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Prescription Abuse: Cause,Consequence and Control
Glen R. Hanson, Ph.D., D.D.S.Professor in Pharmacology, University of Utah
Director of the Utah Addiction Center, University of UtahSenior Advisor, National Institute on Drug Abuse, NIH
What Do We Mean When We Say Prescription Drug Abuse?
Use: Prescribed and clinically appropriate
Misuse: Either not prescribed or
clinically inappropriate
Drug Abuse- use of a drug in a
manner not medically or “socially”
approved (recreationally??).
“Pharm Party”
Prescription
abuse
Drug addiction:
Dependence:
Persistent use resulting in adaptations typically
accompanied by accommodation or tolerance (causing
compensatory escalation) and withdrawal (e.g., aches,
diarrhea, depression and cravings)
Compulsive drug use that consists of repetition
to satisfy intense urges, despite severely negative
consequences
Categories of Rx drug users
• Legitimate (do not break laws and
drugs properly managed and used)
• Legitimate (laws not broken, but
either not being managed properly
or used improperly)
• Illegal (laws broken to obtain and/or
use)
• Combinations
• What is the attitude about the drug?
Necessary for a medical condition
(e.g., pain, stress, anxiety)
If the drug can be obtained
legally, everything will be OK
Obsessed: tremendous energy is
spent on assuring drug access
How many people are abusing
(misusing?) prescription drugs?
Approximately 9 million Americans use
prescription drugs at least once for
“nonmedical” reasons a year.
Approximately 4 million Americans report
using prescription drugs “nonmedically”
monthly.
Survey Says:
In 2010 nonmedical use &
consequences
• >12 yrs lifetime= 20%
• HS Seniors annual use
Vicodin= 10%
OxyContin= 5%
Adderall= 5%
• ~ 15,000 overdose deaths in U.S.A.,
2011
• What is the pharmacological status
of the patient/user?
Physically dependent, but not
addicted
Deriving medical benefit from
the medication
Physically dependent and addicted
• What is the role of the Rx provider &
dispenser?(DRUG DEALERS?)
AWOL (“take a number” attitude;
does not know patient nor history)
Enabler (excessively accommodating)
Candy man
Where do abused Rx drugs
come from (demographics)?
• Dealer = 8%
• Buy the drugs = 21%
• Took/stole the drugs = 12%
• Given the drugs = 33%
• Doctor’s Rx = 19%
• Friend or relative = 66%
• Internet purchases = minor
What should we do about it??
Utah Legislature/Governor
2010 Resolution:
• Objectives: more effective education
and assessment of risk before
prescribing and more effective
monitoring and disposal after
prescription issued
Why Does Someone
Abuse a
Prescription Drug?
Addiction Cycle for Prescription Drugs
• relieve medical condition (e.g., pain, anxiety,
stress, weight gain)
• reinforcing effects (stimulates reward pathways)
• induces physical dependence• often there is a tolerance and withdrawal
issue (usually occurs due to lengthy drug use)
• patients often have substance abuse risk
before treatment (mental risk/prexisting problem• patient uses various strategies to maintain
drug supply (often illegal)
Prevention
• Doctors/pharmacists need to
do their jobs-educate and
warn!
• Obtain accurate history (any drug
abuse problems in family or
personally?)
HOW?
DEFINING SBIRT PROGRAM
• SCREENING, BRIEF INTERVENTION, AND
REFERRAL TO TREATMENT (SBIRT) IS A
COMPREHENSIVE AND INTEGRATED
APPROACH TO THE DELIVERY OF EARLY
INTERVENTION AND TREAMTMENT
SERVICES THROUGH UNIVERSAL SCREENING
TO PERSONS WITH SUBSTANCE USE
DISORDERS AND THOSE AT RISK
Babor et al., 2007
DEFINING SBIRT
• SBIRT is designed to fill the gap between
primary prevention efforts and more
intensive treatment for persons with serious
substance use disorders
SBIRT PHYSICIANS and programs can
reach a significant proportion of the
population using alcohol and other drugs
before high-end interventions are needed
SBIRT PYRAMID
SAMHSA SBIRT PROGRAM, 2009
BRIEF INTERVENTION
BRIEF TREATMENT
REFERRAL TO TREATMENT
Division of Substance Abuse and Mental Health, 2010
AGE-RELATED NEED FOR SBIRT IN UTAH
Screen • Identification of substance related and emotion problems
Brief Intervention
• Uses motivational interviewing to raise awareness of risks and motivate client toward treatment engagement
Brief Treatment
• Evidence based cognitive behavioral treatment with clients who elect further treatment or need follow-up care (including co-occurring disorders)
Referral to Treatment
• Referral of those with more serious or emergent treatment needs
SBIRT CORE COMPONENTS
SBIRT CORE COMPONENTS
• SCREENING – accurate identification of “at risk”,
“high risk”, and “addicted” individuals
• ISSUES TO CONSIDER – important to consider
1) perceived threat, 2) cognitive capacity, 3) self
image, 4) denial – patient and medical staff, and
5) level of trust
SBIRT SCREENING TOOLS
• AUDIT (ALCOHOL USE DISORDERS IDENTIFICATION
TEST) – 10 questions, focuses on hazardous drinking
as well as alcohol use disorders, adult population, 5
min/3 min
• DAST (Drug Abuse Screening Test) – 10 or 28
questions, focuses on drugs, adult and adolescent
populations, 5 min/2 min
• TWEAK (Tolerance, Worry, Eye-Opener, Amnesia,
Cut-Down) – 5 questions, originally developed to
screen for alcohol use in pregnant women; adult
population, 3 min/2min
How can the health care provider
contribute?
• Only use the Rx to treat the
condition for which it was prescribed
• Recognize the symptoms of
dependence and addiction
(& difference)
• Rx addiction is a relapsing disorder
and often requires professional help
Patient Education
• How to safely store
• Legal prohibitions on sharing or
selling/protect family members
and others from unintentional or
intentional misuse
• Promptly dispose of the leftovers !!!
Tools to assist assessments:
• Division of Occupational and
Professional Licensing (DOPL)
Monitoring- regulator of Rx
drug prescribers
Licensing and certification
management-establish
qualifications and require
training (CE requirements)
Monitoring through databases-
approach real-time information
• High-risk patients:
Medication management
agreements
Tight control on Rx numbers and
routine accountability
Drug screens-- with consequences
• Be able to recognize if treatment
is required and get patient
help (be able to explain why
important and how it is done)