What`s New in Pharmacology? - American Judges Association

Report
The Driving Force Behind Crime:
Alcohol and Other Drugs
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To understand the connection between
substance abuse and crime
To discuss the benefits of providing
substance abuse treatment to individuals in
the criminal justice system
To list existing and upcoming medications
that allow (or will allow) addicted individuals
to achieve and maintain sustained recovery
1.
2.
3.
Sativex
Vivitrol
Probuphine
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Median of $2.9 billion in 2006, ranging from
$420 million in North Dakota to $32 billion in
California
Binge drinking = 70% of the cost
Includes criminal justice expenses and motor
vehicle crash costs
State Costs of Excessive Alcohol Consumption, CDC (Aug. 13, 2013)
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36.8% Violent
29.1% Property
21.4% Drug
41.2% Public order
41.0% Other
BJS “Alcohol and Crime: 2002-2008”
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DWI 1,112,384 arrests
Domestic violence (93% in one study)
Child maltreatment
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Well-known and well-documented connection
between criminal activity and substance abuse
Three types of offenses
 drug possession or sales
 related to drug abuse (e.g., stealing to get money for
drugs)
 related to a lifestyle that predisposes the drug abuser
to engage in illegal activity
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Many offenses, including violent crime, are
committed by people who have substance abuse
disorders
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Drug law violations are the most common
type of criminal offense (Glaze and Bonczar 2009) ,
1,305,191 arrests (FBI’s Uniform Crime Reporting (UCR) Program 2009)
Only a small percentage of offenders has
access to adequate services, especially in jails
and community correctional facilities (Taxman et al.
2007; Sabol et al. 2010)
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Offenders who are left untreated for
substance abuse disorders often relapse and
return to criminal activity
Re-arrest and re-incarceration 66% of the
time
Treatment offers the best alternative for
interrupting the drug abuse/criminal justice
cycle.
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Cross-agency coordination and collaboration of
criminal justice professionals, substance abuse
treatment providers, and other social service
agencies
Examples:
 treatment in prison followed by community-based
treatment after release
 drug courts that blend judicial monitoring and
sanctions with treatment by imposing treatment as a
condition of probation
 treatment under parole or probation supervision
60
50
40
30
Marijuana
Cocaine
20
Opiates
10
Meth
0
Meth
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Number of people who were past-year heroin
users in 2011 (620,000) vs. 2007 (373,000)
2011 National Survey on Drug Use and Health
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More than half of the 36,450 overdose deaths
in the United States in 2008 involved a
prescription drug
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July 16, 2012 The New York Times
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Heroin is often cheaper than marijuana,
selling for as little as $5 a hit
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Overdoses have increased almost six-fold in
the last 30 years.
Leading cause of accidental death in the
United States overting motor vehicle crashes
for the first time
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The New York Times, Jan. 1, 2012
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It is estimated 6.2 million Americans– that is
2.5% of the US population- is abusing
prescription drugs
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NBCLatino Aug. 12, 2013
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More than half of the 36,450 overdose deaths
in the United States in 2008 involved a
prescription drug.
The New York Times , July 16, 2012
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Treatment admissions for abuse of
prescription pain relievers have risen 430
percent from 1999-2009
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SAMHSA, 2011
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2.2 million people with opioid dependence in
the U.S.
Approximately 20 percent of this population
is addicted to illicit opioids, such as heroin
The other 80 percent to prescription opioids,
such as oxycodone, hydrocodone,
methadone, hydromorphone and codeine
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1.
2.
3.
Currently, approximately 1 million people in
the United States are addicted to heroin1
More than 3 million people over the age of 12
have used heroin at least once2
An estimated 1.4 million people are
dependent on or abusing other opiate drugs,
including prescription painkillers3
Office of National Drug Control Policy, 2000
National Survey on Drug Use and Health (NSDUH), 2004
NSDUH (Ibid).
