1 - Intro to class - Opioids.pdf

DRUGS & POP CULTURE DR. RACHEL HOSKINS ABOUT ME COURSE OBJECTIVES - 10 week, 1 s.h. course - First year offered! YAY - Review relationship between society, popular culture and drug use - Some topics may be difficult and other topics more entertaining - Have fun in class but not make light of addicti...

DRUGS & POP CULTURE DR. RACHEL HOSKINS ABOUT ME COURSE OBJECTIVES - 10 week, 1 s.h. course - First year offered! YAY - Review relationship between society, popular culture and drug use - Some topics may be difficult and other topics more entertaining - Have fun in class but not make light of addiction. Highlight and respect the toll on people who use drugs or their loved ones - Will not cover all drugs and substances. "If there is a war on drugs, then many of our family members are the enemy. And I don't know how you wage war on your own family." - Robert Wakefield CLASS OBJECTIVES Overview of course and expectations Review common drug and addiction terminology Understand early uses of drugs Review opioids Discuss treatment of acute overdose and treatment of opioid dependence BACKGROUND Prescription opioids are used to treat moderate-severe pain (postsurgery, injury, or health problems like cancer) Increasing use in treating chronic pain although serious risks and lack of evidence for long-term effectiveness More than 191 million opioid prescriptions were dispensed to American patients in 2017 9.49 million or 3.4% of Americans aged 12 and older misuse opioids at least once over a 12-month period. Hydrocodone is the most popular prescription opioid, with 5.1 million misusers. Of the nearly 107,000 drug overdose deaths in 2021, over 75% involved opioids Recent survey showed that two-thirds of people (in US) said they or someone in their family has experienced substance use disorder or overdose. Hedegaard H, Miniño AM, Spencer MR, Warner M. Drug Overdose Deaths in the United States, 1999–2020. National Center for Health Statistics [PDF], December 2021. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control KFF: “KFF Tracking Poll July 2023: Substance Use Crisis And Accessing Treatment,” “KFF Poll: Three-in-Ten People Say They or Someone in Their Family Has Been Addicted to Opioids, w ith Rural Families Hit Hardest, Topline, KFF Health Tracking Poll, July 2023.” PAIN TERMINOLOGY Acute Pain – Pain that usually starts suddenly and has a known cause, like an injury or surgery. It normally gets better as your body heals and lasts less than three months. Chronic pain – Pain that lasts 3 months or more and can be caused by a disease or condition, injury, medical treatment, inflammation, or an unknown reason. Analgesics – Pain relieving medications including over-thecounter medications like acetaminophen (Tylenol ®) or ibuprofen (Advil®) and prescription opioids. Non-opioid therapy – Methods of managing pain that does not involve opioids. These methods can include, but are not limited to, acetaminophen (Tylenol ®) or ibuprofen (Advil®), cognitive behavioral therapy, physical therapy, acupuncture, meditation, exercise, medications for depression or for seizures, or interventional therapies (injections). Centers for Disease Control and Prevention, National Center for Injury Prevention and Control DRUG TERMINOLOGY Illicit drugs – The nonmedical use of a variety of drugs that are prohibited by law. These drugs can include: amphetaminetype stimulants, marijuana/cannabis, cocaine, heroin, other opioids, and synthetic drugs, such as illicitly manufactured fentanyl (IMF) and ecstasy (MDMA). Narcotic drugs – Originally referred to any substance that dulled the senses and relieved pain. Some people use the term to refer to all illegal drugs but technically, it refers only to opioids. Opioid is now the preferred term to avoid confusion. Nonmedical use – Taking prescribed or diverted prescription drugs (drugs not prescribed to the person using them) not in the way, for the reasons, in the amount, or during the timeperiod prescribed. