PRESCRIPTION DRUGS And What Can We Do About It? Why Are Abused

Why Are PRESCRIPTION DRUGS Abused
… And What Can We Do About It?
Nora D. Volkow, M.D.
Director
Prescription Drug Misuse/Abuse is aMajor Problem in the US
Current Drug Use Rates in Persons Ages 12+
22.5 (8.7% )
Illicit Drugs
Marijuana
18.1 (7.0%)
Psychotherapeutics
6.1
Cocaine
1.4
Hallucinogens
1.0
Inhalants
0.6
Heroin
0.3
0
(2.4%)
(0.5%)
(0.4%)
(0.2%)
(0.1%)
5
10
15
20
Numbers in Millions
Source: SAMHSA, 2011 National Survey on Drug Use and Health, 2012.
25
Why Do People Abuse Prescription Drugs?
frontal
cortex
nucleus
accumbens
VTA/SN
700
600
500
400
300
200
100
0
% of Basal Release
Dopamine
Neurotransmission
% of Basal Release
These prescription drugs, like other drugs of abuse
(cocaine, heroin, marijuana)
1100
1000
AMPHETAMINE
raise brain dopamine levels
900
800
0
1
2
3
4
5 hr
Time After Amphetamine
FOOD
200
150
100
50 Empty
Box Feeding
0 0
60
120
Time (min)
180
Di Chiara et al.
Opioids: Examples: OxyContin, Vicodin
How They Work…
Attach to opioid receptors in the
brain and spinal cord, blocking the
transmission of pain messages and
causing an increase in the activity
of dopamine
Opioids are Generally Prescribed for:
•
•
•
Postsurgical pain relief
Management of acute or chronic pain
Relief of coughs and diarrhea
Thalamus
(pain)
NAc
(reward)
Amydala
(reward)
Similarities Between Illicit and Prescription Drugs
Stimulants
Example: Ritalin
How They Work…
Enhance brain activity by increasing the activity of brain
excitatory chemical messengers, such as norepinephrine
and dopamine, leading to mental stimulation
Stimulants Are Generally Prescribed For:
• ADHD
• Narcolepsy
• Depression that does not respond to
other treatments
• Asthma that does not respond to
other treatment
Similarities Between Illicit and Prescription Drugs
Cocaine and Ritalin Act
on the Same Sites in the Brain
Distribution of Dopamine Transporter in the Human Brain
100%
Adderall
11%
Volkow, et al. (BNL)
Methamphetamine
What is the Difference Between
Therapeutic Use and Abuse?
• Dose and Frequency of Dosing
Lower, fixed regimes vs higher, escalating use
• Route of Administration
Oral vs injection, smoking, snorting
• Expectation of Drug Effects
Expectation of clinical benefits vs euphoria “high”
• Context of Administration
School, clinic, home vs bar, discotheque
Rewarding Effects of Drugs Depend on How Fast
they Get into the Brain
% Peak
[11C]Cocaine in brain
[11C]Ritalin in brain
100
100
80
80
60
60
40
40
20
20
0
Reward
Reward
0
0 10 20 30 40 50 60 70 80
0 10 20 30 40 50 60 70 80
iv cocaine
0.06
0.05
0.05
0.04
0.04
0.03
0.03
Fast!!
0.02
0.01
0
0
iv Ritalin
0.06
Fast!!
0.02
0.01
20
40 60 80 100 120
Time (minutes)
0
0
20
40 60 80 100 120
Time (minutes)
Uptake in Striatum (nCi/cc)
Uptake in Striatum (%/cc)
Time (min)
oral Ritalin
0.0035
0.003
0.0025
0.002
Slow!!
0.0015
0.001
0.0005
00
20
40
60
80 100 120
Time (minutes)
Cocaine (iv) and
Ritalin (iv) are
rewarding but
Ritalin (oral) is
not.
The slow brain
uptake of oral
Ritalin allows
treatment without
reward
Unexpected MP
70
% Change
Glucose Metabolism Was Greatly Increased
By the Expectation of the Drug
30
25
20
15
10
5
0
Expected MP
Increases in Metabolism Were About
50% Larger When MP Was Expected
Than Unexpected
0
µmol/100g/min
Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-11468, December 2003.
What Has Raised Our Attention to the
Problem of Prescription Drug Abuse?
