Micromedex, Rang + Dale’s

Neuropharmacology

• Stahl’s Psychopharmacology, Nestler’s Molecular

Neuropharmacology, psychopharmacopeia app, +

many more

Carbidopa/levodopa + Cocaine

• Best effect BEFORE cocaine

• Experience better high

• Easier to come down

http://www.bluelight.org

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Gabapentin

• Combo: oxy, etoh, naproxen (? increased

bioavailability), propranolol, mirtazapine,

buprenorphine, caffeine

• Solo: acidic drink, dose separation, food

• Ø rectal or IV potential

Beta-Blockers

• B1 selective preferred (atenolol), but all are used

• + methamphetamine, MDMA (aka ecstasy, is

controversial)

• Propranolol: dysphoric feeling

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Diltiazem: With Other Substances

• Suboxone

• Amphetamine, methylphenidate, other stimulants

• Morphine

• Cocaine

Bupropion

• Snorted for the best high

• Useful if can’t obtain amphetamine

• Bluelight: directions to remove shell

• Orally with amphetamine

• Some have seized, abusing it

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Paroxetine vs Fluoxetine

• “Do not tolerate fluoxetine, only tolerate paroxetine”

• Paroxetine inhibits CYP450

• Increase levels of medications metabolized by CYP450

• Methadone one of the most common with paroxetine

www.bluelight.org

Quetiapine

• To sleep ‘after a bender’

• Sleep after methamphetamine binge

• Sleep after a dextromethorphan ‘trip’

• Best effect taken before going out

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Monoamine Oxidase Inhibitors (MAOI’s)

• MAOI’s not used, often, clinically anymore

• Potentiate effect of some hallucinogenics

• Many cautions on bluelight

Anticholinergics

• Abuse noted since ~1960

• Mild euphoria

• Benztropine, trihexyphenidyl, etc

• Lomotil, Hydromet (mixed bluelight reviews)

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GI Medications

• Omeprazole

• Famotidine

• Ranitidine

• Cimetidine

Cimetidine

• Extend high of opiates

• Suboxone- increased high

• Decrease metabolism of other medications

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Loperamide

• Prevent withdrawal

• If unable to obtain heroin, other opiates

• Be able to work

Miscellaneous

• Levetiracetam + methylphenidate

• Piracetam (+ stimulants) oxiracetam

• Lamotrigine

• ADHD/ADD meds

Jena, A.B., Goldman, D.P., Foster, S.E., Califano, J.A.. (2011). Prescription Medication Abuse and Illegitimate Internet-Based Pharmacies. Annals

of Internal Medicine, 155, 848-850. Retrieved Feb 5, 2012, from OVID database.

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CYP450 Action

• Discussed in layman’s terms

• Complete chart provided

• Directions on use of chart

• Provided to users in chart an poster form

http://www.bluelight.org

Grapefruit Juice

• Discussed heavily, on all sites, in regards to

cytochrome P450 (cyp450) system

• Request meds metabolized by CYP450, to inhibit

system

• How much to drink, how often to drink, when to drink

around meds, and how the cyp450 system works.

http://www.bluelight.org

13

Kratom

• Food supplement

• Sold on the internet, and stores

• Best if taken orally

• Best abused if mostly opiate naïve

• Some state sedating and euphoric

• Addiction potential

http://www.narconon.org/drug-abuse/kratom-effects.html

https://en.wikipedia.org/wiki/Mitragyna_speciosa

http://www.bluelight.org

What To Look For

• Medication request ≠ disease state, need vs desire

• Specific medication in class of meds

• Often requests early refills

• Symptoms of medication abuse

• New medication added to MassPat

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Signs

• Pain out of proportion: still 8/10 after appropriate

medications

• Pain, woken from sleep for vitals

• Specific times stated for ‘premedication’