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control SUBSTANCE USE TERMINOLOGY Substance Use Disorder (Drug addiction) – The preferred term is substance use disorder (not addiction). When referring to opioids, see the Opioid Use Disorder (OUD) Drug misuse – The use of illegal drugs and/or the use of prescription drugs in a manner other than as directed by a doctor, such as use in greater amounts, more often, or longer than told to take a drug or using someone else’s prescription. Return to Use – Formerly called drug "relapse". Returns to using drugs or alcohol after a period of sobriety. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control TERMINOLOGY Opioid use disorder (OUD) – A problematic pattern of opioid use that causes significant impairment or distress. A diagnosis is based on specific criteria such as unsuccessful efforts to cut down or control use, or use resulting in social problems and a failure to fulfill obligations at work, school, or home, among other criteria. Opioid use disorder is preferred over “opioid abuse or dependence” or “opioid addiction.” https://www.psychiatry.org/psychiatrists/practice/dsm/updates-todsm/coding-updates/2017-coding-updates Overdose – Injury to the body (poisoning) that happens when a drug is taken in excessive amounts. An overdose can be fatal or nonfatal. Signs of opioid overdose: pinpoint pupils, stupor, clammy skin, respiratory depression which can lead to coma or death. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control TOLERANCE & DEPENDENCY Opioid tolerance occurs when a person using opioids begins to experience a reduced response to medication. Need to take more opioids to experience the same effect. Opioid dependence occurs when the body adjusts its normal functioning around regular opioid use. Unpleasant physical symptoms occur when medication is stopped. Withdrawal – feeling ill when opioid use suddenly stops DRUG SCHEDULING Schedule Description Examples I High potential for abuse No currently accepted medical Heroin, LSD, marijuana (cannabis), MDMA/ecstasy, methaqualone, peyote II High potential for abuse, with use potentially leading to severe psychological or physical dependence Accepted medical use Hydrocodone, cocaine, methadone, hydromorphone, meperidine, oxycodone, fentanyl, codeine, Dexedrine, Adderall, Ritalin, etc III Intermediate abuse potential (less than Schedule II but more than Schedule IV) Accepted medical use Codeine (Tylenol with Codeine®), ketamine, anabolic steroids, testosterone, buprenorphine (Suboxone®) IV Abuse potential less than Schedule II but more than Schedule V medications Accepted medical use Diazepam, alprazolam, tramadol V Medications with the least potential for abuse among the controlled substances Accepted medical use Pregabalin, diphenoxylate/atropine, dextromethorphan, codeine products (Robitussin AC®, Phenergan with Codeine®), Lomotil RETURN TO USE Return to Use – Formerly called drug "relapse". Returns to using drugs or alcohol after a period of sobriety. American Addictions Center https://americanaddictioncenters.org/treat-drug-relapse DRUG MONITORING PROGRAM Prescription drug monitoring programs (PDMPs) – State or territorial-run electronic databases that track controlled substance prescriptions. Help providers identify patients at risk of opioid misuse, opioid use disorder, and/or overdose due to overlapping prescriptions, high dosages, or co-prescribing of opioids with benzodiazepines. CDC recommends checking PDMP: When initiating opioid therapy for acute, subacute, or chronic pain. Every 3 months or more frequently when continuing opioid therapy. Ideally, before every opioid prescription for acute, subacute, or chronic pain. EXAMPLE PDMP OPIOIDS Mechanism of Action: Binds to opioid receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of and response to pain "God's Own Medicine"1 "the deadliest foe that has ever menaced [humanity's] future"2 Opium derived from the poppy plant Natural opioid – morphine, codeine Synthetic opioid – heroin, fentanyl 1. 