1. health and fitness
2. addiction

Pharmageddon:
The Rx Drug
Abuse Crisis
Linda B. Kalin, RN, BS, CSPI
Director
Linda.Kalin@unitypoint.org
Hotline: 800-222-1222
Office: 712-279-3710
www.iowapoison.org
Iowa’s PCC
 >50,000 incoming calls
 Over 25% of IPCC cases come from health care
providers (primarily hospital ERs)
National 800 Phone Number
Works just like 911
Program your
cell phone!
24 hours a day- 7 days a week
Federally funded by HRSA
iPhone app
is available
What is Misuse?
 Misuse is “non-medical use” or any use that
is outside of a medically prescribed regimen
 Examples can include:
 48% of IPCC cases involve children under age 6
 Taking for psychoactive “high” effects
 Over 20,000 drug ID calls
 Taking in extreme doses
 Staffed by RNs specially trained in toxicology
 Full-time MD; board-certified medical toxicologist
 Mixing pills
 Using with alcohol or other illicit substances
 Obtaining from non-medical sources
www.iowapoison.org
Commonly Misused Rx Drugs
 Opioids: pain-killers
 Hydrocodone (Vicodin)
 Oxycodone (Oxycontin)
 Sedatives/Tranquilizers: treat
anxiety and sleep disorders
 Xanax, Ativan, Valium, Soma
 Stimulants: ADHD, weight loss
 Adderall, Ritalin, Concerta
04/07/14
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Many deaths are a result of “polypharmacy”
Combining Rx & OTC medications
Taking Rx and OTC meds with alcohol
Using Rx and OTC with other illicit drugs
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Not Just Celebrities
• 1 in 5 students abuse Rx drugs*
 Most common among white students
(23%) and 12th graders (26%); no
difference by gender
 Risk perception plays important role
• Deaths by Rx drugs now exceed
those caused by cocaine, heroin, and
methamphetamine combined…and
exceed deaths by MVAs
2009 National Youth Risk Behavior Survey (YRBS), CDC
Two Wrongs Make…an Epidemic
Generation Rx
 4 billion U.S. prescriptions written in 2010
 Today's teens are more likely to abuse
Rx and OTC drugs than most illicit drugs
 Rx drugs are the 2nd most abused drugs
next to marijuana (3rd is cough medicine)
 Legal, widely available, easily accessible
and affordable
 “Safe” – prescribed by MD
 Consumerism
Social Slang
 Teens and parents believe that Rx drugs are
safe because a doctor prescribes them.
 Xbrs or Xanabars: Xanax
 Vic: Vicodin
 Teens think their parents aren’t as concerned
about Rx drugs as illicit drugs.
 Skittles, Dex, Robo, Tussin (any OTC
cold pill containing DXM)
 Triple Cs or CCC: Coricidin Cough &
Cold medicine
 SIZ’zurp: cough syrup & ETOH
 Trail Mix or Salad Bowl: Pharm Party
 16% of parents said they think Rx drugs are safer
than street drugs.
 Parents don’t realize that some Rx meds are
a synthetic, equally potent version of the
street drugs they fear.
2012 Partnership Attitude Tracking Study; Partnership at Drugfree.org
Warnings Signs
 Pills in medicine cabinet disappearing
 Continually “losing” prescriptions
 Seeking prescriptions from >1 doctor
 Taking higher doses despite warnings
 Stealing, forging or selling prescriptions
 Excessive mood swings
 Sudden drop in performance (school or work)
 Weight loss, agitation, insomnia (stimulants)
04/07/14
UNDER PARENTS’ RADAR
What are opioids?
