Kelly L. Matson, PharmD

Ms. Fong, Ms. Roy, and Ms. Sharkey arePharmD candidates at the University ofRhode Island College of Pharmacy. Dr.Matson is a clinical associate professorat the University of Rhode Island Collegeof Pharmacy, department of pharmacypractice.

Opioid dependence is an epidemicthat has no prejudiceor limits. The number of nonmedicalusers of narcotics has increasedsteadily over the years, makingopioids one of the highest drugclasses abused, second only to marijuana.

 By 2006, the number of users ofnonmedical pain relievers was greaterthan cocaine and heroin users combined(5.2 million vs 2.4 million and0.3 million, respectively).

 Pharmacistsneed to be informed and educated onopioid dependence, so they are ableto recognize, confront, and recommendappropriate programs.

Diagnostic andStatistical Manual of Mental Disorders,Fourth Edition

, as a medical disorderwith an etiology, pathogenesis, clinicalpresentation,diagnosis, and treatmentoptions. Understanding the alteration ofneurobiology in the brain, as well as thesocial dispositions that put opioid usersat risk, encourages clinical diagnosis andtreatment, rather than turning away a"drug seeker," who is judged to havearrived voluntarily at his or her condition.

Sometimes, a legal and valid prescriptionspirals into an uncontrollable addiction.It is important, therefore, for pharmaciststo recognize the signs of opioidabuse and help those patients who arestruggling with the addictive propertiesof these drugs. Pharmacists should bewary of patients who insist on payingcash for their prescription pain relieveror those who may ask questions regardingthe maximum dose of the drug orwhich drug "works better." If suspiciousactions appear in a patient's profile&#8212;usually seen as consecutive narcoticrefills from multiple prescribers&#8212;pharmacistsshould address this pattern withthe patient and call the physician torecall any trends in office visits or complaintsof increasing chronic pain.

The patient and prescription itself mayserve as indicators of a suspected opioidabuser. Although not common, theopioid abuser may display symptoms ofwithdrawal, including agitation, paranoia,or other aberrant behavior. The prescriptionitself should be reviewed carefully,focusing on the quantity, strength, refillamounts, and prescription dates. If anypart of the prescription looks suspicious,a call to the prescriber should be madeto verify the order.

Resources for patients who are ready to address their addiction to opioids. A list of local clinics also should be available in the pharmacy at times of individual counseling.

Buprenorphine Physician andTreatment Program Locator:

National Institute on Drug AbuseFact Sheets for Parents of Teens:

Yellow Pages (Drug Abuse &Addiction Information, TreatmentCenters, Information & ReferralServices, listed by state):

Not every patient who comes intothe pharmacy with a prescription for acontrolled substance is an abuser; however,it is the pharmacist's responsibilityto promote the patient's well-being andconfront the patient who does showsigns of dependence.

 In general, a constantwatchful eye, review of medicalhistory, and medication verification canhelp distinguish a drug abuser froma patient whose needs are medicallynecessary. Additionally, the code of ethicsshould remind pharmacists that apatient's well-being must be the centerof professional practice.

 Trust needs tobe established for the patient to sharehis or her struggles.

Confrontation of an opioid abuser canbe unpredictable. Pharmacists need toreaffirm their commitment to the patientduring this likely emotional time. If possible,direct the patient to the counselingroom to avoid any public embarrassment.Maintain a calm demeanor, explain thelegal and social consequences of abuse,and have brochures with information onlocal rehabilitation clinics and therapistswho specialize in addiction readily accessible.Steady reassurance and empowermentof patients can only help them tomake changes in their lives. It is not to say,however, that all patients will respondpositively to the recommendations madefor drug rehabilitation. If the patient turnshostile or shows signs of potential violence,it is better to walk away from thesituation and signal security.

Although certain aspects of treatmentrequire inpatient care, providing outpatienttreatment is an increasing trend,and it is in this setting where pharmacistsare more likely to interact with patientsand play a role&#8212;not only in recognitionof the disorder, but treatment.

The goal of treatment is completeindependence from addiction, resultingin improved personal relationships, workplacefunction, and role as a member ofthe community. Treatment includes multiplecourses of behavioral and pharmacologictherapy, both of which are necessaryto prevent relapse.

 Treatmentlocation and duration should be tailoredto each patient. Generally, pharmacotherapywill last for 180 days, whereasbehavioral therapy may last for years,and, in some cases, indefinitely.

Behavioral therapy is essential forrecovery and health maintenance.It instructs the patient how to functionwithout opioids, deal with cravings,avoid situations that may causerelapse, and how to handle a relapse if itoccurs. Behavioral therapy also extendsto friends, family, and spouses of theaffected patient and focuses on developinga unified support network. It teachesthe caregiver how not to be an enablerof addiction and helps address feelingsand hardships that he or she may experiencewhile the caring for the patient.

Behavioral therapy includes individualcounseling, cognitive-behavior therapy,support groups, recovery programs, andeducational or informational classes.

