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CORK Bibliography: Primary Care

76 citations. July 2009 to present

Prepared: June 2010

Alford DP. Opioids for chronic pain in patients with substance abuse: Too much, too little or just right? (editorial). Pain 145(3): 267-268, 2009. (18 refs.)

Assanangkornchai S; Sam-Angsri N; Rerngpongpan S; Edwards JG. Anxiolytic and hypnotic drug misuse in Thailand: Findings from a national household survey. Drug and Alcohol Review 29(1): 101-111, 2010. (47 refs.)

Introduction and Aims. The non-medical use of prescription drugs, such as anxiolytics and hypnotics, has become a growing public health problem in Thailand. The objective of this study was to examine the patterns of non-medical use of these drugs, using data from a nationally representative sample of Thais interviewed in 2007. Design and Methods. A nationwide, multi-stage, household survey of 26 633 respondents aged 12-65 years living in 11 348 households throughout Thailand using a face-to-face structured interview questionnaire was carried out. Results. In 2007, 1.58% (734 288) and 1.58% (733 318) of Thais indicated that they had misused anxiolytics or hypnotics, respectively, at some time during their lives. Less than 1% had misused these drugs during the 12 months preceding the interview (426 170 or 0.92% for anxiolytics, 372 920 or 0.80% for hypnotics), fewer during the preceding 30 days (234 871 or 0.50% for anxiolytics, 225 638 or 0.48% for hypnotics).The highest prevalence of past 30 day use was in Bangkok, the lowest in Southern Thailand. More women than men, older than younger respondents, and subjects who considered they were in poor physical health or had emotional problems than those who thought otherwise used the drugs during the 30 days before the interviews. Discussion and Conclusions. The prevalence of anxiolytic/hypnotic misuse/abuse appears to be lower than that reported from more developed countries, but a small increase in problems resulting from the use of these substances has a disproportionately large effect on the overstretched resources of a developing country.

Baldacchino A; Gilchrist G; Fleming R; Bannister J. Guilty until proven innocent: A qualitative study of the management of chronic non-cancer pain among patients with a history of substance abuse. Addictive Behaviors 35(3): 270-272, 2010. (18 refs.)

Introduction: Physicians are often reluctant to prescribe strong opioids for chronic non cancer pain (CNCP). No study has qualitatively examined physicians' beliefs about prescribing opioids for CNCP to patients with a history of substance abuse (PWHSA). Aims: To describe physicians' attitudes and experience of prescribing opioids for CNCP to PWHSA. Design, setting and participants: Nineteen individual interviews and two focus groups were conducted with GPs, Addiction Specialists, Pain Specialists and Rheumatologists. Results: Physicians were "reluctant" to prescribe opioids to PWHSA experiencing CNCP for fear of addiction, misuse or diversion of medications. Many exhibited "distrust" that such patients were experiencing "genuine pain", resulting in patients often being considered guilty until proven innocent. Such negative regard towards these patients was based on previous manipulative "drug seeking" encounters and often resulted in the under treatment of pain. Potential "flags" were identified that alerted physicians to the potential for abuse or diversion of their prescription including: doctor shopping. loosing prescriptions, frequent attendance and early requests for repeat prescriptions. Physicians reported different management approaches and stricter prescribing regimes for PWHSA to limit the potential of addiction, misuse and diversion. Examples of poor pain management were described where drug users had been under treated as a result of negative attitudes or inexperience of staff. Discussion: Applying the chronic disease model to comorbid addiction and CNCP would ensure a health and social care system that makes it difficult to stigmatise patients experiencing these conditions and would facilitate the prescribing of opioid pain medication to patients who could benefit.

Basu D; Banerjee A; Harish T; Mattoo SK. Disproportionately high rate of epileptic seizure in patients abusing dextropropoxyphene. American Journal on Addictions 18(5): 417-421, 2009. (17 refs.)

Dextropropoxyphene (DPP), a weak opioid, is often abused as a psychoactive substance. In this retrospective chart review to document, characterize and put in perspective the often-obtained history of epileptic seizures in patients with DPP abuse, we analyzed the case files of all patients with DPP abuse registered in our center (a tertiary-care drug de-addiction clinic in north India) from May 1, 2001 until April 30, 2007 and those with use of other opioids during the same period. Non-drug-related seizures were excluded from analysis. Out of 312 patients with DPP abuse, 63 (20.2%) had epileptic seizures related to DPP use, in contrast to 0.4%-4.2% of other opioid users. The seizures were mostly characterized as generalized tonic-clonic seizures (87.3%), occurring around two hours following a higher-than-usual dose of DPP. Those with seizures had significantly greater duration of DPP use and higher rates of medical comorbidity compared to patients without seizure. Age, duration of use and medical comorbidity were better predictors of seizure than dosage of drug or use of multiple drugs. Thus, DPP-induced epileptic seizures are common (one in five), and much more frequent than seizures in patients using other opioids. The awareness of this phenomenon has implications for diagnosis and management, as well as for drug regulation policy.

Berchtold A; Jeannin A; Akre C; Michaud PA; Suris JC. First use of multiple substances: Identification of meaningful patterns. Journal of Substance Use 15(2): 118-130, 2010. (57 refs.)

Context: Understanding the process through which adolescents and young adults are trying legal and illegal substances is a crucial point for the development of tailored prevention and treatment programs. However, patterns of substance first use can be very complex when multiple substances are considered, requiring reduction into a few meaningful number of categories. Data: We used data from a survey on adolescent and young adult health conducted in 2002 in Switzerland. Answers from 2212 subjects aged 19 and 20 were included. The first consumption ever of 10 substances (tobacco, cannabis, medicine to get high, sniff (volatile substances, and inhalants), ecstasy, GHB, LSD, cocaine, methadone, and heroin) was considered for a grand total of 516 different patterns. Methods: In a first step, automatic clustering was used to decrease the number of patterns to 50. Then, two groups of substance use experts, three social field workers, and three toxicologists and health professionals, were asked to reduce them into a maximum of 10 meaningful categories. Results: Classifications obtained through our methodology are of practical interest by revealing associations invisible to purely automatic algorithms. The article includes a detailed analysis of both final classifications, and a discussion on the advantages and limitations of our approach.

Booth BM; Curran G; Han X; Wright P; Frith S; Leukefeld C et al. Longitudinal relationship between psychological distress and multiple substance use: Results from a three-year multisite natural-history study of rural stimulant users. Journal of Studies on Alcohol and Drugs 71(2): 258-267, 2010. (44 refs.)

Objective: Substance use is associated with poor mental health, but little is known regarding how use of multiple substances is associated with mental health, particularly longitudinally, in community studies. This article examines this issue in a large (N = 710), natural-history study of rural stimulant (cocaine and/or methamphetamine) users in three states. Method: Respondent-driven sampling recruited recent (past-30-day) stimulant users in three counties each in Arkansas, Kentucky, and Ohio. Participants were interviewed every 6 months for 3 years. Mental health was measured by the Brief Symptom Inventory, and prior 6 months' substance use was measured for 17 possible substances. Data analysis used generalized estimating equations for longitudinal data with the Global Severity Index of the Brief Symptom Inventory as the dependent variable at each interview and substance use as predictor variables measured by number of substances used in the past 6 months and, separately, the 17 individual substances, adjusting for use of substance-use treatment, demographics, and recruitment site. Results: On average, both Global Severity Index score and use of many substances declined over the course of study. Global Severity Index score was significantly associated with (a) greater number of substances used in the past 6 months (p <.0001) and (b) use of crack cocaine, methamphetamine, and nonprescription use of prescription painkillers and tranquilizers. Conclusions: Multiple and specific substances appear to incrementally increase psychological distress. Users of cocaine and methamphetamine are present in rural areas; these associations with poor psychological health raise concerns regarding availability of local treatment services for individuals with mental-health problems, as well as substance abuse.

Boudreau D; Von Korff M; Rutter CM; Saunders K; Ray GT; Sullivan MD et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiology and Drug Safety 18(12): 1166-1175, 2009. (54 refs.)

Objective To report trends and characteristics of long-term opioid use for non-cancer pain. Methods CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult enrollees of two health plans serving over I per cent of the US population. Using automated data, we constructed episodes of opioid use between 1997 and 2005. We estimated age-sex standardized rates of opioid use episodes beginning in each year (incident) and on-going in each year (prevalent), and the per cent change in rates annualized (PCA) over the 9-year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year. Results Over the study period, incident long-term use increased from 8.5 to 12.1 per 1000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1000 at GH (8.5% PCA), and 21.5 to 39.2 per 1000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics. Conclusion: Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study.

Broekmans S; Dobbels F; Milisen K; Morlion B; Vanderschueren S. Pharmacologic pain treatment in a multidisciplinary pain center: Do patients adhere to the prescription of the physician? Clinical Journal of Pain 26(2): 81-86, 2010. (23 refs.)

Background: Medication nonadherence is a frequent problem in chronic conditions. In chronic noncancer pain, medication is often used as an important cornerstone of the treatment. Studies on medication nonadherence in this population, however, are scarce. Aim: The aim of this study was to determine the prevalence of medication underuse and overuse nonadherence in a large sample of chronic pain patients treated in a multidisciplinary pain center. Second, an extensive list of demographic, disease-related, treatment-related and health behavior-related factors was included to compare these factors between adherent, overusers, and underusers, respectively. Methods: Self-report was used to measure medication adherence. Results: Forty-eight percent of the patients were nonadherent, with 34% of them showing underuse and 14% overuse of the prescribed medication. Multivariable analyses showed a significant association between younger age and medication nonadherence (both underuse and overuse). Furthermore, underuse was significantly associated with self-medication. Overuse was associated with current smoking, opioid prescription, and more medication intake moments. Conclusions: We can conclude that medication nonadherence, especially underuse of medication, occurs frequently among patients with chronic nonmalignant pain. Prospective research is needed to learn about the impact of medication overuse or underuse on clinical outcomes. Future research should examine underuse and overuse as different types of nonadherence as different factors might predict this behavior.

Budman SH; Serrano JMG; Butler SF. Can abuse deterrent formulations make a difference? Expectation and speculation. Harm Reduction Journal 6(8), 2009. (45 refs.)

It is critical that issues surrounding the abuse and misuse of prescription opioids be balanced with the need for these medications for the treatment of pain. One way to decrease the abuse of prescription opioid medications is to develop abuse deterrent formulations (or ADFs) that in some way prevent drug abusers from extracting out the active ingredient in order to employ alternate routes of administration, such as injection, snorting, and smoking. Several factors including the pharmacokinetic profile of the drug, the features of the drug formulation that make it attractive or unattractive for abuse, the type of drug abuser, the progression of one's addiction pathway, and one's social environment may all play a role in the abuse of prescription opioids and what methods are used to abuse these drugs. This paper will examine these factors in order to understand how they affect the abuse of prescription opioids and routes of administration, and how the development of ADFs may alter these patterns.

Butler SF; Black R; Serrano JMG; Folensbee L; Chang A; Katz N. Estimating attractiveness for abuse of a not-yet-marketed "abuse-deterrent" prescription opioid formulation. Pain Medicine 11(1): 81-91, 2010. (29 refs.)

Objective. The present study builds on research to model abusers' perceptions of particular analgesics' attractiveness for abuse and extends these methods to derive an estimate of attractiveness for abuse of a not-yet-marketed abuse-deterrent formulation (ADF) of a prescription opioid (Remoxy (R), Pain Therapeutics, Inc., San Mateo, CA, and King Pharmaceuticals, Inc., Bristol, TN). In a previous study, the Opioid Attractiveness Technology Scaling (OATS) method identified, from a drug abuser's point of view, the particular features of a prescription opioid relevant to its attractiveness for recreational use. A second online sample rated the extent to which these features applied to particular products they had actually used/abused. These data were used to model the abusers' overall preference for prescription opioids they had used/abused. Design. In the present study, this method was applied to a not-yet-marketed ADF using substance abuse counselors as proxies for prescription opioid abusers. Thirty-eight counselors were given materials describing the new ADF along with four known products. Results. Thirty-two counselors demonstrated sufficient agreement with abusers' ratings of the overall attractiveness of these drugs. The overall model yielded a significant pseudo R-2 of 0.15 (P < 0.001), with increasing model fit based on preferred route of administration, from swallowing whole (pseudo R-2 = 0.06; P < 0.001) and best for those who preferred to inject (pseudo R-2 = 0.40; P < 0.001). Data from a cross-validation group of 16 counselors/proxies were used to calculate the OATS scores for the five rated drugs and revealed significant differences between the ADF and OxyContin (R) (Purdue Pharma LP, Stamford, CT), Percocet (R) (Endo Pharmaceuticals, Chadds Ford, PA), and Vicodin (R) (Abbott Laboratories, Abbott Park, IL), but not Talwin (R) NX (Sanofi-aventis, Bridgewater, NJ), which was identified in the prior study as a highly unattractive drug for recreational purposes. Conclusions. The OATS method shows promise for providing pre-marketing estimates of attractiveness for abuse of not-yet-marketed ADFs.

