Chronic Pain and Addiction National Rx Drug Abuse Summit 4-10-12

1. Chronic Pain and
Addiction
April 10-12, 2012
Walt Disney World Swan Resort
Dr. Barbara Krantz
Medical Director/Corporate Director of Research
Fellow of the American Society of Addiction Medicine
Diplomat of the American Board of Addiction Medicine

2. Accepted Learning Objectives:
1. Overview on Drug Abuse in US, focusing on
national Statistics on nonmedical
psychotherapeutics including older adult
trends with chronic pain diagnosis.
2. Describe the effects and consequences of
prescription pain abuse as it progresses
over time.
3. Advocate the importance of continuing
education on addiction for pain
management providers.

3. What is Prescription Drug Abuse?
• Prescription drug abuse is the intentional use of a
medication without a prescription; or in a way other than
as prescribed; or for the experience or feeling its causes.
• The three classes of prescription drugs that are most
commonly abused are:
– Opioids, which are most often prescribed to treat pain
– Central nervous system (CNS) depressants, which are used to
treat anxiety and sleep disorders
– Stimulants, which are prescribed to treat the sleep disorder
narcolepsy and attention-deficit hyperactivity disorder (ADHD).

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6. Media Attention

7. Prescription Drug Abuse
What is driving the high prevalence?
- misperceptions about their safety
- increasing environmental availability
- varied motivations for their abuse
- consumer culture amenable to “quick fix”
Among those who abuse prescription drugs, high rates of other
behaviors, including abuse of other drugs and alcohol, have also
been reported.

8. Highlights - Global
• Globally, it is estimated that 13.5 million people take opioids, including 9.2 million
who use heroin. WHO, 2010
• In many countries (notably those from Europe), the majority of heavy drug users
seeking treatment are primarily addicted to opiates UNDCP, 2009
• Worldwide abuse of prescription drugs will soon exceed illicit drug use, warned a
United Nations panel charged with monitoring global patterns of drug abuse.
• In its 2006 report, the International Narcotics Control Board (INCB), based in Vienna,
Austria, noted that medications containing narcotic or psychotropic drugs are
becoming the drugs of choice for many abusers, and that drug traffickers are
responding to the demand through increased diversion and the production of
counterfeit drugs.
• The problem is particularly acute in the United States, where cannabis is the only
illicit drug that is more widely abused than prescription drugs, including analgesics,
stimulants, sedatives, and tranquilizers, according to the INCB. Between 1992 and
2003, the number of US individuals abusing prescription drugs increased from 7.8
million to 15.1 million.

9. National Key Points
• The non-medical use or abuse of prescription drugs is a serious and
growing public health problem in this country. It is the nation’s
fastest growing drug problem.
• Approximately 48 million people ages 12 and older have used
prescription drugs for non-medical reasons in their lifetime.
• The percentage of unintentional drug poisoning deaths involving
opioid analgesics has been increasing since 1999, while those
involving cocaine and heroin have been steadily decreasing.
• Opioid analgesics (i.e. hydrocodone, oxycodone, and methadone)
are more likely than cocaine or heroin to be the cause of
unintentional drug poisoning deaths in U.S.

10. National Key Points From the CDC (2010) Report
2010 CDC Report:
• It stated that there were 27,658 annual fatal unintentional
drug poisonings as of 2008.
• Drug overdose deaths are second only to car crashes for
unintentional injury deaths.
• Overdose is the number one injury-related killer among adults
aged 35-54.
• Rates of unintentional drug overdose deaths have increased
5-fold since 1990.

11. National Key Points
• In 2000, retail pharmacies dispensed 174 million prescriptions for opiods. By
2009, 257 million were dispensed, an increase of 48%.
• Opiate overdoses once almost always due to heroin, are now increasingly
due to abuse of prescription painkillers.
• Parents, patients, healthcare providers and manufacturers play a critical role
in preventing prescription drug abuse.
• The potent medications science has developed have great potential for
relieving suffering as well as great potential for abuse.
• Increasing need to minimize abuse of prescription drugs and ensure access
for their legitimate use.

12. National Key Points
• 1/3 of people aged 12 and over who used drugs for the first time in 2009
began by using a prescription drug non-medically.
• 70% of people who abused prescription pain relievers got them from friends
or relatives, while approximately 5% received them from a drug dealer or
the internet.
• In our military, illicit drug use increased from 5% to 12% among active duty
service members over a 3 year period from 2005 – 2008, primarily attributed
to prescription drug abuse.
• From 1997 to 2007, the milligram per person use of prescription opioids in
the United States increased from 74 mg to 369 mg, an increase of 402%!