• ‘Anaphylaxis’ to one med in class, but not others

• Requests med be left at bedside

Pmp Correctly

• Attempt to locate all entries

• 1st 3 initials of first, last name = unlinked local entries

• Full name = unlinked national entries

• Methadone clinics: currently not required

• VA: Not required unless Provider licensed in State

writing prescription

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Potential Prevention

• Utilize lower risk medications

• ALWAYS oral when possible

• Standing acetaminophen, and other non-

abusive pain medications

Potential Prevention

• Monitor for signs, symptoms

• Utilize Addictions Specialists

• Always pmp, no matter age

• If requesting seizure medications, have patient see a

Specialist

• Research

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Other Supplements

• Roots, etc, preferred, to ensure is actual supplement

• Kava Kava: if unable to obtain alcohol

• Morning Glory seeds: US- coated, to prevent abuse

• Nutmeg: high doses, a lot of water with it

• Salvia: short lasting, difficult to obtain

• Skullcap: if can’t obtain marijuana

• Poppy seeds: difficult to obtain in US

Question 1: Which One Is Not Abused?

A. Carbidopa/levodopa (Sinemet)

B. Gabapentin (Neurontin)

C. Buproprion (Wellbutrin)

D. Atenolol (Tenormin)

E. Fexofenadine (Allegra)

17

Question 2: Which medication would you

choose?

I.V., a 38 yo male, presents with depression. He has a 15

year history of heroin abuse, currently in remission, on

methadone. The team asks your opinion on the best

option for initiation of treatment from the following

options:

A. Fluoxetine (Prozac)

B. Paroxetine (Paxil)

C. Phenelzine (Nardil)

D. Quetiapine (Seroquel)

Question 3: Which medication would you

choose?

U.S.E., a 23 yo female, has been admitted for an open left

tibia fracture. She requires a hydromorphone PCA; MGH

ACT will wean her off and put her back on Suboxone

after discharge. She complains of severe itching from

the opiates, the Team asks your assistance on

treatment:

A. Diphenhydramine 50 mg IV by rapid push

B. Famotidine 20 mg by mouth twice daily

C. Solumedrol 125 mg IV prior to opiates

D. Fexofenadine 180 mg by mouth twice daily

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Thank you!!

Questions and Answers

If I don’t know it, I promise to get back to you

Nancy Balch, PharmD, BCCCP

nbalch@partners.org

The End

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Additional Information

The following slides contain

additional information, from

Bluelight website for those

who may be interested

Cold water extraction: to potentially NOT dissolve

the meds you don’t want (ie acetaminophen):

cold water extraction last night on around 44 pills of

500/30/8mg paracetamol/caffeine/codeine and I thought it

was very accurate as there was only a cloudy mixture left in

the water I used and there was a boat load of powder left on

the multiple tissues I used. However, I drank the crap last

night and while the high was grand at first I eventually began

to feel quite nauseous and nearly got sick. Woke up this

morning feeling like crap and puked up so many times since

then. What are the chances I overdosed on paracetamol?

How much of it would have dissolved in the water

http://www.bluelight.org

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Gabapentin Abuse

• Max benefit: solid meal before, wash down with acidic

drink, fresh squeezed lemon in water = winner, +

naproxen further incr bioavail. Dose >900mg=wasteful,

more you take=less absorb, space doses by ~1-2 hrs, this

particular and lovable med takes 1+ hr to reach peak

effect

• When 1st started taking, was my wife's, only kept filling rx

for me; was bad opiate addict then, always dosed 1800-

3600 mg at a time x 3-4 days til script gone, then I’d look

to score something else, she now gets 4500 mg/day! we

now only get rx cause I’m totally off opiates & all else,

previous dose doesn't do anything for me 3 1/2 weeks

later, so for someone w/apparently high tolerance, need to

dose for at least mellow affect? any advice would be

greatly appreciated!

://www.bluelight.org

With suboxone am a believer, amazing potentiator of buprenorphine! Not only almost doubles

subjective dose feeling but extends effects.Took 1mg of sub sl yesterday 6p, is now 10:30 a,

still feel strongly + last night slept like a baby when usually suffer from insomnia. W/out using

cimetidine, 2 mg suboxone barely holds me, keeps me well, + would not be feeling it next day.