 Opiate: derivative of opium poppy (naturally
occurring from plants)
 Includes morphine and codeine
 Opioid: a compound that binds to opiate receptors
 Semi-synthetic: created from natural opiates
 Fully synthetic: drugs made in a laboratory which cause
the same effect as opium
 Endogenous opioids: naturally produced in the body
(endorphins)
 Narcotic: legal designation
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Synthetic Opioids
Semi-synthetic Opioids
 Hydrocodone with Tylenol: Lortab, Vicodin, Lorcet
 Methadone
 Hydrocodone with ibuprofen: Vicoprofen
 Meperidine (Demerol)
 Hydromorphone: Dilaudid
 Fentanyl
 Oxycodone with Tylenol: Percocet
 Suboxone/Subutex (buprenorphine)
 Oxycodone with aspirin: Percodan
 Tramadol
 OxyContin
 Complex mechanism of action
 Buprenorphine
 Nonscheduled, less abuse potential
 Heroin is also semi-synthetic
Opioids
Opiates: Special Considerations
 Adequate sensitivity for detecting morphine, codeine
 Unable to detect synthetic or semi-synthetic opioids
 Do NOT metabolize to codeine, morphine, or 6-acetylmorphine
• Sustained Release or Long Half-Life
 Oxycontin, methadone
• Opiates Containing Acetaminophen
 Hydrocodone: Vicodin, Lorcet, Lortab
 May result in a false-negative
 Oxycodone: Percocet, Roxicet, Tylox
Oxymorphone
Oxycodone
Fentanyl
Hydromorphone
Propoxyphene
Pentazocine
Hydrocodone
Methadone
Buprenorphine
Dihydrocodeine
Meperidine
Tramadol
Hydrocodone (Vicodin)
 #1 most prescribed drug in U.S.
 131M prescriptions written in 2011
 Zohydro approved 10/25/13
Contains hydrocodone
plus acetaminophen
 First hydrocodone-only opioid
 Pure and stronger form of HC
 Available in 10, 15, 20, 30, 40, 50 mg
 HC designed to be released over 12 hr
 Abusers will be able to crush it, chew
or mix it with alcohol
04/07/14
 Propoxyphene: Darvocet, Wygesic
• Seizures
 Propoxyphene, demerol, tramadol, dextromethorphan
• EKG Changes
 Propoxyphene (QRS widening)
FDA Urging Tighter Controls
 Oct 24, 2013 FDA recommends tighter controls on
drugs containing hydrocodone (Vicodin, Lortab)
 Involves rescheduling from Schedule III to II
 # of drug deaths from opioids quadrupling since 1999
 Changes how doctors prescribe these drugs and
imposes storage and record-keeping changes
 Debate: Will this reduce Rx drug abuse? Will this
affect patient’s access to meds for patients with
legitimate chronic pain?
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Oxycodone (Oxycontin, Percocet)
“Abuse-Proof” OxyContin
 Used to treat moderate to severe pain
 August 15, 2010 new formulation of
controlled-release Oxycontin available
 Drug is coated in a plastic-like polymer
 Designed to discourage abuse by
preventing medicine from being cut,
broken, chewed, crushed or dissolved
 Internet shows how to tamper with
“tamper-proof” Oxy
 Oxycontin (AKA “Pharmaceutical heroin”):
 Produced in a 12-hr timed-release tablet
 Tabs: 10 mg, 20 mg, 40 mg, 60 mg and 80 mg
 Abusers crush the pill to bypass the timerelease mechanism-then chew, snort or inject
 Enhances the “rush”
 This was the “ultimate score” until reformulated
*Tablets changed from “OC” to “OP.” The number on
each tablet corresponds to the milligram dosage.
Unintended Consequences
 As OxyContin abuse dropped
with the new formulation,
heroin abuse rose1.
 Heroin is easier to use, much
cheaper and easily available.
 Small bag of heroin can cost
$5 and an 80 mg dose of Oxy
may cost up to $80 (U.S.