Butler SF; Fernandez KC; Chang A; Benoit C; Morey LC; Black R et al. Measuring attractiveness for abuse of prescription opioids. Pain Medicine 11(1): 67-80, 2010. (26 refs.)

Objective. Prescription opioids are the second most misused/abused drug in the United States behind only marijuana. Recreational prescription opioid users appear to prefer some products over others; however, the extent to which attributes of any particular formulation account for such preferences has yet to be determined. The Opioid Attractiveness Technology Scaling was developed to identify the particular features of a prescription opioid that are relevant to its attractiveness for recreational use, and to use these features to model attractiveness for recreational use of particular prescription opioid formulations. Design. Four hundred and ninety-one self-reported recreational prescription opioid users identified 43 product features as being relevant to determining whether a product is "attractive" or "unattractive" for recreational use. Average ratings were used to determine appropriate weights to be applied to the features. A factor analysis yielded 10, highly differentiated factors. Five hundred and sixty-four prescription opioid abusers were then asked to rate the extent to which the 43 features identified in Study 1 were relevant to specific prescription opioid products they had used. Results. Respondents provided an overall preference rating of these products and a model was created. A random intercept model yielded a significant pseudo R-2 of 0.14 (chi-square = 310.02, degrees of freedom [df] = 10, P < 0.001). The model fit least well, albeit significantly, for abusers who preferred to swallow the drug (pseudo R-2 = 0.06; chi-square = 55.52, df = 10, P < 0.001) and best for those who preferred to inject (pseudo R-2 = 0.37; chi-square = 199.34, df = 10, P < 0.001). Conclusions. The relevance of the model is discussed along with possible modifications that might allow prediction of "attractiveness" of "abuse deterrent" formulations that have not yet been marketed.

Coklo M; Stemberga V; Cuculic D; Sosa I; Bosnar A. Toxicology and methods of committing suicide other than overdose. Medical Hypotheses 73(5): 809-810, 2009. (11 refs.)

Suicide represents a serious public health problem throughout the world. Toxicology plays a crucial role in the investigation of suicide. Psychoactive substances are recognized in the literature as the main suicide-generating stimuli. Ethanol is known to produce disinhibition and increased self-confidence. Other psychoactive substances can predominantly be central nervous system (CNS) stimulants or depressors. In cases of overdose as a method of suicide, the link between toxicology and the method of suicide is a matter of common sense and requires no additional explanation. On the other hand, in cases of non-overdose suicides this link is much more complex, and has not yet been extensively elucidated. We hypothesize a close relationship between toxicology and the choice of the method of committing suicide other than overdose. Negative findings may reflect either poor prescribed drug compliance in psychiatric patients, or suggest the role of other (non-toxicological) suicide-generating stimuli. On the other hand, positive findings influence the choice of the suicide method in a way that it depends on the prevalence of either stimulation or depression of the CNS, and consequent degree of behavioral aggression. Simplified, if the prevailing effect is CNS stimulation (with an increase in aggression), the method would be more drastic and more immediately fatal one, while with the CNS depression the method would be less immediately fatal and less drastic. There are only a few studies on the prevalence of psychoactive substances amongst completed suicides and even fewer studies have attempted to examine the relationship between substances used and the circumstances surrounding suicide. In evaluation of our hypothesis, we suggest thorough studies of toxicology and the choice of methods of committing suicides other than overdose. The scientific knowledge gained this way will eventually make toxicology a useful target in suicide prevention, especially amongst younger population.

Corliss HL; Rosario M; Wypij D; Wylie SA; Frazier AL; Austin SB. Sexual orientation and drug use in a longitudinal cohort study of US adolescents. Addictive Behaviors 35(5): 517-521, 2010. (41 refs.)

Adolescents with a minority sexual orientation (e.g., lesbian, gay, and bisexual) are more likely louse substances than their heterosexual peers. This study aimed to increase understanding of the development of drug use in this vulnerable population by: 1) comparing longitudinal patterns of past-year illicit drug use (e.g., marijuana, cocaine, and ecstasy) and misuse of prescription drugs among minority sexual orientation youth relative to heterosexual youth and, 2) examining how sexual orientation sub-group, gender, and age relate to variation in the risk of drug use. Data come from the Growing Up Today Study, a community-based cohort of U.S. adolescents who were assessed three times between 1999 and 2005 with self-administered questionnaires when they ranged in age from 12 to 23 years (N = 12,644: 74.9% of the original cohort). Multivariable repeated measures generalized estimating equations using modified Poisson regression were used to estimate relative risks. Participants indicating their sexual orientation was mostly heterosexual, bisexual, or lesbian/gay were more likely than completely heterosexual youth to report past-year illicit drug use and misuse of prescription drugs. Gender was an important modifier: bisexual females were most likely to report drug use. Age was also an important modifier of risk; differences in drug use between minority sexual orientation and heterosexual youth were larger during adolescence (12-17 years) than during emerging adulthood (18-23 years). Research must focus on identifying reasons why minority sexual orientation youth are at disproportionate risk for drug use. Such information is essential for developing interventions that are critically needed to reduce drug use in this population. Efforts need to begin early because large sexual orientation disparities in drug use are evident by adolescence.

Crackau B; Loehrmann I; Zahradnik A; Otto C; John U; Bischof G et al. Measuring readiness to change for problematic consumption of prescription drugs: Development of an adapted and shortened Readiness to Change Questionnaire. Addiction Research & Theory 18(1): 110-118, 2010. (23 refs.)

Background: Up to now, no sufficient evidence is available about the stages of change for abstaining from prescription drugs (PD). The aim of this study was to report on the psychometric properties and factor structure of the Readiness to Change Questionnaire adapted for PD (RCQ-PD) and to find a valid and reliable shortened version. Method: A sample of 126 general hospital patients with long-term use of PD (more than 60 days within the last 3 months) or diagnosed with misuse of or dependence on PD was used for the analyses. Factor structure was investigated using exploratory factor analysis. As an aspect of construct validity, the consensus between stages of change and one single-item measure of readiness to change was tested. Results: Factor analysis resulted in a two-factor solution with one bidimensional Precontemplation/Contemplation factor and one unidimensional Action factor. Internal consistency of the RCQ-PD-6 scales ranged between r = 0.73 and 0.89. Precontemplators scored significantly lower on a continuous measure (Readiness Ruler) than participants in Contemplation or Action. Conclusion: Results might be taken as a first indicator of construct validity of the RCQ-PD-6, which provides a reliable measure of the stages of change in patients with PD-related problems.

Dalen K; Bruaroy S; Wentzel-Larsen T; Laegreid LM. Cognitive functioning in children prenatally exposed to alcohol and psychotropic drugs. Neuropediatrics 40(4): 162-167, 2009. (37 refs.)

Cognitive functioning was compared in 29 children diagnosed with fetal alcohol syndrome (FAS), 35 children with fetal alcohol effects (FAE), and 66 psychotropic drugs-exposed (PDE) children using Wechsler tests and the neuropsychological test battery NEPSY. In the FAS group, verbal IQ (VIQ = 78), performance IQ (PIQ = 77), and full scale IQ (FSIQ = 75) were significantly lower as compared to the FAE and PDE groups. In the PDE group VIQ and FSIQ were significantly higher than in the FAE group. In the FAS group, processing speed (PS) was significantly lower than the other three factors. In the FAE group, perceptual organization (PO) was significantly higher, whereas PS was significantly lower than the other factors. In the PDE group, verbal comprehension (VC) was significantly higher than the other factors. Attention subscales on the NEPSY were significantly lower in all the three groups. Prenatal alcohol exposure affects IQ levels more than exposure to psychotropic drugs. Attentional problems were found in all children when tested with the NEPSY in all groups.

Dasgupta N; Mandl KD; Brownstein JS. Breaking the news or fueling the epidemic? Temporal association between news media report volume and opioid-related mortality. PLoS one 4(11): e-7758, 2009. (57 refs.)

Background: Historical studies of news media have suggested an association between reporting and increased drug abuse. Period effects for substance use have been documented for different classes of legal and illicit substances, with the suspicion that media publicity may have played major roles in their emergence. Previous analyses have drawn primarily from qualitative evidence; the temporal relationship between media reporting volume and adverse health consequences has not been quantified nationally. We set out to explore whether we could find a quantitative relationship between media reports about prescription opioid abuse and overdose mortality associated with these drugs. We assessed whether increases in news media reports occurred before or after increases in overdose deaths. Methodology/Principal Findings: Our ecological study compared a monthly time series of unintentional poisoning deaths involving short-acting prescription opioid substances, from 1999 to 2005 using multiple cause-of-death data published by the National Center for Health Statistics, to monthly counts of English-language news articles mentioning generic and branded names of prescription opioids obtained from Google News Archives from 1999 to 2005. We estimated the association between media volume and mortality rates by time-lagged regression analyses. There were 24,272 articles and 30,916 deaths involving prescription opioids during the seven-year study period. Nationally, the number of articles mentioning prescription opioids increased dramatically starting in early 2001, following prominent coverage about the nonmedical use of OxyContin. We found a significant association between news reports and deaths, with media reporting preceding fatal opioid poisonings by two to six months and explaining 88% (p<0.0001, df 78) of the variation in mortality. Conclusions/Significance: While availability, structural, and individual predispositions are key factors influencing substance use, news reporting may enhance the popularity of psychoactive substances. Albeit ecological in nature, our finding suggests the need for further evaluation of the influence of news media on health. Reporting on prescription opioids conforms to historical patterns of news reporting on other psychoactive substances.

DeSantis AD; Hane AC. "Adderall is definitely not a drug": Justifications for the illegal use of ADHD stimulants. Substance Use & Misuse 45(1/2): 31-46, 2010. (25 refs.)

In-depth interviews were conducted in 2007 with 175 undergraduate students (94 males, 81 females, 13 non-Caucasian) at a large, public southeastern research university located in an urban area in the United States. Our primary goal was to identify how these students conceive of Attention Deficit Hyperactivity Disorder (ADHD) stimulants and their illegal use. We discovered that these students frame stimulant use as both physically harmless and morally acceptable. Specifically, these students justify their drug use through the use of four recurring pro-stimulant arguments: 1) comparison-and-contrast, 2) all-things-in-moderation, 3) self-medicating, and 4) minimization arguments. We discuss limitations to the study and conclude by suggesting five strategies for prevention researchers that would directly target these four arguments.

El-Aneed A; Alaghehbandan R; Gladney N; Collins K; Macdonald D; Fischer B. Prescription drug abuse and methods of diversion: The potential role of a pharmacy network. Journal of Substance Use 14(2): 75-83, 2009. (46 refs.)

Prescription drug abuse is a growing problem in North America. Evidence indicates that prescription drugs have replaced traditional 'street' drugs in major metropolitan Canadian sites. Drug abusers tend to use multiple drugs at the same time, escalating the associated risks and increasing the complexity of the issues surrounding drug abuse. To address this problem, interventions at varying levels are needed, one of which includes the support of electronic health records initiatives, such as a pharmacy network. This network will enable health care providers to access patients' comprehensive drug history at the point of care and physicians will be able to e-prescribe medications. Such functionalities can theoretically limit the degree of drug diversion towards the illegal market. Common practices among drug abusers/diverters can be reduced and monitored, such as visiting multiple physicians and pharmacies, prescription forgery, illegal prescribing, and diverting methadone that is used to treat opioid dependence. This discussion paper will introduce the issue of prescription drug abuse within the Canadian context and discuss drug diversion methods. Discussion will focus on to the possible role of a pharmacy network in limiting major diversion methods and supporting the medical system assisting those who suffer from drug abuse problems.

Fischer B; Bouchard M. Commentary on Ware and St Arnaud-Trempe (2010): Nabilone abuse in Canada? Nature provides an effective prevention program. (editorial). Addiction 105(3): 504-505, 2010. (19 refs.)

Floyd LJ; Alexandre PK; Hedden SL; Lawson AL; Latimer WW; Giles N. Adolescent drug dealing and race/ethnicity: A population-based study of the differential impact of substance use on involvement in drug trade. American Journal of Drug and Alcohol Abuse 36(2): 87-91, 2010. (26 refs.)

Background: Among adolescents, peers are an important source of drug procurement. However, little is known about factors associated with youths' involvement in drug trade. Objectives: The aim of the study is to identify substance use behaviors and contextual factors related to drug dealing among Black and White adolescents. Methods: The sample consisted of 13,706 White and Black youths who completed the National Survey on Drug Use and Health. Separate backward logistic regression was used to identify substance use behaviors and contextual factors associated with drug dealing among Black and White youths. Results: Among White youths, drug dealing was associated with use of marijuana, hallucinogens, cocaine, prescription drug misuse, availability of cocaine, and socioeconomic status (SES). Among Black youths, marijuana use and availability of crack and marijuana were associated with drug dealing. Conclusions and Scientific Significance: For White youths, substance use seems to be more relevant to drug dealing. Consequently, preventing and treating substance abuse may reduce involvement in the illegal distribution of drugs among White youths. More research is needed to identify risk and protective factors for drug dealing among Black adolescents.