Medications for Treatment of Opioid Dependence

Induction; treatment of withdrawalfollowing detoxification;maintenance

Treatment of withdrawal followingdetoxification; maintenance

4-16 mg buprenorphine/1-4 mg naloxone sublinguallydaily

Opioid receptor partial agonist/antagonist

Pharmacotherapy addresses withdrawalsymptoms caused by the cessation ofan opioid in a dependent patient. Thesedrugs are designed to either mimic orblock the effect of opioids, allowingpatients to taper off or discourage theiruse. The Table describes common medicationsused in the treatment of opioidaddiction, recommended dosing, mechanismof action, and place in therapy.

Although recognition and treatmentof opioid dependence is increasing, barriersto treatment remain. Social stigmaassociated with opioid addiction, denial,and embarrassment may prevent somepatients from seeking appropriate help.They also may lack the proper supportneeded for therapy. Pharmacists, as anintegral part of the health care teamserving these patients, need to providesupport and encouragement for patientsseeking treatment.

As the last professionals in the healthcare system patients will encounterbeforethey receive their medication,pharmacists should take the time tocounsel patients on potential medicationside effects and drug interactions,especially with prescription pain relievers.By doing so, education and trust isfostered, which will help fight the risingprevalence of opioid abuse.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2006 national survey on drug use and health: national findings. Accessed May 5, 2008. 

www.oas.samhsa.gov/nsduh/2k6nsduh/2k6results.pdf

National Institutes of Health, National Institute of Drug Abuse Research Reports Series. Prescription drugs abuse and addiction. Accessed April 22, 2008. 

www.drugabuse.gov/ResearchReports/Prescription/Prescription.html

Articles

Knowing the warning signs and establishing trust are crucial to identifying and treating the opioid abuser.

Detecting Signs of Opioid Abuse and Treating the Addiction

Ms. Patel, Mr. Kelly, Ms. Capparelli, and Ms. Kuti are PharmD candidates at the University of Rhode Island, Kingston. Dr. Matson is a clinical assistant professor in the College of Pharmacy, Department of Pharmacy Practice, at the University of Rhode Island.

The Partnership for a Drug-FreeAmerica recently reported thatan increasing number of teenagersare abusing a variety of prescriptionand OTC medications.

 Althoughdrug-abuse rates overall have beendecreasing for teens, the rate of prescriptionand OTC drug abuse hasincreased.

 Currently, 1 in 11 teens hasabused an OTC medication, such ascough medicine containing dextromethorphan(DXM), and 1 in 5 hasabused a prescription painkiller.

 In lightof such statistics, it is important to haveknowledge of how to deal effectivelywith the issue of teen drug abuse.

DXM, a codeine derivative, has agonistactivity on serotonergic neurotransmissionand inhibits re-uptake ofserotonin at the synapses. Thus, toxicdoses of DXM can cause serotonin syndrome;effects on the central nervoussystem can include stupor, ataxia, nystagmus,hyperexcitability, dystonia,toxic psychosis, and changes in musclereflexes. An overdose of DXM can alsoproduce respiratory depression, tachycardia,an increase in baseline seizureactivity, and blurred vision.

 Furthermore,DXM has a first-pass metabolite,dextrorphan, which acts as anN-methyl-D-aspartate (NMDA) antagonist,causing additional hallucinogeniceffects.

 DXM is found in a large numberof OTC cough and cold remedies,usually in combination with decongestantsand antihistamines. Ofparticular concern are sympathomimeticagents, such as pseudoephedrineor phenylephrine, or antihistamines,such as brompheniramine orchlorpheniramine. The presence ofadditional medications increases thelikelihood of toxic effects after overdose.

Chemical dependence on opioidsoccurs through binding to multiple opioidreceptors (ie, mu, delta, kappa) inthe brain.

 Through this action, opiatesinhibit the release of the inhibitory neurotransmitterGABA and disinhibit thedopamine pathways, causing moredopamine to be released. Through theiraction on the neurotransmitters, opiatescreate effects of euphoria, analgesia,sedation, bradycardia, respiratorydepression, and gastrointestinal dysmotility.Prolonged use of these agentscauses the brain to stop producingendorphins, leading to chemical andphysical dependence. Addiction followingchronic use is common and resultsin withdrawal on termination.

In many types of drug abuse, randomdrug testing is the tool of choice, butthis is not the case in opiate and OTCmedication abuse.

 With a standarddrug-testing panel, oxycontin is notdetected, and neither are other legalmedications, such as OTC cough medicines.

A drug-screening questionnairealso may be used, such as the CRAFFTquestionnaire.

 This survey has questionsformulated especially for adolescentsabout dangerous behaviorswhen using drugs and alcohol and thesettings in which such usage wouldoccur. Screening for prescription andOTC drug abuse is a responsibility ofhealth care professionals, such aspharmacists and physicians.

 They canexamine past medical history and priorand current medication use, while alsoexplaining the safe usage of medications.Health care professionals shouldalso be aware of patients obtainingmedications from multiple sources.

