Cc Juv 03 2008

NEW DRUGS OF ABUSE&

NEW MEDICATIONS FOR THE TREATMENT OF

ADDICTION

Randall Webber, M.P.H.

Director of External Training

TASC, Inc.

Trends in Adolescent Drug Use:

2008 UpdateRandall Webber, M.P.H.

Director of External Training

TASC, Inc of Illinois

Overall Trends for Adolescents

• Less use of cocaine, PCP, LSD and other street drugs

• More use of both Rx drugs and over-the-counter (OTC) medications

• Greater “recreational” use of Adderall• Marijuana use relatively unchanged• Younger age of first use

The Problem with Pill Identifications:

New York City May 2000 Amphetamine

Chicago May 2000 MDMA

Tucson AZ July 2000 PMA

Portland Oct 2000 MDMA

PMA Effects -

• Sudden blood pressure rise (> 55mm)

• Hyperthermia usual cause of death

• Brain hemorrhage can occur• Does NOT produce the pleasant

Ecstasy effects so users take more causing an overdose.

• No hospital tests available for PMA.

Major Neurotransmitters

InhibitoryEndorphins

ExcitatoryAcetylcholine

InhibitoryGABA

ExcitatoryGlutamate

InhibitorySerotonin

Inhibitory/ExcitatoryDopamine

Methamphetamine

MethamphetamineMethamphetamine

Methamphetamine and MDMA

MDMAMDMA MethamphetamineMethamphetamine

A hydrogen atom shifts position↑

↑two oxygen atoms are added

DXM Examples –No Urine Test Available

“Pink Molly” Buffalo NY

“Star” Indianapolis IN

“Clover” Wide spread across US

“Orange Julius” Seattle WA

“Green Triangle” Wide spread

Produces Produces Olney’s LesionsOlney’s Lesions On Lower Cortex On Lower Cortex

Age of First Non-Medical Use of Rx Drugs & Lifetime Diagnosis of

Substance Abuse

0

5

10

15

20

25

30

35

40

45

13 oryounger

21 orolder

Lifetime Dx of RxDrug Abuse

Annual Numbers of New Non-medical Users of Opiate Pain Relievers: 1965–

2002

Number of New Users of Illicit Drugs: 2006

2.04

2.06

2.08

2.1

2.12

2.14

2.16

2.18

2.2

Rx OpiatesMarijuana

Number of Rx Opiate Users: 2005 Vs 2006

4.4

4.5

4.6

4.7

4.8

4.9

5

5.1

5.2

2005 2006

Rx Opiates

Source of Rx Opiates

0

10

20

30

40

50

60

Friend or Relative

Doctor

Drug Dealer/OtherStrangerInternet

Number of American 12+ y.o. who have used OxyContin VS Heroin

(In Millions)

0

2

4

6

8

10

12

LIFETIMENON-

MEDICALUSE

OxyContin

Heroin

% of Youth Who Believe that Trying Heroin Once or Twice Does NOT pose a

“Great Risk”

56

56.5

57

57.5

58

58.5

2002 2006

Youth 12-17

Types of Opiates

Naturally Occurring Opiates• Opium• Morphine• Codeine• Thebaine

Semi-Synthetic Opiates •Vicodin • Heroin

Brown & White Heroin

Black Tar Heroin (“El Chicle”)

Vicodin

Vicodin

Generic Hydrocodone

Types of Opiates

Synthetic opiates• Demerol (meperidine)• Dilaudid (hydromorphone)• Percodan/OxyContin (oxycodone)• Numorphan (oxymorphone)• Sublimaze (fentanyl)• Methadone (dolophine)• diphenoxylate/atropine (Lomotil)

OxyContin

OxyContin

Types of Opiates

• Karachi (Chicago area only)• No as common now as in 1990s• Drug composition varies. Usually

includes an opiate (ex: Methadone) and at least one sedative (ex: CNS diazepam, phenobarbital).