Gardner PJ; Poole JM. One story at a time narrative therapy, older adults, and addictions. Journal of Applied Gerontology 28(5): 600-620, 2009. (59 refs.)

Various factors including social isolation and financial worries put older adults at risk for addictions. Indeed, older adults are the largest consumers of medication, and alcohol consumption is rising. Yet interventions are limited and problems often go unreported. Unearthing "problem" stories in people's lives (i.e., "the addiction story") and retelling them in more empowering ways, narrative therapy offers a viable therapeutic alternative, and research on narrative therapy has proven encouraging. However, little is known about narrative therapy with older adults and with addictions. Seeking to address these gaps, an ethnographic study was conducted in Toronto, Canada, with a group of older adults receiving narrative therapy for addictions. Findings suggest that the therapy was "helpful" and participants were able to reduce or halt their substance misuse. Most important, aspects of narrative therapy such as storytelling may be particularly well suited to older adults, offering powerful possibilities for applied gerontology.

Garnier LM; Arria AM; Caldeira KM; Vincent KB; O'Graduatey KE; Wish ED. Nonmedical prescription analgesic use and concurrent alcohol consumption among college students. American Journal of Drug and Alcohol Abuse 35(5): 334-338, 2009. (23 refs.)

Background: Research has linked heavy alcohol use with non-medical prescription analgesic use, but no studies have focused on concurrent use. Objectives: To understand the extent to which alcohol use and nonmedical prescription analgesic use co-occur among college students. Methods: The Timeline Followback method was used to split the sample (n = 1,118) into three groups based on their alcohol and nonmedical prescription analgesic use. Results: Of all nonmedical prescription analgesic users, 58% (n = 90) were concurrent users. Concurrent users consumed more drinks per drinking day (7.5) than non-concurrent (5.8) and alcohol-only users (5.2), and drank more often (74.4% of days in the past six months, vs. 45.7% and 36.8%, respectively). Conclusions: and Scientific Significance: Concurrent alcohol and analgesic use is prevalent among nonmedical users of prescription analgesics. Findings: suggest a need for heightened awareness and increased research of the risks of coingestion.

Green R; Moore D. 'Kiddie drugs' and controlled pleasure: Recreational use of dexamphetamine in a social network of young Australians. International Journal of Drug Policy 20(5): 402-408, 2009. (35 refs.)

Background: This article explores the recreational use of diverted dexamphetamine, a pharmaceutical stimulant, amongst a social network of young adults (aged 18-31 years) in Perth, Western Australia (WA). Prior epidemiological research indicates that there are high levels of dexamphetamine prescription, and use of diverted dexamphetamine, in this jurisdiction. Little research exists on the social contexts of diverted dexamphetamine use in Australia or overseas. Methods: Ethnographic fieldwork was conducted over 18 months amongst a network of approximately 60 young adults who regularly used psychostimulants. Data collection involved participant observation conducted in natural settings including nightclubs and private parties. In-depth interviews were also conducted with 25 key contacts which explored drug use histories and themes emerging from fieldwork. Results: The use of diverted dexamphetamine, or 'dexies', was prevalent amongst the social network and integrated into local drug practices. The paper explores the ways in which dexamphetamine use is rationalised, negotiated and represented in the context of the use of alcohol and other psychostimulants such as methamphetamine and ecstasy. Two key aspects are emphasised. First, dexamphetamine use is seen as insignificant by network members and is positioned as 'safer' in relation to the use of other drugs by virtue of its pharmaceutical status. Second, dexamphetamine plays an instrumental role in facilitating the pursuit of 'controlled pleasure' via the heavy consumption of alcohol and other drugs. Conclusion: The findings of the paper have implications for harm reduction policy. In particular, dexamphetamine use facilitates heavy drinking and polydrug use amongst young adults, which may increase the harms associated with such use. Further, current interventions targeting young psychostimulant users, which emphasise their adulterated and illegal nature, may inadvertently contribute to the cultural construction of dexamphetamine as a relatively 'safe' drug.

Hamilton GJ. Prescription drug abuse. Psychology in the Schools 46(9, Special Issue): 892-898, 2009. (29 refs.)

This article presents current statistics on nonmedical use of both categories of prescription medications by high school and college students. The incidence of nonmedical use of prescription medications continues to increase among high school and college students. Two categories of drugs that are commonly used for reasons other than those for which the drugs are prescribed are those used for pain and those prescribed for Attention-Deficit/Hyperactivity Disorder. Demographic and behavioral characteristics of students who are most likely to engage in intentional abuse of stimulants and pain medications as well as stated motivations for use are presented.

Harrell ZAT; Broman CL. Racial/ethnic differences in correlates of prescription drug misuse among young adults. Drug and Alcohol Dependence 104(3): 268-271, 2009. (37 refs.)

This study examined psychosocial correlates of prescription drug misuse over time among young adults. Data from a nationally representative U.S. sample consisting of 4882 cases were analyzed. Multivariate logistic regression analyses revealed that being younger, having less education, as well as alcohol use; marijuana use, inhalant use, and delinquent behavior during adolescence were associated with prescription drug misuse. In Whites, prescription drug misuse was related to age, alcohol use, marijuana use and delinquent behavior. Among Hispanic young adults inhalant use, delinquent behavior and maternal warmth were associated with greater prescription drug use, while marijuana use was predictive of lower prescription drug misuse. Religious attendance was associated with lower prescription drug misuse among Black young adults. These findings suggest that there are unique racial/ethnic profiles for substance use risk behaviors in adolescence. Further investigations should examine culturally specific dimensions culturally specific dimensions that may account for racial/ethnic differences in prescription drug misuse.

Hoiseth G; Karinen R; Sorlid HK; Bramness JG. The effect of scheduling and withdrawal of carisoprodol on prevalence of intoxications with the drug. Basic & Clinical Pharmacology & Toxicology 105(5): 345-349, 2009. (36 refs.)

The centrally acting muscle relaxant carisoprodol has previously been shown to cause psychomotor impairment and to have a narrow therapeutic range. In Norway, carisoprodol was therefore reclassified to the highest scheduling level from 1 August 2007 and withdrawn from the market on 1 May 2008. The aim of this study was to examine to what extent this action resulted in reduced numbers of driving under the influence (DUI) cases and forensic autopsies concerning carisoprodol, as well as reduced numbers of contacts to the National Poisons Information Centre (NPIC) in Norway regarding carisoprodol. From 2004 to 2008, carisoprodol (and/or its metabolite meprobamate) was detected in a total of 1261 DUI cases, decreasing from 312 in 2004 to 47 in 2008. During the same period, carisoprodol was detected in 194 forensic autopsies, also here decreasing, from 53 cases in 2004 to 11 cases in 2008. The NPIC received 1180 contacts primarily concerning carisoprodol over this period, decreasing from 267 contacts in 2004 to 87 contacts in 2008. During the same period, the sales figures for carisoprodol decreased dramatically, and we observed a relation between the numbers of DUI cases, forensic autopsies and contacts to the NPIC concerning carisoprodol and the sales figures for the drug. This study showed that the rescheduling and withdrawal of carisoprodol from the Norwegian market had a positive effect on the prevalence of carisoprodol in impaired driving, deaths and contacts regarding intoxications. This, together with previous publications, indicates that the population reflected in our data uses regularly prescribed carisoprodol and, to a lesser degree, drug from an illegal street market.

Izzo AA; Ernst E. Interactions between herbal medicines and prescribed drugs: An updated systematic review. (review). Drugs 69(13): 1777-1798, 2009. (189 refs.)

The concomitant use of herbal medicines and pharmacotherapy is wide spread. We have reviewed the literature to determine the possible interactions between seven popular herbal medicines (ginkgo, St John's wort, ginseng, garlic, echinacea, saw palmetto and kava) and conventional drugs. Literature searches were performed using MEDLINE, Cochrane Library and EMBASE and we identified 128 case reports or case series, and 80 clinical trials. Clinical trials indicate that St John's wort (Hypericum perforatum), via cytochrome P450 (CYP) and/or P-glycoprotein induction, reduces the plasma concentrations (and/or increases the clearance) of alprazolam, amitriptyline, atorvastatin, chlorzoxazone, ciclosporin, debrisoquine, digoxin, erythromycin, fexofenadine, gliclazide, imatinib, indinavir, irinotecan, ivabradine, mephenytoin, methadone, midazolam, nifedipine, omeprazole, oral contraceptives, quazepam, simvastatin, tacrolimus, talinolol, verapamil, voriconazole and warfarin. Case reports or case series suggest interactions of St John's wort with adrenergic vasopressors, anaesthetics, bupropion, buspirone, ciclosporin, eletriptan, loperamide, nefazodone, nevirapine, oral contraceptives, paroxetine, phenprocoumon, prednisone, sertraline, tacrolimus, theophylline, tibolone, tryptophan, venlafaxine and warfarin. Ginkgo (Ginkgo biloba) decreases the plasma concentrations of omeprazole, ritonavir and tolbutamide. Clinical cases indicate interactions of ginkgo with anti-epileptics, aspirin (acetylsalicylic acid), diuretics, ibuprofen, risperidone, rofecoxib, trazodone and warfarin. Ginseng (Panax ginseng) may interact with phenelzine and warfarin. Kava (Piper methysticum) increases the clearance of chlorzoxazone (a CYP2E1 substrate) and may interact with alprazolam, levodopa and paroxetine. Garlic (Allium sativum) interacts with chlorpropamide, fluindione, ritonavir and warfarin; it also reduces plasma concentrations of chlorzoxazone (a CYP2E1 probe). Echinacea might affect the clearance of caffeine (a CYP1A2 probe) and midazolam (a CYP3A4 probe). No interactions have been reported for saw palmetto (Serenoa repens). Numerous interactions between herbal medicines and conventional drugs have been documented. While the significance of many interactions is uncertain, several interactions, particularly those with St John's wort, may have serious clinical consequences.

Jamison RN; Butler SF; Budman SH; Edwards RR; Wasan AD. Gender differences in risk factors for aberrant prescription opioid use. Journal of Pain 11(4): 312-320, 2010. (49 refs.)

This is a longitudinal predictive study to examine gender differences in the clinical correlates of risk for opioid misuse among chronic pain patients prescribed opioids for pain. Two hundred seventy-five male and 335 female patients prescribed opioids for chronic noncancer pain were asked to complete a series of baseline questionnaires, including the revised Screener and Opioid Assessment for Pain Patients (SOAPP-R). After 5 months, the subjects were administered a structured prescription drug use interview (Prescription Drug Use Questionnaire; PDUQ) and submitted a urine sample for toxicology assessment. Their treating physicians also completed a substance misuse behavior checklist (Prescription Opioid Therapy Questionnaire; POTQ). At 5-month follow-up, women showed higher scores on the PDUQ (P < .05), whereas men had a higher incidence of physician-rated aberrant drug behavior on the POTQ (P < .05). An item analysis of the SOAPP-R, PDUQ, and POTQ showed that women tended to score higher on items relating to psychological distress, whereas the male patients tended to report having more legal and behavioral problems. These results suggest that risk factors associated with prescription opioid misuse may differ between men and women. Perspective: Understanding gender differences in substance abuse risk among chronic pain patients is important for clinical assessment and treatment. This study suggests that women are at greater risk to misuse opioids because of emotional issues and affective distress, whereas men tend to misuse opioids because of legal and problematic behavioral issues.

Jamison RN; Link CL; Marceau LD. Do pain patients at high risk for substance misuse experience more pain?: A longitudinal outcomes study. Pain Medicine 10(6): 1084-1094, 2009. (70 refs.)

Objectives. The Screener and Opioid Assessment of Pain Patients (SOAPP v.1) has been shown to be a reliable measure of risk potential for substance misuse and to correlate with a history of substance abuse, legal problems, craving, smoking, and mood disorders among chronic pain patients. The aim of this study was to examine differences over time on a number of measures among chronic pain patients who were classified as high or low risk for opioid misuse based on scores on the SOAPP. Methods. From an initial sample of one hundred thirty-four participants (N = 134), one hundred and ten (N = 110) completed the SOAPP and were grouped as high or low risk for misuse of medication based on SOAPP scores of >= 7. All subjects were asked to complete baseline measures and in-clinic monthly diaries of their pain, mood, activity interference, medication, and side effects over a 10-month study period. Results. The results showed that although those who were classified as high-risk for opioid misuse reported significantly higher levels of pain intensity, activity interference, pain catastrophizing, disability, and depressed mood at baseline (P < 0.05), only pain intensity ratings were found to differentiate groups over time (P < 0.01). These results were unrelated to perceived helpfulness of pain treatment. Conclusions. Differences in subjective pain intensity were found between those who are high risk for opioid misuse compared with those at low risk for medication misuse, implying that higher-risk patients may experience more subjective pain. Consequently, these patients may be more challenging to treat.