2. William Osler (1849-1919) Richmond Hobson "The Struggle of Mankind Against Its Deadliest Foe." OPIOID DRUG EFFECTS Short term effects: analgesia, euphoria, bliss, pleasure; relaxation; dry mouth; itching; nausea; vomiting; slowed breathing and heart rate. Long term effects: Collapsed veins; abscesses; infection of the lining and valves in the heart; constipation; liver or kidney disease; pneumonia. Risk of HIV and hepatitis. Withdrawal symptoms: Restlessness, muscle/bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps. Medicinal effect: analgesia, antidiarrheal, cough suppressant, induce sleep. CULTIVATING OPIUM Harvested from poppy seed pods Legal growing in Australia, India, Turkey for medicinal use Vast majority of illegal cultivation occurs in Myanmar, previously Afghanistan Drug trafficking in "Golden Triangle" o Myanmar, Laos and Thailand o Opium -> Heroin; methamphetamines ISRAELI BURIAL SITE 14TH CENTURY B.C. Assaf Peretz, Israel Antiquities Authority https://www.timesofisrael.com/israeli-archaeologist-uncovers-earliest-known-use-of-opium-in-the-ancient-world/ ISRAELI BURIAL SITE 14TH CENTURY B.C. Assaf Peretz, Israel Antiquities Authority EARLY OPIOIDS 3400 B.C. - Ancient tablet found near Baghdad – referenced "Joy Plant" 1300 B.C. - Assyrians, Babylonians, Egyptians use in medicine and executions. Ebers Papyrus (next slide) 460 B.C. Hippocrates discussed benefits in treating pain and disease To restore balance – spread on forehead, stuffed up nose, suppository 300 B.C. Alexander the Great leans of opium from Aristotle (and Theophrastus) then introduces to Persia and India Assyrian goddess Nisaba EBERS PAPYRUS Ancient Egyptian 110-page scroll 876 prescriptions Headache: ”Take mortar and pestle and smash together some poppy berries, coriander berries, wormwood, juniper berries, and juniper honey” Constipation: “Drive out the excrement in the body by mixing up some “poppy stalk, castor oil, dates of the male palm, Cyperus grass, coriander, and cold beer” Remedy to Prevent Excess Crying in Children EARLY OPIOIDS CONTINUED 400 A.D. Opium is introduced to China by Arab traders 1500 Opium was reintroduced to Europe by the Portuguese voyage and observed opium sales in Burma, Malay Peninsula, and China. Heavy use in India. Trade = $$$ 1600 East India Company founded under Queen Elizabeth I – included opium; Britain smuggled opium from India to China 1839 Opium Wars 1 & 2 - between Britian and China For more detailed information on timeline: https://www.pbs.org/wgbh/pages/frontline/sho ws/heroin/etc/history.html MODERN USE OF OPIOIDS Early 1800s German pharmacist Friedrich Wilhelm Adam Serturner isolated morphine from opium Named it morphine ("morphium") after the Greek god of dreams "Morpheus" Hypodermic needle invented by Alexander Wood (and Charles Gabriel Pravaz) in 1853 allowed for more widespread clinical use 1800s – C.R. Adler Wright isolated heroine DRUGS IN U.S. HISTORY 18TH CENTURY - EARLY 20TH CENTURY Reports of introduction of opium to U.S. varies o Problematic blaming of Chinese immigrants o Chinese immigrants during Gold Rush (1840s) ▪ Smoking of opium was introduced by Chinese ▪ Opium elixirs and injectable morphine was already in U.S. Opium used to treat soldiers in both the Revolutionary war and Civil war Benjamin Franklin was prescribed opium for bladder stone Alexander Hamilton given opium/alcohol tincture after Aaron Burr duel Opium dens in San Francisco spread to East Coast Bronson B Ho C (2023) Chinese Opium in America 1850-1920. CIVIL WAR AND OPIUM Opium used in soldiers o Morphine o Opium gum o Laudanum (opium/alcohol tincture) Injuries, diarrhea, cough Opium addiction amongst Civil War veterans Stigma – did not have willpower; called "opium slaves" "The Union Army alone issued nearly 10 million opium pills to its soldiers, plus 2.8 million ounces of opium powders and tinctures." David T. Courtwright, Dark Paradise:A History of Opiate Addiction in America LATE 1870S - 1890S Unregulated use in medical field Hypodermic needle allowed increased use Morphine use: pain, asthma, headaches, delirium tremens (alcohol withdrawal), gastrointestinal diseases Prescribed to women - menstral cramps, nervous disorders Late 1890s 1/200 Americans had opiod use disorder o Upper class or middle class women (60%) Opioid crisis peaked in late 1890s o Advances in medicine and public health o Alternative pain relief 1909 Federal Law prohibit use other than medical 1914 Harrison Narcotic Act of 1914 – addressed prescribing habits OVERDOSE DEATHS SYNTHETIC OPIOIDS OVERDOSE OPIOIDS “Opiates” vs. “opioids” Often used interchangeably, however they are different: Opiates – natural opioids such as heroin, morphine and codeine. Opioids – all natural, semisynthetic, and synthetic opioids. Category Name Schedule Opiates (natural opioids) Morphine Codeine II II