13. National Prevalence of Prescription Drug Abuse
• In 2009, 7 million Americans reported current (past month) nonmedical use
of prescription drugs – more that the number using cocaine, heroin,
hallucinogens, and inhalants combined.
• National surveys show that the number of new abusers of several classes of
prescription drugs increased markedly in the United States in the 1990’s.
• Continuing at high rates during the past decade, abuse of prescription drugs
now ranks second (after marijuana) among illicit drug users.
• Perhaps even more disturbing, approximately 2.2 million Americans used
pain relievers non-medically for the first time in 2009 (initiates of marijuana
use were 2.4 million).

15. Indicators of Prescription Drug Abuse
Epidemic in this Country
Treatment admissions for opiates other than heroin rose from 19,870 in 1998 to 111,251
in 2008, over a 450% increase.
The number of fatal poisonings involving prescription opioid analgesics more than
tripled from through 2006, outnumbering total deaths involving heroin and cocaine.
The Drug Abuse Warning Network (DAWN), which monitors emergency department
(ED) visits in selected areas across the Nation, estimates that in 2008, roughly 305,000
ED visits involved nonmedical use of Prescription pain relievers; 19,000 involved CNS
stimulants; and 325,000 involved CNS depressants (anxyiolytics, sedatives, and
hypnotics). Over half involved more than one drug. These numbers have more than
doubled for pain relievers, and nearly doubled for stimulants, and CNS depressants
since 2004.
ED visits related to zolpidem (Ambien) – one of the most popular prescribed non-
Benzodiazepine hypnotics in the United States – also more than doubled during this
period, from about 13,000 in 2004 to about 28,000 in 2008.

16. National Prevalence of Prescription Drug Abuse
More law enforcement agencies are reporting
that pharmaceutical diversion and abuse pose
the greatest drug threat to their areas, in part
because of increases in associated crime and
gang involvement, which put additional strain
on agency budgets and assets.

17. Percentage of State and Local Law Enforcement
Agencies Reporting CPD’s as their Greatest Drug
Threat 2005-2009

18. Percentage of State and Local Law Enforcement Agencies Reporting
Street Gang Involvement in Pharmaceutical Distribution and an
Association Between Pharmaceutical Diversion and Crime, 2008-2009
2008 2009
Street Gang Involvement 44.2% 48.0%
Property Crime 6.0% 8.4%
Violent Crime 3.5% 4.8%
National Drug Threat Survey

19. National Key Elements
Among adolescents, prescription and over-the-counter
medications account for most of the frequently abused drugs
by high school seniors (including tobacco and alcohol).
- Nearly 1 in 12 high school senior reported non-medical
use of Vicodin; 1 in 20 reported abuse of Oxycontin.
- When asked how prescription pain relievers were obtained
for non-medical use, 59% of 12 graders said they were given
to them by a friend or a relative. The number obtaining them
over the internet was negligible.

21. Older Adults

22. Changing Substance Abuse Patterns Among Older
Admissions
• Older substance abuse treatment admissions (aged 50 or older)
increased from 6.6% of all admissions 12 years of age or older in 1992
to 12.2 % in 2008.
• Between 1992 and 2008, the proportion of older admissions that
reported primary alcohol abuse decreased from 84.6% to 59.9%,
• The proportion of older admissions that reported multiple substances
of abuse nearly tripled, increasing from 13.7% in 1992 to 39.7% in 2008.
• In 2008, older admissions who initiated use of their primary substance
of abuse within the past 5 years were more likely than those in 1992 to
have reported prescription pain relievers as their primary substance
(25.8% vs. 5.4%).

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24. Source: Florida Agency for Health Care Administration ED data sets and Inpatient data sets.
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25. Health Effects of the Prescription Drug Abuse
• The abuse of opiods can produce drowsiness,
constipation and depending on the amount taken, can
cause respiratory depression and ultimately death.
Repeated use can lead to physical dependence and
addiction.
• The abuse of the central nervous system depressants
can result in seizures, respiratory depression and
decreased heart rate.
• Stimulant abuse can lead to high body temperature,
irregular heart rate, cardiovascular system failure and
seizures. Taken repeatedly, it can cause paranoia and
anxiety.

26. Effects on the Brain and Body
Opioids act on the brain and body at attaching to specific cell surface
proteins called opioid receptors, which are found in the brain, spinal cord,
gastrointestinal tract and other organs. When these drugs attach to certain
opioid receptors, they alleviate the perception of pain.
These drugs can induce euphoria by indirectly boosting dopamine levels in
the brain regions that influence our perception of pleasure.
Abusers may snort or inject the drug amplifying its euphoric affects and
increasing medical risk such as respiratory arrest, coma and addiction.