Judson R; Langdon SW. Illicit use of prescription stimulants among college students: Prescription status, motives, theory of planned behaviour, knowledge and self-diagnostic tendencies. Psychology, Health and Medicine 14(1): 97-104, 2009. (22 refs.)

Published studies have reported that illicit prescription stimulant use is increasingly common on college campuses in the United States. The present study investigates the relationship between prescription status, motives, theory of planned behaviour, knowledge of side effects and self-diagnostic tendencies and illicit use of prescription stimulants among undergraduates (N = 333). Prescription holders and non-holders responded to a self-administered online survey. Results revealed that dependent variables were significantly different between illicit users and non-illicit users. Specifically, prescription holders were more likely than non-holders to report illicit use. Illicit users, relative to non-illicit users, reported more motives to use, less concern with ethics and safety of use, greater perception of use as socially acceptable, less perceived control over their behaviour without stimulant aid, more knowledge, and, among non-prescription holders, were more likely to self-diagnosis having an attention disorder. This study provides additional insight into students' attitudes, beliefs, knowledge and practices related to prescription stimulant use on campus. Implications for future research and the need for interventions to provide aid to students who are at risk for using stimulant medications illicitly are discussed.

Jumbelic MI. Deaths With transdermal fentanyl patches. American Journal of Forensic Medicine and Pathology 31(1): 18-21, 2010. (19 refs.)

Fentanyl is a potent Schedule II narcotic analgesic recommended for use in the management of unremitting pain not controlled by morphine or other opiate/opioid drugs. The danger inherent to fentanyl is its potency (greater than 50-100 times that of morphine) and rapidity of action, causing respiratory depression within minutes of administration. Advisories have been issued on a state and national level to health care providers and through manufacturers' package inserts for patients. Still, as will be demonstrated in this case review, the use of only a single transdermal patch taken as prescribed for the first time can prove fatal. A drug that requires such extensive warnings-that if unheeded lead to death because of its narrow therapeutic/toxic window, should have strict criteria and limited outpatient use. Initial medical observation and documentation for determining tolerance might be required before issuing a prescription. There has been a rise in the popularity of this drug evidenced by increased deaths among drug abusers and more prescriptions written. In the year 2006, the Center for Forensic Sciences in Onondaga County had 8 cases where fentanyl was considered the cause of death, often with other drugs detected in therapeutic concentrations. This number was a marked increase from the 1 to 2 cases occurring annually from 2002 to 2005. All of these 2006 overdoses because of fentanyl involved the transdermal formulation. The investigative data, blood and liver fentanyl levels, and autopsy findings will be presented.

Kelly BC; Parsons JT. Prevalence and predictors of non-medical prescription drug use among men who have sex with men. Addictive Behaviors 35(4): 312-317, 2010. (35 refs.)

Although non-medical prescription drug use has dramatically increased in many populations during the past decade, this phenomenon remains understudied among men who have sex with men (MSM). Using a community-based sample of MSM, we provide data on the high prevalence of lifetime and recent non-medical prescription drug use among MSM for a range of prescription drug classes such as pain killers, sedatives, sleep aids, stimulants, and erectile dysfunction medications. The paper also highlights differences in rates of recent non-medical prescription drug use within this population, noting that White MSM, HIV-positive MSM, gay-identified MSM, and MSM over 40 were typically more likely to have recently used a range of prescription drugs than their counterparts. After controlling for various factors, the findings demonstrate that age. HIV-positive status, gay identity, low educational level, and White race are significant correlates of both lifetime and recent non-medical prescription drug use among MSM. The data suggest that prevention and treatment efforts for this population are likely to require some tailoring, particularly for HIV-positive MSM who may have different needs than other MSM given their health concerns and medication regimens.

Kim D; Steinhart B. Seizures induced by recreational abuse of bupropion tablets via nasal insufflation. Canadian Journal of Emergency Medicine 12(2): 158-161, 2010. (25 refs.)

Bupropion is a newer generation antidepressant that is commonly used for treatment of depression and for smoking cessation. Seizures are a frequently reported adverse effect of bupropion in therapeutic oral doses; however, there are limited data about the consequences of nasal insufflation of bupropion. We report the case of a patient who presented to the emergency department (ED) with a recent history of generalized tonic-clonic seizures whose etiology was initially a diagnostic mystery. After an initial visit to another ED, the patient presented to our ED later that day with a recurrence of the seizures after crushing and nasally insufflating oral bupropion tablets. We review important implications of this case to emergency medicine, including the potential for abuse of bupropion, the difference between intranasal and oral administration, the changing trends in the etiology of drug-related seizures and the importance of examining the nares in patients with unexplained seizure and delirium.

Krause JS; Zhai YS; Saunders LL; Carter RE. Risk of mortality after spinal cord injury: An 8-year prospective study. Archives of Physical Medicine and Rehabilitation 90(10): 1708-1715, 2009. (34 refs.)

Objective: To evaluate a theoretical model for mortality after spinal cord injury (SCI) by sequentially analyzing 4 sets of risk factors in relation to mortality (ie, adding 1 set of factors to the regression equation at a time). Design: Prospective cohort study of data collected in late 1997 and early 1998 with mortality status ascertained in December 2005. We evaluated the significance of 4 successive sets of predictors (biographic and injury, psychologic and environmental, behavioral, health and secondary conditions) using Cox proportional hazards modeling and built a full model based on the optimal predictors. Setting: A specialty hospital. Participants: Adults (N = 1386) with traumatic SCI, at least 1 year postinjury, participated. There were 224 deaths. After eliminating cases with missing data, there were 1209 participants, with 179 deceased at follow-up. Interventions: Not applicable. Main Outcome Measures: Mortality status was determined using the National Death Index and the Social Security Death Index. Results: The final model included 1 environmental variable (poverty), 2 behavioral factors (prescription medication use, binge drinking), and 4 health factors or secondary conditions (hospitalizations, fractures/amputations, surgeries for pressure ulcers, probable major depression). Conclusions: The results supported the major premise of the theoretical model that risk factors are more important the more proximal they are in a theoretical chain of events leading to mortality. According to this model, mortality results from declining health, precipitated by high-risk behaviors. These findings may be used to target those who are at high risk for early mortality as well as to direct interventions to the particular risk factor.

Kugelberg FC; Holmgren A; Eklund A; Jones AW. Forensic toxicology findings in deaths involving gamma-hydroxybutyrate. International Journal of Legal Medicine 124(1): 1-6, 2010. (46 refs.)

Concentrations of the illicit drug gamma-hydroxybutyrate (GHB) were determined in femoral venous blood and urine obtained at autopsy in a series of GHB-related deaths (N = 49). The analysis of GHB was done by gas chromatography after conversion to gamma-butyrolactone and quantitation of the latter with a flame ionization detector. The cutoff concentration of GHB in femoral blood or urine for reporting positive results was 30 mg/L. The deceased were mainly young men (86%) aged 26.5 +/- 7.2 years (mean +/- SD), and the women (14%) were about 5 years younger at 21.4 +/- 5.0 years. The mean, median, and highest concentrations of GHB in femoral blood (N = 37) were 294, 190, and 2,200 mg/L, respectively. The mean urine-to-blood ratio of GHB was 8.8, and the median was 5.2 (N = 28). In 12 cases, the concentrations of GHB in blood were negative (< 30 mg/L) when the urine contained 350 mg/L on average (range 31-1,100 mg/L). Considerable poly-drug use was evident in these GHB-related deaths: ethanol (18 cases), amphetamine (12 cases), and various prescription medications (benzodizepines, opiates, and antidepressants) in other cases. Interpreting the concentrations of GHB in postmortem blood is complicated because of concomitant use of other psychoactive substances, variable degree of tolerance to centrally acting drugs, and the lack of reliable information about survival time after use of the drug.

Law BF; Hettick JM; Hornsby-Myers J; Siegel PD. Analytical methodology and assessment of potential second-hand exposure to fentanyl in the hospital surgical setting:. Journal of Addictive Diseases 29(1): 51-58, 2010. (14 refs.)

Second-hand exposure to aerosols containing fentanyl and other opiates during surgical procedures has been implicated as possibly contributing to maintenance of addiction among medical professionals, specifically anesthesiologists. This article outlines a pilot study that was conducted to verify a reported finding fentanyl in the air of operating suites. Environmental fentanyl air sampling and analysis methods were developed and evaluated for this study. Multiple sampling media and extraction solvents were evaluated for trace fentanyl air sampling. Non-specific binding losses were reduced by using silanized binder-free glass fiber sampling media with subsequent methanol extraction. Filtration air samples were then collected in surgical suites during the entire operation time from two cardiovascular surgical procedures. Both surgical procedures were conducted at the same hospital but on different days. Samples were extracted and analyzed by high-performance liquid chromatography/tandem mass spectrometry using a capillary high-performance liquid chromatography coupled to a quadrupole time-of-flight mass spectrometer. The total air volume collected per surgery was 290 to 300 L at a rate of 1 LPM giving an limit of quantification for fentanyl of 57 pg/m(3) air (17 pg/filter). No fentanyl was detected in the air during cardiovascular surgical operations from either surgical suite.

Lennernas H. Ethanol-drug absorption interaction: Potential for a significant effect on the plasma pharmacokinetics of ethanol vulnerable formulations. Molecular Pharmaceutics 6(5): 1429-1440, 2009. (84 refs.)

Generally, gastric emptying of a drug to the small intestine is controlled by gastric motor activity and is the main factor affecting the onset of absorption. Accordingly, the emptying rate from the stomach is mainly affected by the digestive state, the properties of the pharmaceutical formulation and the effect of drugs, posture and circadian rhythm. Variability in the gastric emptying of drugs is reflected in variability in the absorption rate and the shape of the plasma pharmacokinetic profile. When ethanol interacts with an oral controlled release product, such that the mechanism controlling drug release is impaired, the delivery of the dissolved dose into the small intestine and the consequent absorption may result in dangerously high plasma concentrations. For example, the maximal plasma concentration of hydromorphone has individually been shown to be increased as much as 16 times through in vivo testing as a result of this specific pharmacokinetic ethanol-drug formulation interaction. Thus, a pharmacokinetic ethanol-drug interaction is a very serious safety concern when substantially the entire dose from a controlled release product is rapidly emptied into the small intestine (dose dumping), having been largely dissolved in a strong alcoholic beverage in the stomach during a sufficient lag-time in gastric emptying. Based on the literature, a two hour time frame for screening the in vitro dissolution profile of a controlled release product in ethanol concentrations of up to 40% is strongly supported and may be considered as the absolute minimum standard. It is also evident that the dilution, absorption and metabolism of ethanol in the stomach are processes with a minor effect on the local ethanol concentration and that ethanol exposure will be highly dependent on the volume and ethanol concentration of the fluid ingested, together with the rate of intake and gastric emptying. When and in which patients a clinically significant dose dumping will happen is almost impossible to predict and will depend on drinking behavior and the highly variable gastrointestinal factors of importance for dissolution, transit and absorption. Therefore, controlled release products which show a vulnerability to ethanol during two hours in vitro should be required to demonstrate clinical safety by going through in vivo testing with an alcoholic beverage of up to 40% ethanol and of a sufficient volume (probably 120 mL or more), consumed in a relatively short period of time. Alternatively, such preparations should be reformulated in accordance with quality-by-design principles.

Levin FR; Mariani JJ; Brooks DJ; Xie S; Murray KA. Delta(9)-Tetrahydrocannabivarin testing may not have the sensitivity to detect marijuana use among individuals ingesting dronabinol. Drug and Alcohol Dependence 106(1): 65-68, 2010. (33 refs.)

The purpose of this study was to determine whether Delta(9)-tetrahydrocannabivarin (THCV), a plant cannabinoid, is a sensitive measure to detect recent marijuana use in cannabis dependent patients. It has been purported that smoking an illicit plant cannabis product will result in a positive THCV urinalysis, whereas the oral ingestion of therapeutic THC such as dronabinol will result in a negative THCV urinalysis, allowing for discrimination between pharmaceutical THC products and illicit marijuana products. In a double-blind placebo-controlled trial to determine the efficacy of dronabinol in cannabis dependence, all 117 patients produced a positive urine for the marijuana metabolite 11-nor-Delta(9)-THC-9-carboxylic acid: THC-COOH, but 50% had an undetectable (<1 ng/ml) THCV-COOH test. This suggests that THCV may not be a sensitive enough measure to detect recent marijuana use in all heavy marijuana users or that its absence may not discriminate between illicit marijuana use and oral ingestion of THC products such as dronabinol. We propose that the lack of THCV detection may be due to the variability of available cannabis strains smoked by marijuana users in community settings.

