of Prescription Drug Abuse on the College Campus Josh Hersh MD Staff Psychiatrist Miami University Minimal Abuse Maximum C are Multiple articles on scope of the problem Prescription Drug ID: 624323
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Prevention and Treatment of Prescription Drug Abuse on the College Campus
Josh Hersh M.D.Staff Psychiatrist Miami University
Minimal
Abuse
Maximum
C
areSlide2
Multiple articles on scope of the problem“Prescription Drug Abuse Rises on Campuses”—ABC News
“Report: Prescription Drug Deaths Skyrocket”—Foxnews.com“Stimulant Abuse Rises on the College Campus”—The Columbus Dispatch“Prescription Drug Abuse on the
Rise
in
America”—Chicago TribuneSlide3
2009 CDC Statistics3433 H1N1 swine flu deaths1385 deaths from alcohol poisoning28,754 prescription drug overdose deaths Slide4
How Common is Misuse?World Health Association estimates about 50% of people do not take prescription drugs as prescribed (higher with controlled substances)Maryland study found 35.8% of college students reported
that they had diverted a drug at least once in their lifetime.1 Prescription stimulants --61.7% diversion ratePrescription opiates--35.1% diversion rate 33.6
%
of students freely
shared
medication
9.3
%
of students sold medication
1
J
Clin Psychiatry. 2010 March; 71(3):
262–269Slide5
Reasons for Prescription Drug AbuseStimulants—cramming, delaying sleep, weight loss, Sleep Disorders, ADHD symptoms, recreational, dependency
Opiates—pain (especially athletes), anxiety, insomnia, recreational, dependencyBenzodiazepines—anxiety, insomnia, recreational, dependencySlide6
Reasons for Co-Administration/Co-AbuseCombining stimulants with alcohol to drink longer and counteract sedationCombining opiates or benzodiazepines with alcohol to increase intoxication (dramatically increases rate of overdose)Combining benzodiazepines with stimulants to decrease anxiety from stimulantsSlide7
TRUE Or falseMany more people overdose from illegal drugs than prescription drugsMost people that misuse prescription drugs do not have their own prescriptionSlide8
True or FalseTaking a stimulant such as Adderall would help anyone studyStudents who take stimulants such as Adderall get better gradesMixing stimulants such as Adderall with alcohol will help you drink more and stay awake so you will have less problems from alcoholSlide9
Consequences of Abuse/DependenceMedical risks (cardiac and stroke risks, liver damage, nasal perforation, blood-borne diseases, overdose)Psychiatric
illness (depression, anxiety, psychosis, sleep disturbance)Inability to function at work or schoolRelationship problemsFinancial problems Illegal behaviorSlide10
Prevention of Prescription Drug AbuseTreatment algorithms to treat ADHD, Anxiety Disorders, Sleep Disorders, and
pain (Minimal Abuse/Maximum Care) Student education on scope of problem and
how to care for controlled
substances
Legal consequences for criminal behavior (e.g. selling meds, forging scripts, etc.)
Enforcement of medical standards
MINIMAL
ABUSE
MAXIMUM
CARESlide11
Treatment of ADHDInitial Phone Screening to refer students to proper
treatment settingBrain Booster Workshop and ADHD Workshop to educate students on behavioral interventions and medication risksAttention Problem Evaluation (APE) to screen for other causes of inattention and create comprehensive treatment plan
MINIMAL
ABUSE
MAXIMUM
CARESlide12
Brain Booster Workshop60 minute long workshop that details behavioral interventions to treat attention problemsThis includes sleep hygiene, usage of the Miami planner, and techniques to help with focus while studying
Open to all full time Oxford Campus studentsRequired for all students seeking treatment of ADHD unless they have had extensive exposure to behavioral treatments in the pastSlide13
ADHD WorkshopOne hour psychoeducational workshop required prior to ADHD treatment for ALL students seeking medicationIncludes education about ADHD and procedures for taking medicationEducation about risks and benefits of medication including suggestions for avoiding misuse and diversion
Providing lockboxesSlide14
This year …1. Lock boxes distributed in the community with targeted populations: pediatric, adult and students2. Assessed Rx abuse on campus via Miami Nursing Department
3. Applied for grant to help fund additional Lock Boxes4. Pharmacy selling lock boxes to studentsSlide15
1. Survey says!23 out of 34 students completed the follow up
Lock box surveyOf these, 23 students: - 5
have had their medications lost or previously stolen (
21%
)
-
18
said they used the lock box daily (
78
%
)
-
22
agreed that passing these lock boxes out free of charge to students was very
helpful
(
95
%
)Slide16
1. Survey says!Of the 18 students that use the lock box daily
:-13 had looked at the messaging about prescription drug abuse (72%
)
-
14
agreed the messaging helped them understand the importance of taking
medications
as prescribed (
77
%
)
-
17
stated that they would not make any changes to the messaging (
94%
)Slide17
Comments from students“It would be helpful to give the lockbox to every student when they are initially prescribed a controlled substance.”