FAX
CESAR
August 6, 2012
Vol. 21, Issue 31
A Weekly FAX from the Center for Substance Abuse Research
University
of
Maryland,
College
Park
Estimated Number of Buprenorphine- and Hydromorphone-Related
ED Visits More Than Doubles from 2006 to 2010
The estimated number of emergency department (ED) visits related to the nonmedical use of opioid pain killers increased 79% from 201,280
in 2006 to 359,921 in 2010, according to the most recent data from the Drug Abuse Warning Network (DAWN). The greatest increases were
seen in buprenorphine- and hydromorphone-related ED visits. In 2006, the nonmedical use of buprenorphine was involved as either a direct
cause or a contributing factor in an estimated 4,440 ED visits, compared to 15,778 in 2010—an increase of 255%. The estimated number of
visits related to the nonmedical use of hydromorphone increased 161% over the same 5-year period (see figure below). While the number of
ED visits for the nonmedical use of buprenorphine and hydromorphone is relatively small compared to other opioid pain relievers, the
magnitude of the increase suggests that there may be emerging problems with the nonmedical use of these drugs that warrant the
monitoring of their use and related consequences.
Estimated Number of U.S. Emergency Department Visits Related to the
Nonmedical Use of Opioid Pain Relievers, 2006 to 2010
Number of ED Visits for Nonmedical Use
Drug Name (Common Brand Names)
2006
4,440
6,780
64,891
57,550
45,130
20,416
6,220
16,012
6,928
1,440
201,280
Buprenorphine (Suboxone, Subutex, Temgesic, Buprenex)
Hydromorphone (Palladone, Dilaudid)
Oxycodone (Oxycontin, Percodan, Percocet)
Hydrocodone (Vicodin, Lorcet, Lortab)
Methadone (Methadose)
Morphine (MS Contin, Morphine IR)
Propoxyphene (Darvon)
Fentanyl (Actiq, Duragesic)
Codeine (Tylenol with Codeine)
Meperidine (Demerol)
Total Opioid Pain Relievers
2010
15,778
17,666
146,355
95,972
65,945
29,605
8,832
21,196
7,928
1,151
359,921
Percent Change
2006 to 2010
+255%
+161%
+126%
+67%
+46%
+45%
+42%
+32%
+14%
-20%
+79%
NOTES: Nonmedical use includes taking more than the prescribed dose; taking a drug prescribed for another individual; deliberate poisoning by another person; and
documented misuse or abuse. Five categories of opioid pain relievers (dihydrocodeine, opium, pentazocine, phenacetin, and all other narcotic analgesics) were
not included in the above table because the estimate for either 2006 and/or 2010 did not meet standards of precision (relative standard error greater than 50%
or an unweighted count or estimate less than 30).
SOURCE: Adapted by CESAR from Substance Abuse and Mental Health Services Administration (SAMHSA), National Estimates of Drug-Related Emergency Department Visits,
2004-2010 - Nonmedical Use of Pharmaceuticals, 2012. Available online at
http://www.samhsa.gov/data/DAWN.aspx#DAWN%202010%20ED%20Excel%20Files%20-%20National%20Tables.
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The New Your Times, July 2, 2013
Drug addiction is a complex illness—characterized by
intense and, at times, uncontrollable drug craving,
along with compulsive drug seeking and use that
persist even in the face of devastating consequences.
 Addiction produces far-reaching health and social
consequences:
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 increases a person’s risk for a variety of other mental and
physical illnesses
 interferes with a person’s normal functioning in the family,
the workplace, and the broader community
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Effective treatment programs typically incorporate
many components, including pharmacotherapies.
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Medications can be an important component
of effective drug abuse treatment for
offenders.
By allowing the brain to function more
normally, they enable the addicted person to
leave behind a life of crime and drug abuse.
Addiction medications are underused in the
treatment of drug abusers within the criminal
justice system, despite evidence of their
effectiveness.
Heroin, morphine, and some prescription
painkillers (e.g., OxyContin, Vicodin, and
Fentanyl) are all opiates.
 They act on specific (opiate) receptors in the
brain
 Interact with naturally produced substances
known as endorphins or enkephalins– important
in regulating pain and emotion
 Opiates as a general class of drugs have
significant abuse liability.
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Methadone maintenance therapy:
 In the 1960's, methadone gained recognition as an
effective treatment for heroin addiction.
 Administered daily, methadone treatment is
currently regulated so that only specialized clinics
can provide it.
 Patients’ illicit opioid use declines, often
dramatically, during methadone maintenance
treatment1.