Longo M; Wickes W; Smout M; Harrison S; Cahill S; White JM. Randomized controlled trial of dexamphetamine maintenance for the treatment of methamphetamine dependence. Addiction 105(1): 146-154, 2010. (31 refs.)

Aim: To investigate the safety and efficacy of once-daily supervised oral administration of sustained-release dexamphetamine in people dependent on methamphetamine. Design: Randomized, double-blind, placebo-controlled trial. Participants: Forty-nine methamphetamine-dependent drug users from Drug and Alcohol Services South Australia (DASSA) clinics. Intervention: Participants were assigned randomly to receive up to 110 mg/day sustained-release dexamphetamine (n = 23) or placebo (n = 26) for a maximum of 12 weeks, with gradual reduction of the study medication over an additional 4 weeks. Medication was taken daily under pharmacist supervision. Measurements: Primary outcome measures included treatment retention, measures of methamphetamine consumption (self-report and hair analysis), degree of methamphetamine dependence and severity of methamphetamine withdrawal. Hair samples were analysed for methamphetamine using liquid chromatography-mass spectrometry. Findings: Treatment retention was significantly different between groups, with those who received dexamphetamine remaining in treatment for an average of 86.3 days compared with 48.6 days for those receiving placebo (P = 0.014). There were significant reductions in self-reported methamphetamine use between baseline and follow-up within each group (P < 0.0001), with a trend to a greater reduction among the dexamphetamine group (P = 0.086). Based on hair analysis, there was a significant decrease in methamphetamine concentration for both groups (P < 0.0001). At follow-up, degree of methamphetamine dependence was significantly lower in the dexamphetamine group (P = 0.042). Dexamphetamine maintenance was not associated with serious adverse events. Conclusions: The results of this preliminary study have demonstrated that a maintenance pharmacotherapy programme of daily sustained-release amphetamine dispensing under pharmacist supervision is both feasible and safe. The increased retention in the dexamphetamine group, together with the general decreases in methamphetamine use, degree of dependence and withdrawal symptom severity, provide preliminary evidence that this may be an efficacious treatment option for methamphetamine dependence.

LoVecchio F; Ozimek J; Sawyers B; Thole D. Outcomes after accidental pediatric ingestions of (dextro) amphetamine and methylphenidate. American Journal of Emergency Medicine 27(8): 933-934, 2009. (4 refs.)

The authors report the presentation and outcomes for young children, average age 3.1 years, who accidentally ingested methylphenidate. Of 118 patients, 24% took a double dose of their medication. Seventy-six percent were naive to the medication, of which 84% developed symptoms and were evaluated at a health facility. All of cases had favorable outcomes; including the 17% given benzodiazepines for agitation and the 18% who were observed for 12 hours. These results are similar to those previously published, although the number of studies is limited. One study found that 31% of those with accidental doses exhibited symptoms, most commonly tachycardia, agitation, and lethargy. These symptoms are more common among those naive to the drug. It is also noted that there is evidence of improvement of outcome in those who are symptomatic and receive gastric decontamination.

Lundqvist C; Aaseth K; Grande RB; Benth JS; Russell MB. The severity of dependence score correlates with medication overuse in persons with secondary chronic headaches. The Akershus study of chronic headache. Pain 148(3): 487-491, 2010. (32 refs.)

The objective was to compare the Severity of Dependence Scale (SDS) score and pattern of medication use in persons with secondary chronic headache (>= 15 days/month for at least 3 months) in a cross-sectional epidemiological survey. A posted questionnaire screened for chronic headache. Neurological residents interviewed those with self-reported chronic headache. The International Classification of Headache Disorders was used. Split file methodology was employed for data analysis. People with secondary chronic headaches were identified in an age and gender stratified sample of 30,000 30-44 year olds from the general population. The interviews and examinations were conducted at the Akershus University Hospital, Oslo, Norway. The main outcome measure was the SDS score in those with and without medication overuse. Fifty-five (49%) of the 113 persons with secondary chronic headaches were found to have medication overuse. Fifty-eight percent overused simple analgesics and 31% overused combination analgesics. The SDS score was significantly higher among those with than without medication overuse (5.5 vs. 1.9). The sensitivity, specificity, positive and negative predictive values were 0.82, 0.82, 0.82 and 0.83, respectively. Thus the SDS score correlates with medication overuse, and a high SDS score suggests dependency-like behaviour in persons with secondary chronic headache. The use of SDS score in subjects with frequent pain episodes may contribute to the detection of medication overuse and better management of this group of patients.

MacLaren VV; Best LA. Multiple addictive behaviors in young adults: Student norms for the Shorter PROMIS Questionnaire. Addictive Behaviors 35(3): 252-255, 2010. (21 refs.)

The Shorter PROMIS Questionnaire (SPQ Christo, Jones, Haylett, Stephenson, Lefever & Lefever, 2003) is a multidimensional self report that measures 16 addictive behaviors. This study examined the psychometric properties of the SPQ and collected normative data from 948 students at two Canadian universities. Factor analysis confirmed the existence of two categories of addictive behavior, which Haylett and her colleagues (2004) labelled hedonistic and nurturant. The hedonistic categories included behaviors such as the use of prescription drugs, gambling, caffeine, illegal drugs, alcohol, tobacco and compulsive sex. The nurturant group included behaviors such as compulsive helping, work, relationships, shopping, disordered eating and exercise. Men (N=250) scored higher than women on dominant relationships, exercise, gambling, illegal drugs, alcohol. tobacco and sex. Women (N=698) scored higher on compulsive shopping, food binging and starving. These results suggest that the SPQ may be a useful index of multiple addictive behaviors in college-age people.

Maxwell JC; McCance-Katz EF. Indicators of buprenorphine and methadone use and abuse: What do we know? American Journal on Addictions 19(1): 73-88, 2010. (56 refs.)

Abuse of prescription opioids is a growing problem. The number of methadone pain pills distributed now exceeds liquid methadone used in opioid treatment, and the increases in buprenorphine indicators provide evidence of the need to monitor and intervene to decrease the abuse of this drug. The need for additional and improved data to track trends is discussed, along with findings as to the characteristics of the users and combinations of drugs. Data on toxicities related to methadone or buprenorphine, particularly in combination with other prescribed drugs, are presented and clinical implications and considerations are offered. These findings underscore the need for physicians to be aware of potential toxicities and to educate their patients regarding these issues.

McCance-Katz EF; Sullivan LE; Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: A review. American Journal on Addictions 19(1): 4-16, 2010. (92 refs.)

Drug interactions are a leading cause of morbidity and mortality. Methadone and buprenorphine are frequently prescribed for the treatment of opioid addiction. Patients needing treatment with these medications often have co-occurring medical and mental illnesses that require medication treatment. The abuse of illicit substances is also common in opioid-addicted individuals. These clinical realities place patients being treated with methadone and buprenorphine at risk for potentially toxic drug interactions. A substantial literature has accumulated on drug interactions between either methadone or buprenorphine with other medications when ingested concomitantly by humans. This review summarizes current literature in this area.

McCarthy S; Cranswick N; Potts L; Taylor E; Wong ICK. Mortality associated with Attention-Deficit Hyperactivity Disorder (ADHD) drug treatment a retrospective cohort study of children, adolescents and young adults using the general practice research database. Drug Safety 32(11): 1089-1096, 2009. (37 refs.)

Background: Following reports of sudden death in patients taking medication to treat attention-deficit hyperactivity disorder (ADHD), this study aimed to identify cases of death in patients prescribed stimulants and atomoxetine and to determine any association between these and sudden death. Method: The UK General Practice Research Database (GPRD) was used to identify patients aged 2-21 years from I January 1993 to 30 June 2006 with a prescription for methylphenidate, dexamfetamine or atomoxetine. Patients were followed from the date of first prescription until whichever came first: date of death, transferred-out date, age >21 years or end of the study period. Results: From a cohort of 18 637 patient-years, seven patients died. Cause of death was obtained for six of the patients. None were deemed to be cases of sudden death. Compared with a general population rate of sudden death in the literature, the worst-case scenario of one case of sudden death gave an incident rate ratio of 1.63 (95% CI 0.04, 9.71). Although it was not the primary Outcome of the study, following reports of suicide in the cohort the standardized mortality ratio (SMR) of suicide was calculated. Due to differences in the definition of suicide used for children and adults, patients were categorized into two age groups: 11-14 years and 15-21 years. The SMR for suicide for patients aged 11-14 years was 161.91 (95% CI 19.61, 584.88). The SMR for suicide for patients aged 15-21 years was 1.84 (95% CI 0.05, 10.25). Conclusion: This study demonstrated no increase in the risk of sudden death associated with stimulants or atomoxetine. However, an increased risk of suicide was seen. Although we cannot exclude that the medications may contribute to the increased risk of suicide, there are other factors such as depression and antisocial behaviour that frequently co-exist with ADHD, which can also predispose to teenage suicide. Clinicians should identify patients at increased risk of cardiovascular events and identify those patients at increased risk of suicide, particularly males with co-morbid conditions, and monitor them appropriately.

McLean S; Bruno R; Brandon S; de Graaff B. Effect of filtration on morphine and particle content of injections prepared from slow-release oral morphine tablets. Harm Reduction Journal 6(37), 2009. (24 refs.)

Background: Injections of mixtures prepared from crushed tablets contain insoluble particles which can cause embolisms and other complications. Although many particles can be removed by filtration, many injecting drug users do not filter due to availability, cost or performance of filters, and also due to concerns that some of the dose will be lost. Methods: Injection solutions were prepared from slow-release morphine tablets (MS Contin(R)) replicating methods used by injecting drug users. Contaminating particles were counted by microscopy and morphine content analysed by liquid chromatography before and after filtration. Results: Unfiltered tablet extracts contained tens of millions of particles with a range in sizes from < 5 mu m to > 400 mu m. Cigarette filters removed most of the larger particles (> 50 mu m) but the smaller particles remained. Commercial syringe filters (0.45 and 0.22 mu m) produced a dramatic reduction in particles but tended to block unless used after a cigarette filter. Morphine was retained by all filters but could be recovered by following the filtration with one or two 1 ml washes. The combined use of a cigarette filter then 0.22 mu m filter, with rinses, enabled recovery of 90% of the extracted morphine in a solution which was essentially free of tablet-derived particles. Conclusions: Apart from overdose and addiction itself, the harmful consequences of injecting morphine tablets come from the insoluble particles from the tablets and microbial contamination. These harmful components can be substantially reduced by passing the injection through a sterilizing (0.22 mu m) filter. To prevent the filter from blocking, a preliminary coarse filter (such as a cigarette filter) should be used first. The filters retain some of the dose, but this can be recovered by following filtration with one or two rinses with 1 ml water. Although filtration can reduce the non-pharmacological harmful consequences of injecting tablets, this remains an unsafe practice due to skin and environmental contamination by particles and microorganisms, and the risks of blood-borne infections from sharing injecting equipment.

Nielsen MKK; Johansen SS; Dalsgaard PW; Linnet K. Simultaneous screening and quantification of 52 common pharmaceuticals and drugs of abuse in hair using UPLC-TOF-MS. Forensic Science International 196(1-3): 85-92, 2010. (34 refs.)

An UPLC-TOF-MS method for simultaneous screening and quanti. cation of 52 drugs in hair was developed and validated. The selected drugs represent the most common classes of pharmaceuticals and drugs of abuse such as amphetamines, analgesics, antidepressants, antipsychotics, benzodiazepines, cocaine, ketamine and opioids. Hair samples were extracted with methanol: acetonitrile: ammonium formate (2 mM, 8% acetonitrile, pH 5.3) overnight at 37 degrees C. The target drugs were separated and quantified using a Waters ACQUITY UPLC coupled to a Waters Micromass LCT Premier XE Time-of-Flight mass spectrometer. Total chromatographic run time was 17 min. The data were treated with the MassLynx software ChromaLynx XS and QuanLynx for automated identification and quanti. cation, respectively. The limits of detection ranged from 0.01 to 0.10 ng/mg using a 10-mg hair sample and the limit of quanti. cation was 0.05 ng/mg for 87% of the analytes. A good linear behaviour was achieved for most of the analytes in the range from LOQ to 10 or 25 ng/mg except for the amphetamines. The method showed an acceptable precision and trueness, since the obtained CV and BIAS values were <= 25% for 81% of the analytes. The extraction recoveries for 92% of the analytes ranged between 84 and 106% and the extraction recoveries for all analytes were better than 60%. The method was applied to 15 autopsy hair samples from forensic investigations showing a wide abuse pattern of many pharmaceuticals and drugs of abuse within a period of less than three months. The present study demonstrated that the combination of accurate mass and retention time can provide good selectivity, which demonstrates that the TOF instrument is adequate for both screening and quanti. cation purposes. Furthermore, it was shown that screening with the ChromaLynx XS software is less sensitive and selective for some analytes than the QuanLynx software, especially in low concentrations.