Opiate Withdrawal

– Drug hunger (craving)

– Dilated pupils– Yawning– Lacrimation (eyes tear)– Rhinitis (runny nose)– Restlessness– Anxiety– Depression– Muscle and bone pain

Opiate Withdrawal

– Stomach, leg and back cramps– Nausea– Insomnia – Diarrhea – Vomiting – Chills/cold flashes with goose

bumps ("cold turkey")– Sweating – Leg spasms (“kicking the habit”)

ADHD Medications

Two Major ADD Medications

• Ritalin• Adderall (dextroamphetamine)

Ritalin

Reported Sources of Rx ADHD Medications Among Past-Year Non-medical Users, 2005*

0

10

20

30

40

50

60

70 Given by friend orfamily member

Taken/Stolen

ObtainedFraudulently fromdoctor

Bought fromfriend/family member

Internet pharmacy

* Among adults ages 18 to 49 without a prior diagnosis of or prescription for ADHD

Consequences of Long-Term ADHD Medication Use

(One Study)• Prescribed use of Ritalin among

preadolescents• Depression• Anxiety • Decreased ability to derive pleasure from

alcohol and other drugs (AOD)• Decreased ability to derive pleasure from

natural rewards (food, sex, etc.)• Potential outcome: Increased use of

AOD

“NEW” DRUGS

• Ambien (zolpidem tartrate)• Lunesta (eszopiclone )• Rozerem (Ramelteon)• DXM- Dextromethorphan

DEXTROMETHORPHAN

Dextromethorphan

• Coricidin Cough and Cold

• “3-C”, “triple C”, “Skittles”

Dextromethorphan

• Robitussin DM (‘Tussin”)

Medicines containing DXM may also contain other substances

DXM- Dextromethorphan• May be mixed with or substituted for

MDMA (“ecstasy”)• In one study, 21% of “ecstasy”

contained DXM• Common cough suppressant drug• In therapeutic doses, is sedating• In larger doses, behaves like PCP

DXM Plateaus

• Abusers describe the DXM experience as occurring on four different plateaus. First Plateau: Mild inebriation. Second Plateau:

♦Effects similar to alcohol intoxication (slurred speech)

♦May be mild hallucinations. ♦Short-term memory may be temporarily impaired.

Third Plateau:

♦Impaired sense, particularly vision

DXM Plateaus

Fourth Plateau:

♦ Mind and body dissociation/"out-of-body" experience ♦ Loss of some or all of senses ♦ Effects at this plateau to ketamine or PCP.– detachment– disorientation– nystagmus – stupor – vomiting – “Robo Rash” itching.

SEDATIVE/HYPNOTICS

Ambien: Regular Release

Ambien: Sustained Release

Ambien (zolpidemtartrate )

• Non-benzodiazepine hypnotic• Available in 5-mg and 10-mg

tablets• Schedule IV substance• Effect of 40 mg similar to

Valium 20 mg

Ambien• Mechanism of action: Subunit

modulation of the GABA-A receptor chloride channel macromolecular complex

• GABA-A receptor complex:

– Is located on GABA alpha subunit

– Referred to as the benzodiazepine (BZ) or Ω (omega) receptor.

• At least three subtypes of this receptor have been identified.

Ambien• Indicated for the short-term

treatment of insomnia• Use should be limited to 7 to 10

days• Abnormal thinking and behavior

changes have been reported:– decreased inhibition (e.g.,

aggressiveness and extroversion that seems out of character)

– Sleep walking, driving, eating, cooking...

Ambien:

• Abnormal thinking and behavior– agitation– hallucinations– depersonalization– amnesia – In primarily depressed patients-

worsening of depression including suicidal thinking

Ambien: Withdrawal Symptoms

• Dysphoria• Panic attack & nervousness• Insomnia • Abdominal and muscle cramps• Nausea & Vomiting• Sweating• Lightheadedness• Tremors• Convulsions

Lunesta (eszopiclone )

Lunesta (eszopiclone )

• Thought to also work through various GABA subreceptors.

• Addiction potential unclear.

ZIMOVANE (Zopiclone)

• First introduced in 1988 as hypnotic agent

• Marketed in 85 foreign countries as Imovane® , but has never been registered in the U.S.

• Closely related to eszopiclone (Lunesta)

• Abuse and dependency has been documented

ZIMOVANE (Zopiclone)

• Rarely seen as a street drug in the U.S., but common in Canada

Rozerem (Ramelteon )• Appears to work through MT1 and MT2

(melatonin) receptors. • Has an addiction potential, but the

degree of this potential is unclear.• A highly unusual hypnotic, which

appears to work through melatonin receptors.

• Melatonin– A neurotransmitter that is manufactured from

serotonin– Involved in regulating circadian rhythms, and

physical responses to changes in seasons.

Rozerem (Ramelteon )

Rozerem (Ramelteon )

Rozerem (Ramelteon )• In clinical testing has shown no

potential for abuse. • Does not bind or attached to

receptors that affect memory, balance, cognition, or respiratory depression.

Nystagmus