DEA)
1Effect
Iowa Opioid and Heroin OD Deaths
70
62
60
50
Rx Opioid Deaths
+1,450%
40
30
Heroin OD Deaths
+900% 10
20
10
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1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
of Abuse-Deterrent Formulation of OxyContin, N Engl J Med 2012;
367:187-189 July 12, 2012
Heroin (Schedule I drug)
 Teen heroin use is growing
 Initiations to heroin have increased 80%
among 12-17 year olds since 2002
 90% of teen heroin addicts are white
 Most users started with Rx opioids (SAMSHA)
 Fastest-acting opioid; extremely high
potential for abuse
 Powder is usually cut with other chemicals
“black tar
heroin”
04/07/14
 Unknown dose and purity
IDPH, 2012
“Speedball”
 Heroin + cocaine in same syringe
 Produces intense rush of euphoria
 Combines the effects of both drugs
while negating less desirable effects
 Heroin cancels out anxiety & paranoia
created by cocaine
 Cocaine negates sedation of heroin use
 Cocaine wears off far more quickly
 Potentially fatal overdose
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Tramadol (Ultram, Ultracet)
Fentanyl
 Unique synthetic opioid analgesic
 Ex. Duragesic, Actiq, Sublimaze, Abstral
 Originally thought to have weak opiate
effects and little potential for abuse (1995)
 “Synthetic heroin”- 80 x stronger than
morphine, faster acting than high grade
heroin, lasts twice as long
 Only available non-scheduled opiate
 Drug-drug interactions can occur (when
combined with other serotoninergic drugs)
 Manufactured illicitly as powder or tablets;
often sold or mixed with heroin
 High doses can cause seizures
 Not detected in routine drug screens
Methadone
Morphine
 Developed to treat heroin dependence; now
widely prescribed for long-lasting pain relief
 Opiate derived from the poppy plant
 Available as a low-cost generic drug
 Causes 30% of Rx painkiller deaths; accounts
for only 2% of painkiller Rxs (CDC, 2009)
 Much longer half-life than other opiates; can
build up in a person’s body and cause toxicity
 Available in tablet, syrup, injection, suppository
 Sustained release preparations:
 MS Contin, Oramorph, Kadian, Avinza
 Taking a large single dose can cause severe
respiratory depression, coma or death
 Added risk when taken with sedatives or other
Rx painkillers
Oxymorphone (Opana)
 Becoming much more popular with abusers
(especially with Oxycontin’s new formulation)
 Euphoria exceeds that of oxycodone and
some say heroin as well
 Person with low tolerance will get a powerful
high from ~1/8 of a high dose (40 mg ER)
through snorting
Buprenorphine




Used for opioid dependence
Office-based, expands availability
Ceiling effect
Lower abuse potential; safer in overdose
 Sublingual administration (AKA “Bupe strips”)
 Subutex (Bup) and Suboxone (Bup + Naloxone)
 Tablets withdrawn in 2012 due to accidental
pediatric risks
 Zubsolv® released 2013 (Bup + Naloxone)
04/07/14
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Treatment of Opiate Overdose
 GOOD SUPPORTIVE CARE!
 NaHCO3 for wide QRS from propoxyphene
 Narcotic Antagonist: Naloxone
 Effective at reversing respiratory depression
 CAUTIOUS use (if at all) with opioid-dependent
 May lead to pulmonary edema
Opioid Withdrawal
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Dysphoric mood
Nausea or vomiting
Diarrhea
Goosebumps
Runny nose
Dilated pupils
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Sweating
Yawning
Muscle aches
Fever
Insomnia
 Duration of effect SHORTER than opioid effect
– Re-sedation and  RR or apnea may reappear
Krokodil (Desomorphine)
 Home-made opiate synthesized from codeine
 Toxic chemicals used in synthesis- “flesh eating”
• Iodine; strong alkalis, HCL acid, red phosphorus,
lighter fluid, industrial cleaning oil
• Highly impure, contaminated with toxic byproducts
 Named for its crocodile appearance of skin
 More powerful and cheaper than heroin
 AKA “poor man’s heroin”, “dirty cousin of morphine”
 No confirmed cases in U.S.