Nunn A; Zaller N; Dickman S; Trimbur C; Nijhawan A; Rich JD. Methadone and buprenorphine prescribing and referral practices in US prison systems: Results from a Nationwide Survey. Drug and Alcohol Dependence 105(1/2): 83-88, 2009. (51 refs.)

Background: More than 50% of incarcerated individuals have a history of substance use, and over 200,000 individuals with heroin addiction pass through American correctional facilities annually. Opiate replacement therapy (ORT) with methadone or buprenorphine is an effective treatment for opiate dependence and can reduce drug-related disease and recidivism for inmates. Provision of ORT is nevertheless a frequently neglected intervention in the correctional setting. Objective and methods: We surveyed the 50 state; Washington, District of Columbia (DC); and Federal Department of Corrections' medical directors or their equivalents about their facilities' ORT prescribing policies and referral programs for inmates leaving prison. Results: We received responses from 51 of 52 prison systems nationwide. Twenty-eight prison systems (55%) offer methadone to inmates in some situations. Methadone use varies widely across states: over 50% of correctional facilities that offer methadone do so exclusively for pregnant women or for chronic pain management. Seven states' prison systems (14%) offer buprenorphine to some inmates. The most common reason cited for not offering ORT was that facilities "prefer drug-free detoxification over providing methadone or buprenorphine." Twenty-three states' prison systems (45%) provide referrals for some inmates to methadone maintenance programs after release, which increased from 8% in 2003; 15 states' prison systems (29%) provide some referrals to community buprenorphine providers. Conclusion: Despite demonstrated social, medical, and economic benefits of providing ORT to inmates during incarceration and linkage to ORT upon release, many prison systems nationwide still do not offer pharmacological treatment for opiate addiction or referrals for ORT upon release.

Office of Applied Studies, Substance Abuse and Mental Health Administration. The New DAWN Report. Issue 29 (rev. August 2009). Rockville MD: Substance Abuse and Mental Health Administration, 2009. (10 refs.)

For 2004, according to the Drug Abuse Warning Network (DAWN) about 106 million ED visits occurred in short-term, general, non-Federal hospitals in the United States in 2004. DAWN estimates that about 2.5 million of these ED visits were drug related. The ADHD drugs examined in this report were implicated in less than 1 percent of those drug-related visits. Methylphenidate was involved in an estimated 5,148 ED visits, and amphetamine-dextroamphetamine was involved in an estimated 5,119 ED visits. A total of 10,146 ED visits involved one of these two drugs. (A few visits involved both drugs, so the total is slightly less than the sum of the drug-specific estimates.) In 2004, an estimated 10,146 drug-related emergency department (ED) visits involved methylphenidate or amphetamine-dextroamphetamine, two medications used to treat attention-deficit/hyperactivity disorder (ADHD). The most frequent reason for these ED visits was nonmedical use (47%), followed by adverse reactions (35%), accidental ingestions (11%), and suicide attempts (7%). The rate of ED visits for adverse reactions to these two ADHD drugs for patients aged 12 to 17 years was double that for patients aged 18 to 24 years (3.3 and 1.6 visits per 100,000 population, respectively), while rates for nonmedical use were similar (5.3 and 5.5, respectively). Two thirds (66%) of the ED visits for nonmedical use of these two drugs involved other substances-such as alcohol, illicit drugs, or pharmaceuticals.

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Administration. The NSDUH Report: Trends in Nonmedical Use of Prescription Pain Relievers: 2002 to 2007. (February 5, 2009). Rockville MD: Substance Abuse and Mental Health Administration, 2009. (5 refs.)

Use of prescription pain relievers without a doctor's prescription or only for the experience or feeling they caused ("nonmedical" use) is, after marijuana use, the second most common form of drug use in the United States. [Note: apparently the use nicotine is not being considered] When used appropriately under medical supervision, hydrocodone (e.g., Vicodin(r)), oxycodone (e.g., OxyContin(r)), morphine, and similar prescription pain relievers provide needed pain relief. When taken without a physician's direction and oversight, these medications can cause serious adverse consequences and produce dependence and abuse. According to the Drug Abuse Warning Network (DAWN), approximately 324,000 emergency department visits in 2006 involved the nonmedical use of pain relievers (including both prescription and over-the-counter pain medications). This issue of "The NSDUH Report" examines trends in the nonmedical use of prescription pain relievers in the past month among persons aged 12 or older. Summary: In 2007, 2.1% of persons aged 12 or older (an estimated 5.2 million persons) reported using prescription pain relievers nonmedically in the past month; this rate does not differ significantly from that in 2002. Trends in past month nonmedical use of pain relievers varied by age with declines among youths aged 12 to 17 (from 3.2% in 2002 to 2.7% in 2007), but increases among young adults aged 18 to 25 (from 4.1 to 4.6%) and adults aged 26 or older (from 1.3 to 1.6%). Though the rate of use was fairly stable for females between 2002 and 2007, it increased for males.

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Administration. The NSDUH Report: Nonmedical Use of Pain Relievers in Substate Regions: 2004 to 2006. (June 19, 2008). Rockville MD: Substance Abuse and Mental Health Administration, 2009. (9 refs.)

Misuse of prescription drugs is second only to marijuana as the nation's most prevalent drug problem, and the annual average number of people using pain relievers nonmedically for the first time in the past 12 months has exceeded the number of new marijuana users since 2002. Accordingly, misuse of prescription pain relievers has been cited as a growing public health problem. A new Substance Abuse and Mental Health Services Administration (SAMHSA) report provides data on substance use within smaller geographic areas within States. Data in this issue of "The NSDUH Report" highlight substate estimates of the nonmedical use of prescription pain relievers. They were extracted from a larger report entitled "Substate Estimates from the 2004-2006 National Surveys on Drug Use and Health. " Key findings: Data from the 2004 to 2006 NSDUHs indicate that past year nonmedical use of pain relievers ranged from a low of 2.48% in a ward of the District of Columbia to a high of 7.92 percent in northwest Florida. Of the 15 substate regions with the highest rates of nonmedical use of pain relievers, 10 were in southern States and 5 substate regions were in States in the West. Of the 15 substate regions with the lowest rates of nonmedical use of pain relievers, 7 substate regions were in southern States, 4 substate regions were in midwestern States, 3 substate regions were in northeastern States, and 1 substate region was in a western State.

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings. NSDUH Series H-36. Rockville MD: Substance Abuse and Mental Health Administration, 2009. (104 refs.)

Highlights: This report presents the first information from the 2008 National Survey on Drug Use and Health (NSDUH), an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The survey is the primary source of information on the use of illicit drugs, alcohol, and tobacco for those aged 12 years and older. Information is provided on different classes of substances, the inititiation of use, prevention efforts, and involvement or need for treatment. In 2008, an estimated 20.1 million Americans aged 12 or older were current (past month) illicit drug users, a rate of 8.0% of the population. Marijuana was the most commonly used illicit drug (15.2 million past month users), a rate of 6.1%, similar to 2007. Of note, for those using pain relievers nonmedically, the majority (55.9%) got the drug they most recently used from a friend or relative for free, who had gotten it from a single doctor. Another 18.0% got the drug from one doctor. Only 4.3% got pain relievers from a drug dealer or other stranger, and 0.4 percent bought them on the Internet. Among those who reported getting the pain reliever from a friend or relative for free, 81.7% reported in a follow-up question that the friend or relative had obtained the drugs from just one doctor. In terms of alcohol use, slightly more than half of Americans aged 12 or older reported being current drinkers of alcohol in the 2008 survey (51.6%), similar to the prior year. More than one fifth (23.3%) reported binge drinking, for those aged 18 to 25 in 2008, the rate of binge drinking was 41.0%. In 2008, 28.4% used tobacco, with a decline in the proportion of users in the 12-17 age group. Data is presented in 76 tables and 70 figures.

Public Domain

Officer J. Trends in drug use of Scottish drivers arrested under Section 4 of the Road Traffic Act: A 10 year review. Science & Justice 49(4): 237-241, 2009. (12 refs.)

A Study of Section 4 RTOA cases Submitted to the SPSA forensic science laboratory in Edinburgh over a 12 year period was carried out. The main aims of the study were to identify the most frequently encountered drugs and to determine if there were any major drugs trends from the data collected. Three groups of cases from 1996 to 2000 (102 cases), 2003 (26 cases) and 2008 (295 cases) were examined. The large increase in Submissions was mainly due to the introduction of SPSA, whereby the laboratory began to carry out the analysis for all criminal and RTOA cases in Scotland. The preliminary results for the 8 drug groups (amphetamine and related compounds, benzodiazepines, cannabinoids, cocaine, methadone, methylamphetamine and related compounds, morphine and opiates) identified a number of major trends: cannabinoids were consistently present in 40-50% of cases: benzodiazepines more than doubled in frequency to over 80%; there has been a significant increase in cases positive for morphine and methadone - up from less than 2% each to 31% and 23% respectively; there has been an increase in the number of cases screening positive for opiates (19% to 29%); and the frequency of positive cases for cocaine, amphetamine and methylamphetamine remained unchanged (approximately 22%, 6% and 5% respectively), A significant finding was the huge increase in polydrug use. The number of cases positive for 4 or more drug groups has increased from 4% in 1996-2000 to 25% in 2008. In comparison, in the 1996-2000 group 72% of cases were only positive for one drug group compared to 17% in 2008. For those cases which were negative for all 8 drug groups, a screen for potentially impairing prescription and over the counter medicines was carried Out. The most frequently encountered medicines were sedatives, sedative antidepressants, sedative antihistamines and antiemetics. These were often found in conjunction with alcohol below the legal limit for driving.

Opaleye ES; Noto AR; Sanchez ZV; de Moura YG; Galduroz JCF; Carlini EA. Recreational use of benzydamine as a hallucinogen among street youth in Brazil. Revista Brasileira De Psiquiatria 31(3): 208-213, 2009. (18 refs.)

Objective: To describe the recreational use of benzydamine, an anti-inflammatory drug, among street youth in Brazil. Method: Design: a descriptive, cross sectional survey. Setting: 93 welfare services for the street youth in 27 Brazilian capitals. Participants: 2807 street youth, 10 to 18 years old. Main outcome measures: demographic characteristics, drug use pattern (lifetime use, use in the past 30 days, frequency, and characteristics of use in the past month) and effects of benzydamine through the use of a questionnaire. Results: 78 reported lifetime recreational benzydamine use (67 cases identified only in three capitals). Among the 30 respondents reporting drug use in the last month (the month preceding the survey), 66.7% (n = 20) used the drug on 4 or more days (in the month preceding the survey). The most frequently (50%) pleasure effects reported were hallucination and nonspecific sensory changes described as "trips". Unwanted effects were reported by 75% of respondents, they were especially nausea and vomiting (21.4%). In the majority of the cases, drug was obtained from drugstores without a medical prescription. Conclusion: This study identifies the recreational use of benzydamine among street youth, mainly in the Northeast of Brazil, and also indicates the need for special controls on the dispensation of this substance.

Otiashvili D; Zabransky T; Kirtadze I; Piralishvili G; Chavchanidze M; Miovsky M. Why do the clients of Georgian needle exchange programmes inject buprenorphine? European Addiction Research 16(1): 1-8, 2010. (62 refs.)

Aim: The aim of the study was to understand the prevalence and patterns of the non-medical injecting use of buprenorphine among drug injectors in Georgia. Method: A self-administered questionnaire was distributed among injecting drug users enrolled in Georgian needle exchange programmes. The questions covered topics related to drug use career, patterns (frequency, history, dosage) and reasons for the use of buprenorphine. Results: Pharmaceutical buprenorphine in the form of Subutex (R) was the most commonly injected drug in terms of lifetime (95.5%) and last-month (75%) prevalence of use. 48% of those study participants who had injected Subutex at some point reported having used it to cope with withdrawal or to give up other opioids. 90.5% of Subutex injectors used 1-2 mg as a single dose, and the mean frequency of its injection was 6 times per month. 75% of Subutex injectors had used 3 or more types of illegal drugs during the last 30 days. Conclusion: While widely misused by Georgian drug injectors, Subutex is neither the principal nor the favourite drug, and it is rather used as self-treatment. The authors consider the introduction of buprenorphine maintenance treatment to be a promising effective measure to decrease its non-medical and illegal use.

Oulis P; Konstantakopoulos G. Pregabalin in the treatment of alcohol and benzodiazepines dependence. (review). CNS Neuroscience & Therapeutics 16(1): 45-50, 2010. (39 refs.)

We review all available studies on the use of the newer anticonvulsant drug pregabalin (PGB) in the treatment of both alcohol dependence (AD) and benzodiazepine dependence (BD). In AD, the available evidence includes one open-label and one double-blind randomized studies, whereas in BD, only a few case reports and one open-label study are as yet available. In both conditions, PGB was found efficacious with significant improvement in withdrawal symptoms at the dosage ranges of 150-450 mg/day (AD) and 225-900 mg/day (BD). Moreover, its side effects were mild and transient. Despite the limited quality of the studies design, their findings suggest that PGB might constitute a novel efficacious and safe option in the treatment of both AD and BD.