27. Effects on the Brain and Body
Stimulants elicit a gradual and sustained increase in dopamine, which produces the
expected therapeutic effects seen in many patients with ADHD, calming and
focusing.
Methylphenidate is similar to cocaine, in that it binds to similar molecular targets in
The brain, thereby increasing dopamine in reward circuits.
When administered intravenously, both drugs cause a rapid and large increase in
dopamine, which is experienced as a rush.
For those who abuse stimulants, the range of adverse health consequences
Include hyperthermia, seizures and cardiovascular complications.

28. Effects on the Brain and Body
CNS depressants, typically prescribed for the treatment of anxiety, sleep disorders,
acute stress reactions, and muscle spasms, include drugs such as benzodiazepines
(e.g., valium, xanax) and barbiturates (e.g., Phenobarbital) – which are sometimes
prescribed for seizure disorders. Most CNS depressants act on the brain by affecting
the neurotransmitter gamma – Aminobutyric acid (GABA), which works by decreasing
brain activity. CNS depressants enhance GABA’s effects and thereby produces a
drowsy or calming effect to help those suffering From anxiety or sleep disorders. These
drugs are also particularly dangerous when mixed with other medications or alcohol;
overdose can suppress respiration and lead to death. The newer non-benzodiazepine
sleep medications, such as zolpidem (Ambien), exzopicione (Lunesta), and zalepron
(Sonata), have a different chemical structure, but act on some of the same brain
receptors as benzodiazepines and so many share some of the risks - they are
thought, however, to have fewer side effects and less dependence potential.

29. Case History – M.P.
- 63 Years of age, Caucasian female
- Opiates and benzodiazepines
- Current meds: Prempro
- Past surgical history
- Past medical history

30. Case History – M.P.
- Chronic Pain:
- Fibromyalgia
- Chronic shoulder
- Chronic back
- Psychiatry: major depressive disorder
- E&B
- Labs
- Detox

33. Case History – D.S.
- 72 Years of age, Caucasian male
- Alcohol, opiates and benzodiazepines
- Current meds:
- Hydralazine 30 mg
- Celebrex 200 mg
- Atenolol 50 mg
- Simvastatin 20 mg
- Omeprazole 20 mg
- Androgel 2.5/0
- Past surgical history
- Past medical history

34. Case History – D.S.
- Chronic Pain:
- Rheumatoid arthritis
- Osteoporosis
- Lumbar fracture
- Thoracic compression fractures
- Psychiatry: depressive disorder NOS
- E&B
- Labs
- Detox

37. Prescription Drug Abuse Prevention Plan Goals
• Have an approved and implemented Risk Evaluation and Mitigation Strategy for certain
long-acting and extended release opioids within 12 months.
• Write and disseminate a Model Pain Clinic Regulation Law within 12 months.
• Engage and work with Federal agencies and stakeholders to develop and implement a
national public education campaign on prescription drug abuse and safe and proper
medication disposal within 24 months.
• IHS will increase the number of collaborative practice agreements that involve
pharmacists prescribing privileges and monitoring of pain medication prescribing within
18 months.
• Complete rule-making and implement regulations for medication disposal within 24
months.
• Have legislation passed that requires prescribers applying for DEA registration to
complete training on the appropriate and safe use, and proper storage and disposal of
schedule II and III opioids. Legislation to be passed within 24 months.

38. Prescription Drug Abuse Prevention Plan Goals
• FDA intends to issue a guidance document on developing abuse deterrent drug
formulations and on post-market assessment of their performance within 24 months.
• Have DOD, VA, and HHS provide controlled substance prescription information
electronically to PDMP’s in states in which they operate healthcare facilities and
pharmacies within 24 months.
• Increase by 25% the number of states reimbursing for SBIRT within 24 months.
• Increase by 25% the number of HIDTA’s involved in intelligence gathering and
investigation around prescription drug trafficking and participation on statewide and
regional prescription drug task force within 24 months.
• Have legislation in all 50 states establishing Prescription Drug Monitoring Programs
within 36 months.
• Expand by 10%, within 36 months, the available funding for treatment to increase
access since only a small fraction of drug users currently undergo treatment.
• Decrease by 15% the number of unintentional overdose deaths related to opioids
within 60 months.

39. HANLEY CENTER
933 45th Street
West Palm Beach, FL 33407
(Office) 561-841-1106
(Fax) 561-841-1100
Email: bkrantz@hanleycenter.org
Website: hanleycenter.org
Toll Free: 866-4HANLEY

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