Dosing schedule:1 hr before su -600 mg cimetidine, then dose sub, then every 6 hrs after 400

mg cimetidine until I no longer feel the sub, usually sometime after the 24 hr mark. Still well;

just no longer conciously feel the sub. Big money saver with cost of suboxone: 50 tabs of 200

mg cimetidine < $5. Even if have tried cimetidine with other opiates, try with sub, you might be

like me and able to get double the mileage out of your sub..

Recently trying to lower my suboxone maint dose to conserve my stash. Prescribed 3mg a

day; I insufflate my pills, not to get high, but find it most effective road for me. Taking 4mg

recently, ran a little low on my stash, I have begun to taper. To 3 mg three days ago and

feeling crappy. Achey/depressed below 4 mg & has always been the case (on sub maint for 4-

5 yrs, attempted to stop multiple times). 9 am took 800 mg cimetidine 1 hr before insufflating 2

mg sub, and now at 4:30 pm while I am writing this, I still feel better than I have the past few

days at 3 mg. Also took 5 hr energy shot a few hrs ago. I read somewhere they help potentiate

suboxone because of the caffeine and vitamin b. Update: again I am totally blown away by

how well this works! It has allowed me to take half my normal dose and literally be well enough

to make it 48 hours without redosing. Granted I didn't feel fantastic day two, but it certainly

made conserving my stash so much more pain free than what I've experienced the numerous

other times I have ran low at the end of the month. Anyways, I am amazed at how well this

worked. Tomorrow I will try this without the 5 hour energy shot and see if it works as well.

Cheers to the OP for tipping me off about this! I have tried literally everything to lower my dose

without suffering from horrible depression. (plugging, alcohol solution, white grapefruit juice,

etc.

://www.bluelight.org

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-Loperamide: taking for almost 2yrs whenever I run out of my monthly MSIR rx prescribed to me for chronic

back pain. Believe it or not, I'm not your typical junkie who began using drugs at young age to cope; was a "good

boy" until began experiencing nightmare known as chronic pain. I hope none of you ever have to experience it if

you aren't already; it'll flip your world upside-down.

-If I take around 70 tabs loperamide it DOES stop all of MY withdrawals for roughly 20 hrs and gives me a

decent albeit "dirty" buzz x several hrs. Contrary to popular belief, does NOT constipate ME for an eternity.

Takes roughly 1-2 hrs for loperamide to take effect. Have been taking opiates almost every day for 4 yrs.

Tagamet tabs (200mg/ tab)..1g (5 tabs) ORAL, Loperamide tabs (2mg/tab)... 160mg (80 tabs) ORAL

3am, picked up soda, thought about Tagamet to experiment. Generics $5/60 tabs. Brand about $8 for 30 tabs.

3:15am -Took 1g (5 tabs) in my truck before leaving. Feeling optimistic about it, not expecting anything major.

3:30am -Decided to eat before dosing loperamide. Most say to wait 45 min-hr before loperamide for best result

4:15am - Dosed 80mg (40 tabs) of loperamide after pizza. Remember to dose according to YOUR tolerance

5:15am - Feeling the same as before; nothing worth writing about

6:15am - Took additional 80mg (40 tabs) to see if get me anywhere. Normally take that daily to stave off

w/drawal to function at work. Sounds crazy but more common than you think; can become dependent on

loperamide; I experience horrible withdrawals roughly 24hrs after dosing. Remember dose to YOUR tolerance!

-Lamictal: Been taking sub for maint for > 1 ½ yr, for me is godsend. Won't go in whole history, suffice to say a

heroin addict on/off for long time. When started sub was taking 8-12mg/day, felt absolutely *nothing* no matter

how much took (up to 24mg) or in what manner (tried snorting=nothing). Then about 3 m into sub treatment my

doctor put me on Lamictal -mood stabilizer - and I immediately Noticed it's potentiator effects. now I take 8mg

of sub in morn and 8mg at night and about 75-100mg of the Lamictal with each dose. it's a bit strange because

it's not 100% of the time and it's not always the same strength but probably 75% of the time I *do* get high - not

a lot, and the euphoria only lasts for maybe an hour, but nonetheless - it's definitely there.