Drug OD in the US Have More
Than Tripled since 1990 and
INCREASES Greater for
Women (Five-FOLD)
More Than 5-Fold Increase
In Treatment Admissions For
Prescription Painkillers
In the Past Decade
180,000
157,171
160,000
12
142,124
140,000
122,185
10
120,000
98,386
100,000
8
82,359
80,000
71,048
60,824
60,000
40,000
6
52,664
45,882
37,649
4
28,326
100 people die from drug
overdoses every day in the US
2
20,000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
0
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
*Deaths are those for which poisoning by drugs (illicit, prescription, and over-the-counter) was the underlying cause.
Source: SAMHSA Treatment Episode Data Set
(TEDS), 2000-2010
National Vital Statistics System.
Drug Overdose Death Rates by State 2008.
CDC Vital Signs, July 2013.
Number of Opioid Prescriptions Dispensed by
U.S. Retail Pharmacies, Years 1991-2011
250
Opioids
Hydrocodone
Oxycodone
Prescriptions (millions)
219
200
192
180
169
150
131
139
144
151
158
120
100
76
78
80
86
91
96
100
109
50
0
IMS’s Source Prescription Audit (SPA) &
Vector One®: National (VONA)
201
202
210
Overdose Deaths
Prescriptions
The Dynamic Relationship between Rates of
Opioid Prescriptions and Rates of
Opioid-Related Overdose Deaths in the US
2002
2006
Source: IMS Vector One National , CDC Wonder, & the US Census
2009
Opioids Overdose Death
by Age Group, US, 2008
Opioid Prescriptions
by Age
20 to 29
No. of Prescriptions (millions)
35
30 to 39
40+
159
180
160
30
30
140
25
120
20
100
19
15
80
60
10
40
6
5
2
-
2002
2006
2009
20
Rate per 100,000
10 to 19
No. of Prescriptions, Age 40+ (millions)
0 to 9
-
2012
IMS Health, Vector One® National
Paulozzi LJ, J Safety Res 2012; 43(4): 283-289.
Specific Drug Involvement in
Pharmaceutical Overdose Deaths USA, 2010
120
100
100
PERCENT
80
Drug Involvement in Pharmaceutical Overdose Deaths
Opioid Analgesic Involvement in Deaths for Specific Drugs
77.2
75.2
65.5
58
57.6
60
54.2
50
40
29.4
17.6
20
7.8
6.1
1.3
0.1
0
Opioid Analgesics Antiepileptic & Benzodiazepines
Antiparkinsonism
Drugs
Barbiturates
Antidepressants
Antipsychotic &
Neuroleptic Drugs
Jones, CM et al. JAMA, February 20, 2013; 309(7): 657-659.
Other
Psychotropic
Drugs
Source of Prescription Drugs
(how they obtained the drugs they most recently used nonmedically)
Rates averaged across 2009 and 2010
60.0%
55.0%
Percent
50.0%
40.0%
30.0%
20.0%
17.3%
11.4%
10.0%
4.8%
4.4%
0.4%
0.0%
Given by a Bought from a Took from
Through a
From drug
friend/relative friend/relative friend/relative prescription
dealer or
for free
without
from one
other stranger
asking
doctor
Source: 2010 National Survey on Drug Use and Health, SAMHSA 2011.
Bought on
internet
Prescription Drug Abuse: What can be done?
• Medications
-- Less abusable analgesics
-- Easy to administer Naloxone
• Clinician Information and
Education
• Primary Prevention
Uptake in Striatum (nCi/cc)
Need for New Medications
• Develop medications with
0.0035
0.003
0.0025
0.002
0.0015
0.001
0.0005
00
lower abuse potential
Slow!!
20
40
60
80 100 120
Time (minutes)
• Develop slow release formulations
(low dose and long duration)
•
Develop novel formulations to
reduce abuse liability
Overdose Intervention
• Naloxone Distribution for opioid
overdose victims. The potential for
direct intervention to save lives.
• Naloxone Nasal Spray Development
Needle-free, unit-dose, ready-to-use
opioid overdose antidote
NIDA STTR Grantee – AntiOp, Inc., Daniel Wermeling, CEO
Contact: E-mail: [email protected], Tel: 859-221-4138
Education for Healthcare Providers
CME Courses developed by NIDA & Medscape Education, funded by ONDCP
Safe Prescribing for Pain
Skills and tools clinicians can
use to screen for and prevent
abuse in patients with pain
Managing Pain Patients
Who Abuse Rx Drugs
Learn symptoms of opioid
addiction and dependence in
patients with chronic pain,
and how to screen for, prevent,
and treat such conditions