1. Condelli WS, Dunteman GH. Exposure to methadone programs and heroin use. American
Journal of Drug and Alcohol Abuse 1993;19:65-78.
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Buprenorphine
 Long-acting partial agonist that acts on the same
receptors as heroin and morphine
 Relieves drug cravings without producing the same
intense “high” or dangerous side effects.
 Abuse-deterrent formulation with naloxone
▪ Naloxone has no effect when Suboxone is taken as prescribed, but if
an addicted individual attempts to inject Suboxone, the naloxone
will produce severe withdrawal symptoms
 Currently available in two formulations that are taken
sublingually:
▪ a pure form of the drug
▪ a more commonly prescribed formulation called Suboxone (a
combination with naloxone)

NIDA-supported basic
and clinical research
showed that, alone or
in combination with
naloxone,
buprenorphine
significantly reduced
opiate drug abuse and
cravings and was a safe
and acceptable
addiction treatment.
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Simply substituting one addictive drug for another?
Taking these medications as prescribed allows
patients to
 hold jobs,
 avoid street crime and violence,
 and reduce their exposure to HIV by stopping or
decreasing injection drug use and drug-related high-risk
sexual behavior.
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Patients stabilized on these medications can also
engage more readily in counseling and other
behavioral interventions essential to recovery.
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Condemns denying patients long-term
maintenance treatment with methadone or
buprenorphine
“A particular form of ill-treatment and
possibly torture of drug users is the denial of
opiate substitution treatment”
Considered a human rights violation when it
occurs in jails and prisons
UN General Assembly Feb. 1, 2013
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Naltrexone
 an opioid receptor blocker, or antagonist—it blocks
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opioids from binding to their receptors and thereby
prevents their euphoric and other effects.
Highly effective in reversing the effects of opiate
overdose
No potential for abuse, and it is not addictive
Noncompliance is a common problem
Best suited for highly motivated, recently detoxified
patients who desire total abstinence because of
external circumstances
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Revia
Daily pill
Problem is medication compliance
Subject to diversion
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Vivitrol
 long-acting injectable version of naltrexone,
called Vivitrol, was approved to treat opioid
addiction.
 Because it only needs to be delivered once a
month, this version of the drug can facilitate
compliance
Offers an alternative for those who do not wish to
be placed on agonist/partial agonist medications
 Side effects such as injection site reactions
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Intoxication can impair brain function and motor
skills.
 Heavy use can increase risk of certain cancers,
stroke, and liver disease.
 Alcoholism or alcohol dependence is a
diagnosable disease characterized by
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 a strong craving for alcohol,
 and/or continued use despite harm or personal injury.
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Alcohol abuse, which can lead to alcoholism, is a
pattern of drinking that results in harm to one's
health, interpersonal relationships, or ability to
work.
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Acamprosate (Campral®)
 acts on the gamma-aminobutyric acid (GABA) and
glutamate neurotransmitter systems
 Reduces symptoms of protracted withdrawal,
such as insomnia, anxiety, restlessness, and
dysphoria.
 Has been shown to help dependent drinkers
maintain abstinence for several weeks to months,
 May be more effective in patients with severe
dependence.
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Disulfiram (Antabuse®)
 Interferes with degradation of alcohol,
 Causes accumulation of acetaldehyde, which, in turn,
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produces a very unpleasant reaction that includes flushing,
nausea, and palpitations if a person drinks alcohol.
Utility and effectiveness are limited because compliance is
generally poor.
Can be effective among patients who are highly motivated
Some patients use it episodically for high-risk situations
It can also be administered in a monitored fashion, such as
in a clinic or by a spouse, improving its efficacy.
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Naltrexone
 blocks opioid receptors that are involved in the
rewarding effects of drinking and the craving for
alcohol.
 It has been shown to reduce relapse to problem
drinking in some patients.
 Vivitrol also FDA-approved for treating
alcoholism, and may offer benefits regarding
compliance.
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Topiramate
 Is thought to work by increasing inhibitory (GABA)
neurotransmission and reducing stimulatory
(glutamate) neurotransmission
 Precise mechanism of action is not known.
 Although it has not yet received FDA approval for
treating alcohol addiction, it is sometimes used offlabel for this purpose.