Peralta RL; Steele JL. Nonmedical prescription drug use among US college students at a midwest university: A partial test of social learning theory. Substance Use & Misuse 45(6): 865-887, 2009. (52 refs.)

We estimate the prevalence of nonmedical prescription drug (NMPD) use and test social learning theory as an explanation for NMPD use based upon data from a large pilot study. Data were collected from 465 college students at a Midwestern university in the USA using a self-administered questionnaire. The sample was predominantly white (88%), 43% were female and the mean age was 22. Most participants (80%) were not members of social fraternities or sororities. A majority of students did not report NMPD use: 39.4% of respondents reported lifetime NMPD use, 31% reported past-year use, and 14.4% reported past-month use. Multivariate regression results partially supported social learning theory as an explanation for lifetime NMPD use. Limitations and suggestions for future research are suggested.

Potter JS; Prather K; Kropp F; Byrne M; Sullivan CR; Mohamedi N et al. A method to diagnose opioid dependence resulting from heroin versus prescription opioids using the Composite International Diagnostic Interview. Contemporary Clinical Trials 31(2): 185-188, 2010. (15 refs.)

Treatment research with opioid-dependent populations has not traditionally distinguished between those dependent on prescription opioids versus dependent upon heroin. Evidence suggests there is a substantial subpopulation of individuals with opioid dependence resulting largely or exclusively from prescription opioid use. Because this subpopulation may respond to treatment differently from heroin users, a method for discriminating DSM-IV opioid dependence due to prescription opioid use would provide more precision when examining this population. This paper describes an innovative method using a currently available diagnostic instrument, to diagnose DSM-IV opioid dependence and distinguish between dependence resulting from prescription opioids versus dependence upon heroin.

Ravera S; Hummel SA; Stolk P; Heerdink RE; de Jong-van den Berg LTW; de Gier JJ. The use of driving impairing medicines: A European survey. European Journal of Clinical Pharmacology 65(11): 1139-1147, 2009. (27 refs.)

To analyse the consumption of a number of medicines with a known potential for increasing the risk of road traffic accidents in the general population of Europe. Questionnaires were distributed through the European Drug Utilization Research Group (EuroDURG) and Post-Innovation Learning through Life-events of drugs (PILLS) networks. A total of 30 countries (the current EU Member States, Iceland, Norway and Switzerland) were asked to supply data on the use of driving impairing medicines for the period 2000-2005, aggregated at the level of the active substance and presented in Defined Daily Doses (DDDs) per 1000 inhabitants per day. National utilization data were provided by 12 of the 30 countries. Based on these data, a considerable increase in consumption was only seen for the antidepressants and the selective serotonin reuptake inhibitors. A slight increase, decrease or no increase was seen for the rest of the drugs studied (i.e. opioids, antipsychotics, anxiolytics, hypnotics and sedatives, drugs that are used in addictive disorders and antihistamines). Limitations were encountered when data on driving impairing medicines were compared between countries (e.g. variation in the data sources and providers, population coverage, inclusion of hospital data, use of divergent ATC/DDD versions) and, therefore, a cross-national comparison could not be performed. During the study period, trends within countries showed slight to no increase in the consumption of selected medicinal drug groups, with the exception of the antidepressants and the selective serotonin reuptake inhibitors: they showed a remarkable increased use during the study time-frame. Our results illustrate that it is still difficult to perform a valid and comprehensive collection of drug utilization data on driving impairing medicines. Therefore, efforts to harmonize data collection techniques are required and recommended.

Ruetsch C. Empirical view of opioid dependence. Journal of Managed Care Pharmacy 16(1, Supplement B): s9-s13, 2010. (28 refs.)

BACKGROUND: The impact of opioid dependence on employers, managed care, and society is significant. Inappropriate use of narcotic analgesics leads to uncontrolled pain management, dependence, and may lead to patient deaths, creating a tremendous cost burden to the health care system. OBJECTIVE: To provide an overview of the clinical and economic impact of treating opioid dependence on managed care, employers, and society. SUMMARY: An estimated 6% to 15% of people in the United States abuse drugs, and approximately 20% of Americans report using prescription opioids for nonmedical use. This is associated with an annual cost of nearly half a trillion dollars, taking into account the medical, economic, social, and criminal impact of this abuse. A recent study showed that patients who abuse opioids generate mean annual direct health care costs 8.7 times higher than nonabusers. The National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), found that patients who report opioid abuse miss more than 2.2 days of work monthly, compared with the 0.83 days per month reported for the average person. Presenteeism and productivity are also affected by misuse and dependence on opioids. CONCLUSION: The costs associated with opioid dependence are significant. Physicians, employers, and managed care organizations must be proactive in appropriately diagnosing and treating patients who suffer from substance abuse disorders in order to lessen this economic burden.

Schonfeld L; King-Kallimanis BL; Duchene DM; Etheridge RL; Herrera JR; Barry KL et al. Screening and brief intervention for substance misuse among older adults: The Florida BRITE Project. American Journal of Public Health 100(1): 108-114, 2010. (25 refs.)

Objectives. We developed and examined the effectiveness of the Florida Brief Intervention and Treatment for Elders (BRITE) project, a 3-year, state-funded pilot program of screening and brief intervention for older adult substance misusers. Methods. Agencies in 4 counties conducted screenings among 3497 older adults for alcohol, medications, and illicit substance misuse problems and for depression and suicide risk. Screening occurred in elders' homes, senior centers, or other selected sites. Individuals who screened positive for substance misuse were offered brief intervention with evidence-based practices and rescreened at discharge from the intervention program and at follow-up interviews. Results. Prescription medication misuse was the most prevalent substance use problem, followed by alcohol, over-the-counter medications, and illicit substances. Depression was prevalent among those with alcohol and prescription medication problems. Those who received the brief intervention had improvement in alcohol, medication misuse, and depression measures. Conclusions. The BRITE program effectively shaped state policy by responding to legislative mandates to address the needs of an increasing, but underserved, elder population. The pilot paved the way for obtaining a federally funded grant to expand BRITE to 27 sites in 17 counties in Florida.

Setlik J; Bond GR; Ho M. Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications. Pediatrics 124(3): 875-880, 2009. (37 refs.)

OBJECTIVE: We sought to better understand the trend for prescription attention-deficit/hyperactivity disorder (ADHD) medication abuse by teenagers. METHODS: We queried the American Association of Poison Control Center's National Poison Data System for the years of 1998-2005 for all cases involving people aged 13 to 19 years, for which the reason was intentional abuse or intentional misuse and the substance was a prescription medication used for ADHD treatment. For trend comparison, we sought data on the total number of exposures. In addition, we used teen and preteen ADHD medication sales data from IMS Health's National Disease and Therapeutic Index database to compare poison center call trends with likely availability. RESULTS: Calls related to teenaged victims of prescription ADHD medication abuse rose 76%, which is faster than calls for victims of substance abuse generally and teen substance abuse. The annual rate of total and teen exposures was unchanged. Over the 8 years, estimated prescriptions for teenagers and preteenagers increased 133% for amphetamine products, 52% for methylphenidate products, and 80% for both together. Reports of exposure to methylphenidate fell from 78% to 30%, whereas methylphenidate as a percentage of ADHD prescriptions decreased from 66% to 56%. Substance-related abuse calls per million adolescent prescriptions rose 140%. CONCLUSIONS: The sharp increase, out of proportion to other poison center calls, suggests a rising problem with teen ADHD stimulant medication abuse. Case severity increased over time. Sales data of ADHD medications suggest that the use and call-volume increase reflects availability, but the increase disproportionately involves amphetamines.

Spiller H; Bailey JE; Dart RC; Spiller SS. Investigation of temporal changes of abuse and misuse of prescription opioids. Journal of Addictive Diseases 29(1): 78-83, 2010. (7 refs.)

We analyzed intentional exposures to prescription opioids (buprenorphine, fentanyl, hydrocodone, hydromorphone, morphine, methadone and Oxycodone) using the Research Abuse, Diversion and Addiction-Related Survllience System (RADARS (R)) Poison Center data over a 5 year period 2003-2007 to see if there were temporal trends in the abuse and misuse of prescription drugs associated with (1) weekends vs. weekdays and (2) during select holiday periods vs. non-holiday periods. Over the study period 25 of 120 holiday period days showed a decrease of at least 1 SD from the mean and 9 of 120 holiday period days showed an increase of at least 1 SD from the mean. Over the study period there were 144,653 intentional exposures. Mean percent of cases by day of week ranged from 14.03% to 14.39%, with slightly higher use on weekend days. There was no significant difference when evaluating prevalence of intentional exposures by day of week (p = 0.99). There was no significant difference when evaluating weekend versus weekday (p > 0.05). In summary, the prevalence of abuse and misuse of prescription drugs was not impacted by day of the week or difference between weekday and weekend. The impact of 8 traditional holidays appeared to be associated with a minor decrease in abuse and misuse of prescription drugs. No temporally related increase in abuse and misuse of prescription drugs was noted and conversely a trend toward decreased abuse and misuse of prescription drugs was suggested.

Terry-McElrath YM; O'Malley PM; Johnston LD. Reasons for drug use among American youth by consumption level, gender, and race/ethnicity: 1976-2005. Journal of Drug Issues 39(3): 677-713, 2009. (45 refs.)

This study examined self-reported reasons for the use of nine substances among nationally representative samples of U.S. high school seniors participating in the Monitoring the Future study from 1976 through 2005. In general, social/recreational reasons were the most commonly reported reasons for the use of most drugs. However, for psychotherapeutic drugs, coping with negative affect and physical needs were reasons most commonly mentioned. Results indicated that the proportion of students reporting various reasons has shifted significantly over time. Further, we found significant differences by gender and race/ethnicity in reported reasons for use. Prevention and intervention efforts must address the facts that (1) while social usage reasons do predominate, it is essential to consider coping and drug-effect reasons for use as well; and (2) there are appreciable differences by gender and race/ethnicity in reasons for drug use.

Thompson J; Thompson JR. Acute myocardial infarction related to methylphenidate for adult attention deficit disorder. Journal of Emergency Medicine 38(1): 18-21, 2010. (17 refs.)

Adult Attention Deficit Disorder is increasingly diagnosed and treated. Psychostimulant medications, such as methylphenidate, are commonly prescribed for this condition, but the long-term safety of such medications in an adult population is unknown at present. Because these medications are closely related to amphetamines, it is expected that toxic side effects would be similar. We present the case of a 27-year-old man who suffered an acute myocardial infarction due to coronary vasospasm related to use of methylphenidate complicated by concomitant use of pseudoephedrine.

Toblin RL; Paulozzi LJ; Logan JE; Hall AJ; Kaplan JA. Mental illness and psychotropic drug use among prescription drug overdose deaths: A medical examiner chart review. Journal of Clinical Psychiatry 71(4): 491-496, 2010. (25 refs.)

Objective: Between 1999 and 2006, there was a 120% increase in the rate of unintentional drug overdose deaths in the United States. This study identifies the prevalence of mental illness, a risk factor for substance abuse, and chronic pain among prescription drug overdose deaths in West Virginia and ascertains whether psychotropic drugs contributing to the deaths were used to treat mental illness or for nonmedical purposes. Method: In 2007, we abstracted data on mental illness, pain, and drugs contributing to death from all unintentional prescription drug overdose deaths in 2006 recorded by the West Virginia Office of the Chief Medical Examiner. Decedent prescription records were obtained from the state prescription drug monitoring program. Results: Histories of mental illness and pain were documented in 42.7% and 56.6% of 295 decedents, respectively. Psychotropic drugs contributed to 48.8% of the deaths, with benzodiazepines involved in 36.6%. Benzodiazepines contributing to death were not associated with mental illness (adjusted odds ratio [AOR] =1.1; 95% CI, 0.6-1.8), while all other psychotropic drugs were (AOR = 3.9; 95% CI, 2.0-7.6). Of decedents with contributory benzodiazepines, 46.3% had no prescription for the drug. Conclusions: Mental illness may have contributed to substance abuse associated with deaths. Clinicians should screen for mental illness when prescribing opioids and recommend psychotherapy as an adjunct or an alternate to pharmacotherapy. Benzodiazepines may have been used nonmedically rather than as a psychotropic drug, reflecting drug diversion. Restricting benzodiazepine prescriptions to a 30-day supply with no refills might be considered.

Veilleux JC; Colvin PJ; Anderson J; York C; Heinz AJ. A review of opioid dependence treatment: Pharmacological and psychosocial interventions to treat opioid addiction. (review). Clinical Psychology Review 30(2): 155-166, 2010. (119 refs.)