Semisynthetic Oxycodone (Oxycontin) Hydrocodone (Vicodin) Hydromorphone Oxymorphone Heroin (sometimes listed as natural) II II II II I Synthetic Fentanyl Methadone Tramadol Carfentanil (elephant tranquilizer) Protonitazene & Isotonitazene II II IV II I MORPHINE EQUIVALENT DOSE (FOR YOUR REFERENCE ONLY) Drug (mg) Morphine Equivalent Dose Conversion Factor Tramadol 0.1 Codeine 0.15 Morphine 1.0 Hydrocodone 1.0 Oxycodone 1.5 Oxymorphone 3.0 Methadone 3.0 Hydromorphone 4.0 Fentanyl (Patch in mcg/hr) 2.4 Adapted from Lexi-Drugs (7.2 mcg/72 hr) MORPHINE Often used as what to compare other opioids to Brand names: MS Contin; Duramorph; Kadian; Arymo ER Street names: M, Dreamer, Emsel, First Line, God’s Drug, Hows, M.S., Mister Blue, Morf, Morpho, Miss Emma, Unkie Approved for management of severe pain; Schedule II Available as oral immediate and extended relief capsules/tablets, oral solution rectal suppository, intravenous (IV), intramuscular (IM) Abuse deterrent formulations available o Manipulation is difficult and administration via non-oral routes less appealing OXYCODONE Brand names: OxyContin, Percodan, Percocet Street names: O.C., Oxycet, Oxycotton, Oxy, Hillbilly Heroin, Percs Approved for management of severe acute or chronic pain Schedule II Available as oral immediate and extended-release capsule/tablet, solution o Combination with acetaminophen (Tylenol) ▪ Percocet, Endocet OXYMORPHONE Brand names: Opana Street names: Biscuits, Blue Heaven, Blues, Mrs. O, O Bomb, Octagons, Stop Signs Approved for management of severe pain Schedule II Available as oral immediate and extended-release tablet HYDROCODONE Brand names: Lortab, Lorcet, Vicodin Street names: Vike, Watson-387 Approved for management of severe pain Schedule II Available as extended-release capsule and abuse deterrent capsule Most commly available as a combination product o Hydrocodone/ibuprofen o Hydrocodone/acetaminophen (Tylenol) - Lortab, Lorcet, Vicodin, Norco o Hydrocodone/homatropine – Hycodan – Cough Suppressant o Hydrocodone/pseudoephedrine – Rezira cough and decongestant o Hydrocodone/Pseudoephedrine/Chlorpheniramine - Zutripro – cough, decongestant, antihistamine cold medicine HYDROMORPHONE Brand names: Dilaudid Street names: D, Dillies, Footballs, Juice, Smack Approved for management of severe pain Schedule II Available as oral immediate and extended-release tablets, oral solution, rectal suppository, IV FENTANYL Brand names: Actiq, Duragesic, Sublimaze Street names: Apache, China Girl, China White, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, Tango and Cash, TNT Approved for treating acute or chronic severe pain (advanced cancer pain) and anesthesia. Available as: injectable forms, transdermal patches (e.g., Duragesic®️), lozenges, lollipops, sublingual and buccal tablet. 50 to 100 times more potent than morphine. Illegally made fentanyl may be mixed with heroin or other drugs, such as cocaine, or pressed in to counterfeit prescription pills = deadly Overdose deaths illicitly made fentanyl are increasing IOWA SEES 105% INCREASE IN FENTANYL PILL SEIZURES IN 2023 https://www.kcrg.com/2024/01/17/iowa-sees-105-increasefentanyl-pill-seizure-2023/ "Officials say that in 2023 they removed an estimated 141,000 pills in the Hawkeye state, marking a 105% increase from 2022." MEPERIDINE Brand name: Demerol Street names: Demmies, Pain Killer, Peth, Dillies Indications: acute pain; preop; labor/delivery Schedule II Preparations: Primarily IV; meperidine/promethazine oral capsule (I never have seen this oral form) CODEINE Brand names: Codeine Contin, Tylenol #3, Tylenol #4 Street names: Captain Cody, Cody, Lean, Schoolboy, Sizzurp, Purple Drank With glutethimide: Doors & Fours, Loads, Pancakes and Syrup Approved for mild to moderate pain. Cough suppressant by direct central action in the medulla; produces generalized CNS depression Available as oral tablet single ingredient or combined with acetaminophen or butalbital and caffeine; syrup combined with promethazine (Phenergan)or guafenesin (Cheratussin AC, Robitussin AC, G Tussin) or chlorpheniramine (Z-Tuss) Codeine (CII); Tylenol #3 (CIII); cough/cold syrups (generally CV) (scheduling depends on quantity of codeine in product) HEROIN No commercial uses Street names: Brown sugar, China