-I find that if I take too much of both I get drowsy and I nod - but without the raging euphoria we all know so

well so it's kind of pointless. best I can compare it to is when I didn't have a habit and I would eat a bunch of

codeine, a nice opiate buzz but nothing overwhelming.

I haven't tried the Cimetidine as of yet but I'm off to the pharmacy now so I'll let y'all know how that works out.

://www.bluelight.org

References • Affaticati, A., Gerra, M.L., Amerio, A., Inglese, M., Antonioni, M.C., et al (2015,

December). The Controversial Case of Biperiden From Prescription Drug to Drug of

Abuse. Journal of Clinical Psychopharmacology, 35 (6), 749-750. Retrieved Aug 20,

2017, from OVID database.

• Baker, J.S., Graham, M., Davies, B. (2006, July). Gym users and abuse of prescription

drugs. Journal of the Royal Society of Medicine, 99, 331-332. Retrieved Jul 30, 2017,

from OVID database.

• Maier, L., Schaub, M.P. (2015). The Use of Prescription Drugs and Drugs of Abuse for

Neuroenhancement in Europe Not Widespread But a Reality. European Psychologist,

20 (3), 155-166. Retrieved Feb 5, 2012, from OVID database.

• Jewell, C.E., Tomlinson, J., Weaver, M. (2011). Identification and Management of

Prescription Opioid Abuse in Hospitalized Patients. Journal of Addictions Nursing, 22,

32-38. Retrieved Feb 5, 2012, from OVID database.

• Jena, A.B., Goldman, D.P., Foster, S.E., Califano, J.A.. (2011). Prescription Medication

Abuse and Illegitimate Internet-Based Pharmacies. Annals of Internal Medicine, 155,

848-850. Retrieved Feb 5, 2012, from OVID database.

• Cai, R., Crane, E., Poneleit, K., Paulozzi, L. (2010, June 10). Emergency Department

Visits Involving Nonmedical Use of Selected Prescription Drugs – United States, 2004-

2008. Centers for Disease Control and Prevention MMWR Morbidity and Mortality

Weekly Report, 59 (23), 705-709. Retrieved Feb 5, 2012, from OVID database.

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References • Cooper, R. (2013). Over-the-counter medicine abuse – a review of literature. Journal of

Substance Use, 18 (2), 82-107. Retrieved Feb 5, 2012 from OVID database.

• Lessenger, J.E., Feinberg, S.D. (2008, January-February). Abuse of Prescription and

Over-the-Counter Medications. Journal of American Board of Family Medicine, 21, 45-

54. Retrieved Feb 5, 2012 from OVID database.

• Levine, D. (2007). ‘Pharming’: the abuse of prescription and over-the-counter drugs in

teens. Current Opinion in Pediatrics, 19, 270-274. Retrieved Feb 5, 2012 from OVID

database.

• Worley, J.. (2014, July/September). Identification and Management of Prescription Drug

Abuse in Pregnancy. The Journal of Perinatal & Neonatal Nursing, 28 (3), 196-203.

Retrieved Feb 5, 2012 from OVID database.

• Goldsworthy, R.C., Schwartz, N.C., Mayhorn, C.B. (2008). Beyond Abuse and

Exposure: Framing the Impact of Prescription-Medication Sharing. American Journal of

Public Health, 98, 1115-1121. Retrieved Feb 5, 2012 from OVID database.

• http://www.bluelight.org

• FDA (2011, August 12). Strategies to Reduce Medication Errors: Working to Improve

Medication Safety. Retrieved from FDA website

http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm

• https://www.statnews.com/2017/07/06/gabapentin-opioid-abuse/

• http://www.narconon.org/drug-abuse/kratom-effects.html

• https://en.wikipedia.org/wiki/Mitragyna_speciosa

References

The following links from Erowid may be interesting for

you and display education provided to users of such

sites:

• https://erowid.org/chemicals/opiates/opiates_info3.sht

ml

• https://erowid.org/psychoactives/testing/testing_faq.s

html

• https://erowid.org/experiences/exp.php?ID=83751

• https://erowid.org/chemicals/opiates/opiates_mcderm

otts_guide.shtml

• https://erowid.org/experiences/exp.php?ID=75597