Opioid dependence is a problem of national concern, especially with dramatically increased rates of abuse and dependence of prescription opioids. The current article provides an up-to-date review of the literature on opioid dependence treatment, with a focus on conclusions drawn by experts in the field (e.g., Cochrane reviews and meta-analyses) and methodologically rigorous studies (e.g., randomized controlled trials). We describe the major classes of drug treatments available, including opioid agonist (e.g., methadone, buprenorphine, LAAM), antagonist (e.g., naltrexone) and non-opioid pharmacotherapies (e.g., alpha2 adrenergic agonists). These treatments are discussed in the context of detoxification and long term treatment options such as abstinence-based and maintenance strategies. We review the state of the literature as to prevention of opioid overdose and discuss the widespread problem of comorbidity among opioid-dependent populations. We also focus prominently on evidence for inclusion of psychosocial approaches in treatment regimens, either as stand-alone or in conjunction with psychopharmacological options.

Vergne DE; Anton RF. Aripiprazole: A drug with a novel mechanism of action and possible efficacy for alcohol dependence. CNS & Neurological Disorders. Drug Targets 9(1): 50-54, 2010. (40 refs.)

Alcohol dependence is a costly and socially devastating illness. The dopamine system has received increased attention due to the consensus that dopaminergic dysfunction is at the core of the addiction process. Agents that modulate this system might be beneficial in reducing craving, reward, and relapse. Aripiprazole is a 3(rd) generation atypical antipsychotic U.S. Food and Drug Administration-approved for the treatment of schizophrenia, bipolar disorder, and treatment-resistant major depression. Its principal mechanism of action appears to be associated with partial agonism at the D-2 dopamine receptor. Nevertheless, relatively recent pre-clinical data shows that aripiprazole might exert its action by way of agonism, partial agonism, and antagonism at both dopamine and serotonin receptors. In animal models of alcoholism aripiprazole produced an overall decrease in drinking behavior. Clinical trials with aripiprazole in alcoholics have shown some positive, but inconsistent, results. Given aripiprazole's putative activity on frontal-subcortical circuits subserving reward/craving and impulsive behavior, it might prove to be beneficial for neuropsychiatric conditions in which dysregulation of reward and impulsivity, among them alcoholism, are at the core of the syndrome. This article proposes a potential role for aripiprazole in alcoholism treatment, and suggests that more randomized controlled trials should be designed at appropriate doses to better understand aripiprazole's potential role as a treatment option. More options are needed to treat alcoholics that fall into different subgroups (e.g., those with impulsive disorders), or non-responsive to available treatments. Early results with aripiprazole are promising and warrant further exploration.

Vuong C; Van Uum SHM; O'Dell LE; Lutfy K; Friedman TC. The effects of opioids and opioid analogs on animal and human endocrine systems. (review). Endocrine Reviews 31(1): 98-132, 2010. (411 refs.)

Opioid abuse has increased in the last decade, primarily as a result of increased access to prescription opioids. Physicians are also increasingly administering opioid analgesics for noncancer chronic pain. Thus, knowledge of the long-term consequences of opioid use/abuse has important implications for fully evaluating the clinical usefulness of opioid medications. Many studies have examined the effect of opioids on the endocrine system; however, a systematic review of the endocrine actions of opioids in both humans and animals has, to our knowledge, not been published since 1984. Thus, we reviewed the literature on the effect of opioids on the endocrine system. We included both acute and chronic effects of opioids, with the majority of the studies done on the acute effects although chronic effects are more physiologically relevant. In humans and laboratory animals, opioids generally increase GH and prolactin and decrease LH, testosterone, estradiol, and oxytocin. In humans, opioids increase TSH, whereas in rodents, TSH is decreased. In both rodents and humans, the reports of effects of opioids on arginine vasopressin and ACTH are conflicting. Opioids act preferentially at different receptor sites leading to stimulatory or inhibitory effects on hormone release. Increasing opioid abuse primarily leads to hypogonadism but may also affect the secretion of other pituitary hormones. The potential consequences of hypogonadism include decreased libido and erectile dysfunction in men, oligomenorrhea or amenorrhea in women, and bone loss or infertility in both sexes. Opioids may increase or decrease food intake, depending on the type of opioid and the duration of action. Additionally, opioids may act through the sympathetic nervous system to cause hyperglycemia and impaired insulin secretion. In this review, recent information regarding endocrine disorders among opioid abusers is presented.

Walley AY; Farrar D; Cheng DM; Alford DP; Samet JH. Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue. Journal of General Internal Medicine 24(9): 1007-1011, 2009. (24 refs.)

BACKGROUND: Opioid-dependent patients often have co-occurring chronic illnesses requiring medications that interact with methadone. Methadone maintenance treatment (MMT) is typically provided separately from medical care. Hence, coordination of medical care and substance use treatment is important to preserve patient safety. OBJECTIVE: To identify potential safety risks among MMT patients engaged in medical care by evaluating the frequency that opioid dependence and MMT documentation are missing in medical records and characterizing potential medication-methadone interactions. METHODS: Among patients from a methadone clinic who received primary care from an affiliated, but separate, medical center, we reviewed electronic medical records for documentation of methadone, opioid dependence, and potential drug-methadone interactions. The proportions of medical records without opioid dependence and methadone documentation were estimated and potential medication-methadone interactions were identified. RESULTS: Among the study subjects (n=84), opioid dependence documentation was missing from the medical record in 30% (95% CI, 20%-41%) and MMT documentation was missing from either the last primary care note or the last hospital discharge summary in 11% (95% CI, 5%-19%). Sixty-nine percent of the study subjects had at least 1 medication that potentially interacted with methadone; 19% had 3 or more potentially interacting medications. CONCLUSION: Among patients receiving MMT and medical care at different sites, documentation of opioid dependence and MMT in the medical record occurs for the majority, but is missing in a substantial number of patients. Most of these patients are prescribed medications that potentially interact with methadone. This study highlights opportunities for improved coordination between medical care and MMT.

Wang YG; Swick TJ; Carter LP; Thorpy MJ; Benowitz NL. Safety overview of postmarketing and clinical experience of sodium oxybate (Xyrem): Abuse, misuse, dependence, and diversion. Journal of Clinical Sleep Medicine 5(4): 365-371, 2009. (40 refs.)

Study Objectives: This study reviewed the cumulative postmarketing and clinical safety experience with sodium oxybate (Xyrem (R)), a treatment approved for cataplexy and excessive daytime sleepiness in narcolepsy. Study objectives were to investigate the occurrence of abuse/misuse of sodium oxybate since first market introduction in 2002, classify cases using DSIM-IV criteria for substance abuse and dependence, and describe specific characteristics of these cases. Methods: We retrospectively reviewed postmarketing spontaneous adverse event (AE) reports from 15 countries for all cases containing reporting terminology related to abuse/misuse to determine its occurrence. All death cases independent of causality were reviewed to identify associated risk factors. Results: Approximately 26,000 patients worldwide received sodium oxybate from first market introduction in 2002 through March 2008. of those 26,000 patients, 0.2% reported >= 1 of the events studied. These included 10 cases (0.039%) meeting DSM-IV abuse criteria, 4 cases (0.016%) meeting DSIM-IV dependence criteria, 8 cases (0.031%, including 3 of the previous 4) with withdrawal symptoms reported after discontinuation of sodium oxybate, 2 confirmed cases (0.008%) of sodium oxybate-facilitated sexual assault, 8 cases (0.031%) of overdose with suicidal intent, 21 deaths (0.08%) in patients receiving sodium oxybate treatment with 1 death known to be related to sodium oxybate, and 3 cases (0.01%) of traffic accidents involving drivers taking sodium oxybate. During this period, approximately 600,000 bottles of sodium oxybate were distributed, and 5 incidents (0.0009%) of diversion were reported. Conclusion: Cumulative postmarketing and clinical experience indicates a very low risk of abuse/misuse of sodium oxybate.

Ware MA; St Arnaud-Trempe E. The abuse potential of the synthetic cannabinoid, nabilone. Addiction 105(3): 494-503, 2010. (49 refs.)

Aim: Nabilone is a synthetic cannabinoid prescription drug approved in Canada since 1981 to treat chemotherapy-induced nausea and vomiting. In recent years, off-label use of nabilone for chronic pain management has increased, and physicians have begun to express concerns about nabilone becoming a drug of abuse. This study evaluates the evidence for abuse of nabilone, which is currently ill-defined. Study design Scientific literature, popular press and internet databases were searched extensively for evidence of nabilone abuse. Focused interviews with medical professionals and law enforcement agencies across Canada were also conducted. Findings: The scientific literature and popular press reviews found very little reference to nabilone abuse. Nabilone is perceived to produce more undesirable side effects, to have a longer onset of action and to be more expensive than smoked cannabis. The internet review revealed rare and isolated instances of recreational use of nabilone. The database review yielded little evidence of nabilone abuse, although nabilone seizures and thefts have occurred in Canada in the past few years, especially in Ontario. Most law enforcement officers reported no instances of nabilone abuse or diversion, and the drug has no known street value. Medical professionals reported that nabilone is not perceived to be a matter of concern with respect to its abuse potential. Conclusions: Reports of nabilone abuse are extremely rare. However, follow-up of patients using nabilone for therapeutic purposes is prudent and should include assessment of tolerance and dependence. Prospective studies are also needed to definitively address the issue of nabilone abuse.

Webb JR; Thomas JW; Valasek MA. Contemplaing cognitive enhancement in medical students and residents. Perspectives in Biology and Medicine 2(200-214), 2010. (76 refs.)

Medical school and residency can be stressful times, involving years of intensive academic study and pressure to earn high grades. Students and residents must learn to care for the sick, a task requiring long work hours and sleep deprivation. In such an environment, it is important to monitor the mental health of trainees and the factors that influence it. This essay examines a relatively unexplored facet of physician mental health: the use of pharmacological stimulants by students and residents to study better, earn higher grades, stay awake longer, and take better care of patients. Practical and ethical considerations of stimulant use in the medical profession, along with future directions for medical student mental health, are discussed.

Weisner CM; Campbell CI; Ray GT; Saunders K; Merrill JO; Banta-Green C et al. Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders. Pain 145(3): 287-293, 2009. (43 refs.)

Long-term opioid therapy for non-cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long-term opioid use in persons with non-cancer pain and a substance abuse history. Using health plan data (1997-2005), the study compared age-sex-standardized rates of incident, incident long-term and prevalent long-term prescription opioid use, and medication use profiles in those with and without Substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999-2005), prevalence of long-term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997-2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and CH rates increased from 15.7% to 52.4%. Long-term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long-acting opioids, and were more often frequent users of sedative-hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long-term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice.

Weiss RD; Potter JS; Copersino ML; Prather K; Jacobs P; Provost S et al. Conducting clinical research with prescription opioid dependence: Defining the population. American Journal on Addictions 19(2): 141-146, 2010. (19 refs.)

Most treatment studies of opioid-dependent populations have focused predominantly on heroin users, despite a recent increase in those dependent upon prescription opioids. A key methodological challenge involved in studying the latter group involves defining the population. Specifically, researchers must decide whether to include (1) concurrent heroin users and (2) individuals with pain. The multi-site Prescription Opioid Addiction Treatment Study is examining treatments for this population. This paper describes various inclusion criteria considered by the study team related to heroin use and pain. The goal was to recruit a distinct but generalizable population of individuals dependent upon prescription opioids.

Weiss RD; Potter JS; Provost SE; Huang Z; Jacobs P; Hasson A et al. A multi-site, two-phase, Prescription Opioid Addiction Treatment Study (POATS): Rationale, design, and methodology. Contemporary Clinical Trials 31(2): 189-199, 2010. (37 refs.)

The National Institute on Drug Abuse Clinical Trials Network launched the Prescription Opioid Addiction Treatment Study (POATS) in response to rising rates of prescription opioid dependence and gaps in understanding the optimal course of treatment for this population. POATS employed a multi-site, two-phase adaptive, sequential treatment design to approximate clinical practice. The study took place at 10 community treatment programs around the United States. Participants: included men and women age >= 18 who met Diagnostic and Statistical Manual, 4th Edition criteria for dependence upon prescription opioids, with physiologic features; those with a prominent history of heroin use (according to pre-specified criteria) were excluded. All participants received buprenorphine/naloxone (bup/nx). Phase 1 consisted of 4 weeks of bup/nx treatment, including a 14-day dose taper, with 8 weeks of follow-up. Phase 1 participants were monitored for treatment response during these 12 weeks. Those who relapsed to opioid use, as defined by pre-specified criteria, were invited to enter Phase 2; Phase 2 consisted of 12 weeks of bup/nx stabilization treatment, followed by a 4-week taper and 8 weeks of post-treatment follow-up. Participants were randomized at the beginning of Phase 1 to receive bup/nx, paired with either Standard Medical Management (SMM) or Enhanced Medical Management (EMM; defined as SMM plus individual drug counseling). Eligible participants entering Phase 2 were re-randomized to either EMM or SMM. POATS was developed to determine what benefit, if any, EMM offers over SMM in short-term and longer-term treatment paradigm. This paper describes the rationale and design of the study.