White, Dope, H, Horse, Junk, Skag, Skunk, Smack, White Horse, With OTC cold medicine and antihistamine: Cheese Common forms: White or brown powder, black sticky substance - “black tar heroin” "Over 11% of all opioid overdose deaths in 2021 involved heroin1. Nearly all people who use heroin also use at least one other drug2. However, from 2020 to 2021, the heroin overdose death rate decreased by nearly 32%1. Shifts from heroin-based market to fentanyl-based" Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2022. Available at http://wonder.cdc.gov. Jones CM, Logan J, Gladden RM, Bohm MK. Vital Signs: Demographic and Substance Use Trends Among Heroin Users — United States, 2002–2013. MMWR Morb Mortal Wkly Rep 2015; 64(26):719-725. 2019 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States Surveillance Special Report Centers for Disease Control and Prevention: U.S. Department of Health and Human Services. Published November 1, 2019. HARM REDUCTION Strategies to reduce negative consequences associated with drug use. Social justice movement built on a belief in, respect for, the rights of people who use drugs. Reduce stigma. Support hope and healing by offering employment and mentoring. Overdose Prevention: provide educational info on safer drug use, increasing access to naloxone, and hold overdose prevention trainings. Supports Syringe Service Programs. Reduces hepatitis and HIV infections by 50%. Facilitates trainings and workshops. Policy and Advocacy TREATMENT Medication-assisted treatment (MAT) – Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies. o Methadone o Buprenorphine o Naltrexone Behavioral Therapies: o Contingency management, or motivational incentives o 12-Step facilitation therapy o Mobile medical application: reSET-O used in conjunction with treatment that includes buprenorphine and contingency management NALOXONE Approved for reversing the effects of opioid overdose, can save lives if administered in time. May require multiple doses 2-3 minutes o Off label use for opioid induced constipation and pruritus (itching) Brand names: Narcan, Kloxxado, Zimhi Available as IV, IM, subcutaneous, intranasal Available with or without prescription; commonly prescribed with opioid prescription Side effects: intense withdrawal symptoms including nausea, diarrhea, muscle cramps and anxiety (may last 30-40 minutes) NALOXONE LOCAL NEWS https://pharmacy.uiowa.edu/news/2024/01/increasing-accessnaloxone-iowa-schools https://pharmacy.uiowa.edu/news/2019/08/ui-college-pharmacyleads-fight-against-drug-overdoses NALTREXONE Brand name: Vivitrol Approved for opioid use disorder; alcohol use disorder o Combined with bupropion for weight-loss (Contrave) Mechanism of action: binds to and blocks opioid receptors to reduce and suppress opioid cravings. Available as daily oral tablet and extended-release IM injection every 4 weeks Side effects: nausea, vomiting, dizziness, headache, sleepiness or difficulty sleeping, pain in joints and muscle cramps, decreased appetite BUPRENORPHINE BUPRENORPHINE & NALOXONE Brand names: Belbuca, Brixadi, Brixadi (Weekly), Butrans, Sublocade, Subutex (discontinued); Combined with naloxone Suboxone; Zubsolv Street names: Bupe, Subs, Oranges, Strips Schedule III Approved for Treatment of opioid use disorder to be used with counseling and psychosocial support. Mechanism of Action: partial opioid agonist Side effects: nausea, abdominal pain, constipation, headache, dizziness, sweating. Can cause euphoria, respiratory depression however much weaker than full agonist (methadone) METHADONE Brand names: Dolophine, Methadose Street names: Amidone, Fizzies With MDMA: Chocolate Chip Cookies Schedule II Mechanism of action: long-acting full opioid agonist Methadone clinic Approved for chronic pain, opioid use disorder, opioid withdrawal Available as oral liquid and tablet, injection Side effects: Nausea, vomiting, constipation, sweating, restlessness, itchy skin, respiratory depression ADDITIONAL INFORMATION & READING Acker, C.J. (2002) Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control. John Hopkins University Press. Courtwright, D.T. (2001) Dark Paradise: A History of Opiate Addiction in America. Harvard University Press. Halpern, J.H. (2019). Opium; How an Ancient Flower Shaped and Poisoned Our World. Hachette Books. Ophelia.com