Benzodiazepines (BDZ)
 Most benzo names end in "pam" or "am”




Xanax (alprazolam)
Valium (diazepam)
Klonopin (clonazepam)
Ativan (lorazepam)
 Medically used for anxiety, insomnia, alcohol
withdrawal, treat seizure disorders, inducing
amnesia for uncomfortable procedures
 Rapid tolerance; highly addictive
 Withdrawal may be severe (similar to alcohol)
04/07/14
Sedative-Hypnotics
 Used to treat anxiety and sleep disorders
 Mechanism: enhances GABA
 Acts to slow normal brain function
 Benzodiazepines
 Non-benzo hypnotics
 Ambien (zolpidem)
 Sonata (zaleplon)
 Lunesta (eszopiclone)
 Barbiturates (ex. phenobarbital)
 Soma (skeletal muscle relaxant)
Sedative-Hypnotic Effects
 Sedation
 Slurred speech
 Incoordination
 Unsteady gait
 Impaired attention or memory
 Stupor or coma
 Overdose risk increased with opioids or in
combination with other sedatives, including
alcohol
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Sedative-Hypnotic Withdrawal
  heart rate
Attention Deficit Disorder (ADD)
AD/Hyperactivity Disorder Drugs
 Short term effects:
  blood pressure
 Euphoria
  sweating
  energy/productivity
 Hand tremor
  concentration and  alertness
 Nausea/vomiting
  appetite
 Transient hallucinations or illusions
 Anxiety and agitation
 Seizures
Adderall Abuse (aka “Addys”)
 Powerful combination of four time-released
amphetamines
 AKA: “Study Pill,” “Ivy League Crack”
  libido
  wakefuless,  sleep
 High potential for abuse; may cause
dependence and addiction
Lots of Medical Risks
 Norepinephrine release causes
constriction of blood vessels, elevated
blood pressure and rapid heart rate
 Abused for its energetic, stimulating and
euphoric effects
 Increased activity levels
 Snorted and taken IV (more direct routes to
the bloodstream and likely more dangerous)
 Increased risk of seizures
 Schedule II drug
Psychiatric Symptoms
 Dangerously high body temperatures
 Potentially fatal arrhythmias, heart attack,
or stroke
Dextromethorphan (DXM)
 Psychiatric symptoms associated with use of
larger doses of amphetamines include
depression, anxiety, psychosis, and suicidal
ideation
 Over-the-counter cough suppressant
 Symptoms may depend on differences in
sensitivity, frequency and quantity of use, and
method of administration
 Excess doses can cause symptoms
similar to PCP and ketamine
 Abstinence syndrome may occur (dysphoria,
anhedonia, irritability, insomnia, anxiety, low
energy)
 >Large doses of cough syrup taken
(8-12 oz); often causes vomiting
04/07/14
 >120 products contain DXM or DM
 Structurally related to morphine
 Effects vary with the amount taken
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Coricidin HBP Cough & Cold*
4 Plateaus* of “Skittling”
 AKA: Triple C, Red Devils, Skittles
1. Mild inebriation
 Contains 30 mg DM per tab
2. Described as being “stoned and drunk”:
slurred speech, mild hallucinations, impaired
short-term memory
 Therapeutic dose= 30 mg q 6-8 hr
 Abusers: 250-1500 mg in one dose
 #1 stolen product from pharmacies
 OTC meds are perceived as “no risk”
* Coricidin HBP Cold and Flu® is commonly mistaken
for the Cold and Cough and contains acetaminophen!
Other OTC highs
3. Extremely strong hallucinations, confused
thinking, double or blurred vision
4. “Out of body” dissociative sensation and loss of
motor control; effects like PCP and Ketamine
*May also cause N/V, difficulty breathing,  heart rate, seizures, coma
Which contains more alcohol?
 Diphenhydramine (Benadryl® and
Dimenhydrinate (Dramamine®)
 Large doses can cause hallucinations
and delirium
 Used as a cheap high
 Effects: somnolence, anticholinergic
effects (large pupils, flushing, fever, dry
mouth), tachycardia (common), N/V
 Overdose can lead to serious cardiac
dysrhythmias, coma and death
First Responders
• Never leave the person alone!
• GET HELP! “Better safe than sorry!”
• Turn the person on his/her side and
monitor breathing until help arrives.
• Remember, a person’s BAC can continue
to rise even while he or she is passed out:
Don’t try to guess the level of drunkenness!
• Don’t assume a person is going to be fine
just by sleeping it off!
04/07/14
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