“Great idea for students living in dorms.”“Less likely to have medications stolen because someone would not go through the “extra hoop” to steal the box.”“Awesome program and works very well for securing prescription drugs.
“It’s too risky to tell friends I am on these medications because during finals everyone wants it”Slide18
What is the next step?We didn’t get the grant!So, we encouraged our pharmacy to start selling lock boxes at cost to anyone who needs/wants one!Slide19
Treatment of Anxiety DisordersAnxiety management workshops and/or individual therapy first
Try non-addictive substances first (SSRI’s, buspirone, and beta blockers)If benzodiazepines are needed, limit amount of benzodiazepines (i.e. 10 per month)Monitor frequently for signs of misuse and diversion
MINIMAL
ABUSE
MAXIMUM
CARESlide20
Treatment of Sleep Disorders
Try behavioral techniques (sleep hygiene, white noise, etc.)Consider non-controlled substance such as trazodoneLimit amounts of controlled substance such as zolpidem (10 per month)Referral to sleep disorders clinic for concerns about narcolepsy or sleep apnea
MINIMAL
ABUSE
MAXIMUM
CARESlide21
Treatment of Pain
Referrals and communication with surgeons, PCP’s, physical therapy, and/or counselorsPreference for non-controlled substances such as NSAID’sLimit supply of opiates for severe, acute painMeet frequently and monitor for signs of misuse and diversion
MINIMAL
ABUSE
MAXIMUM
CARESlide22
Prevention Doesn’t Always Work!Slide23
Diagnosis of Prescription Drug Abuse/DependenceHistory (non-judgmental stance, admission of problems, wanting help)Pain, Anxiety
Disorders, Sleep Disorders, and ADHD (ask about self-medicating)DSM-IV criteria (abuse vs. dependence)Drug seeking behavior) Signs of intoxication or withdrawal Prescription drug monitoring systemUrine drug testsSlide24
Screening ToolsComprehensive Drug Use Screening and Assessment: NIDA-Modified ASSIST Interactive online screening tool, includes
tobacco, alcohol, prescription, and illicit drugsGenerates a numeric Substance Involvement Score that suggests the level of medical intervention necessaryHttp://www.drugabuse.gov/nidamed/screeningSlide25
Management of Prescription Drug Abuse and DependenceIdentify “Stage of Change”Pre-contemplation—Security if needed
Don’t enable the problem--Contact all physicians prescribing to the student and make them aware of problem
Contemplation and Action
N
on-
judgemental
stance—disease
model
Let them know options for treatment
Inpatient vs. outpatient treatmentSlide26
Treatment of Opiate Dependence on the College CampusOpiate Dependence is a growing problem on the college campusImproves retention of studentsPrevents overdoseTreatment is effective
Decrease criminal behaviorDecrease the spread of infectious disease (e.g. HIV, HCV/HBV, STI)Slide27
Medication Assisted Treatment of AddictionUsing medication, in conjunction with counseling and peer support groups to treat addictionCan help with harm reduction (prevention of hepatitis C, overdose deaths, criminality)Can be used to help people achieve abstinenceSlide28
Buprenorphine/Naloxone Partial opioid agonist; ceiling effect at higher doses (safer than most opioids in overdose)Can be lethal for unexposed or if combined with sedativesBlocks effects of other agonists (difficult to get high off opioids while on buprenorphine)
Binds strongly to opioid receptor, long acting (once daily dosing)Has withdrawal syndrome (needs to be tapered off slowly)Slide29
Buprenorphine/Naloxone in College Health Practice
DeMaria
et. al. J
Am
Coll
Health. 2008 Jan-Feb;56(4):391-3.
The implementation of
buprenorphine/naloxone in
college health
practiceSlide30
NaltrexoneNaltrexone is effective for preventing relapse on opiatesWorks by blocking the effects of opiates at the opiate receptorAvailable in oral (Revia) and monthly injectable (
Vivitrol) formsNo tolerance or dependenceCan stop at any time when readySlide31
Treatment of Stimulant Use DisorderNo FDA approved medications to treat prescription stimulant abuseStimulant induced psychosis often managed with antipsychotics and safe environmentSupervised administration of stimulants if required for ADHD or narcolepsyMay be difficult to experience withdrawal and complete courseworkSlide32
Treatment of Benzodiazepine Use DisorderOutpatient taper is risky, consider inpatient treatmentEducation on dangers of mixing benzodiazepine with alcohol and opiatesUsing medications such as SSRI’s, hydroxyzine, and clonidine to help with post-acute withdrawal symptoms
Regular urine drug testingCommunication with parents