Currently, for acute ingestion of DXMand prescription opiates, gastric decontaminationwith activated charcoalis recommended. Other medicationsmay be useful in treating overdosesymptoms, however. Naloxone is commonlyused to reverse central nervoussystem depressant and neurologiceffects, while benzodiazepines play arole in the treatment of seizures, agitation,and muscle activity.

For chronic use of opioids, severalmedications are available to treataddiction. These medications includenaltrexone, methadone, and buprenorphine.

These medications work in severalareas of drug abuse, includingdetoxification, maintenance, and withdrawal. In the case of addiction, medicationalone is not sufficient andshould be accompanied by nonpharmacologicinterventions.

 Individual orgroup detoxification is often recommended,and support groups such asNarcotics Anonymous have been shownto help with behavioral changes.

 Treatmenthas been shown to improvesocial and psychological functioning ofsubstance abusers significantly.

 Despitethese positive outcomes, manypeople are unsuccessful with their firstround of treatment, so it is importantto make sure that they are not discouragedfrom trying treatment again.

The greatest risk for drug abuse ispeer pressure. Children desire acceptancefrom their friends and classmates,and sometimes this can leadthem down the path of substanceabuse. Most children usually startusing drugs when they are around 14years old; however, it is not uncommonfor some to begin earlier.

 US Department of Health and Human Services National Clearinghouse for Alcohol & Drug Information: 

 National Institute on Alcohol Abuse and Alcoholism: 

 Substance Abuse and Mental Health Services Administration: 

Parents are the first line of preventionagainst drug abuse. They can observetheir child and be aware of anywarning signs, such as changes insocial circles, sleep patterns, motivation,academic performance, attitudeand personality, eating habits, physicalchanges in appearance, borrowingmoney often, suddenly having extracash, or unusual odors on their child'sclothes or in their child's room.

Communication between parentsand their child at an early age aboutdrugs and related issues is a simple yeteffective way to provide knowledgeand support. Additionally, respectingadolescents' opinion or questions willgive them a chance to participate inthe discussions, allowing a dynamicconversation as opposed to a onesidedlecture from an authority figure.

When suspecting that a child is usingdrugs, take action immediately, becausethe longer one waits, the moredifficult it will be to remedy the situation.Parents should closely monitortheir child's activities. They also shouldmake an effort to talk with their child,keep open those vital lines of communication,and be familiar with theirchild's friends and partners. Changingcurfews, cell phone or computer privileges,or even taking a child directly outof the problematic social circle aresome appropriate measures. In makingsuch changes, however, the childneeds to be transitioned to safer andmore positive activities, such as athletics,music, dance, extracurricular clubs,and religious organizations. Parentscan try to relate to their child byexplaining what they see, how theyfeel about their child's actions, and&#8212;most importantly&#8212;their concern fortheir child's future well-being.Providing strong support as the concernedparent, while reinforcing thenegative consequences, is a compassionateapproach to a child's substance-abuse problem.

Some cases of drug abuse cannot becontrolled by parental interventionalone, and multiple resources are availableto help. Health care professionalsare highly trained to intervene in thesesituations and include physicians, nurses,psychiatrists, and also neighborhoodpharmacists who can providenecessary support and information.School counselors, faith leaders, andcommunity health centers should notbe overlooked as well.

Generation Rx: national study reveals new category of substance abuse emerging: teens abusing Rx and OTC medications intentionally to get high [press release]. Washington, DC:  Partnership for a Drug Free America; April 21, 2005. Available at: 

Micromedex Healthcare Series. Greenwood Village, CO: Thomson Healthcare Inc. 2006.

Wilder J. Drug screening methods unreliable. Gannett Healthcare Group; May 3, 2007. Available at: 

McPherson TL, Hersch RK. Brief substance use screening instruments for primary care settings: a review. 

National Institute on Drug Abuse. Preventing and recognizing drug abuse. Available at: 

www.nida.nih.gov/ResearchReports/Prescription/prescription6.html

Tommasello AC. Substance abuse and pharmacy practice: what the community pharmacist needs to know about drug abuse and dependence. 

National Institutes of Drug Abuse. NIDA Infofacts: Understanding Drug Abuse and Addiction. Available at: 

www.drugabuse.gov/Infofacts/understand.html

University of Virginia Health System. Pediatrics: Substance Abuse/Chemical Dependence. Available at: 

www.healthsystem.virginia.edu/uvahealth/adult_pediatrics/

US Department of Education, Office of Intergovernmental and Interagency Affairs, Educational Partnerships and Family Involvement Unit. Tips for Parents on Keeping Children Drug Free. Available at: 

www.ed.gov/parents/academic/involve/drugfree/drugfree.pdf

American Academy of Pediatrics. Suspect Your Teen Is Using Drugs or Drinking? A Brief Guide to Action for Parents. Available at: 

www.mediacampaign.org/early_intv/parent_broch.pdf

Neighborhood pharmacists can provide support and information.