 Topiramate has been shown in studies to significantly
improve multiple drinking outcomes, compared with
a placebo.
Roadside devices, CBT, brain imaging
Genomics and
epigenetics
 High resolution
mapping of targeted
brain areas
 Anti-addiction
vaccines
 Medication
combinations
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Anti-drug vaccines seek
to induce antibodies
that bind their target
drugs and drug
metabolites
Results in drug-antibody
complexes that are too
large to cross the bloodbrain barrier
In effect, keep drug from
reaching brain
The vaccine makes oxycodone visible to the immune system
by linking it to the highly immunogenic protein keyhole
limpet hemocyanin (KLH). Antibodies formed in response to
the vaccine “see” and bind to oxycodone as if it were part of
the KLH molecule.
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Developed at the Scripps Research Institute
Creates antibodies against heroin and its
psychoactive metabolites
Causes effective and continuous
sequestration of brain-permeable
constituents of heroin in the bloodstream
following vaccination.
Efficient obstruction of heroin activity in
treated rats
Still in preclinical trials
Joel E. Schlosburg, Leandro F. Vendruscolo, Paul T. Bremer, Jonathan W. Lockner, Carrie L. Wade, Ashlee A. K. Nunes, G. Neil Stowe,
Scott Edwards, Kim D. Janda, and George F. Koob . Dynamic vaccine blocks relapse to compulsive intake of heroin
PNAS 2013 : 1219159110v1-201219159. From: http://www.pnas.org/content/early/2013/05/02/1219159110.abstract
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Developed by researchers at Weill Cornell
Medical College
Researchers tested the anti-cocaine vaccine in
primates
Vaccine prevented cocaine from reaching the
brain and producing “high”
Vaccine is designed to induce anti-cocaine
antibodies that isolate cocaine, preventing
access to the central nervous system
Still in preclinical trials
Developed by researchers at the University of
Minnesota
 Vaccine as a potential aid in the treatment of
oxycodone and hydrocodone abuse and dependence
 Vaccine aims to lower motivation to take prescription
opioids by blocking rewarding and reinforcing effects
 Vaccinating rats before injecting them with
oxycodone or hydrocodone reduced the amount of
drug reaching the brain by an average of 86 percent
after a 0.1 mg/kg dose, and 54 percent after a 0.5
mg/kg dose.
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Ibudilast reduces
craving and improves
cognitive functioning
 Small study at UCLA
 FDA approval in future
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Huffington Post, April 3, 2013
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AV411 (also called ibudilast) reduced
methamphetamine seeking in animal models
of stress- and drug-induced relapse
AV411 affects the brain's glial cells rather
than neurons, may avoid side effects caused
by other anti-addiction medications
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Possible use in treating cocaine abuse and
unhealthy eating
Fosters transition from casual use to
dependence: orexin neurotransmission
mediates dopamine release after cocaine use
Rats that had been treated with orexin
antagonist SB334867 did not work as hard to
get cocaine as rats that had not been injected
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Marijuana-dependent
outpatients who were
treated with gabapentin
in a pilot clinical trial
reported fewer
symptoms of drug
withdrawal than patients
who received a placebo.
Gabapentin might
reduce withdrawal
symptoms that
discourage quitting and
drive relapse.
Gabapentin Facilitates Abstinence. Patients who
received gabapentin used less marijuana during
treatment than did a comparison group that received
placebo, according to both self-report and urinalysis.
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Patch Developed for THC
Transmucosal patch increases drug's
absorption
Delivery method for medical purposes
Sativex – sublingual delivery
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University of Mississippi, Dec. 15, 2012
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“Heavy” drinkers (>26 drinks/week)
Kudzu extract for 7 days
Significant reduction in number of beers
consumed
Lukas, SE, et al., “An extract of the Chinese herbal root kudzu reduces alcohol drinking by heavy drinkers in a naturalistic
setting,” Alcoholism: Clinical & Experimental Research 29:756-762, 2005
Counteract the effects
of alcohol
 Chinese raisin tree
used as hangover cure
for centuries
 Interacts with GABA
receptors where
alcohol binds
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Journal of Neuroscience, 2012
First to detect
alprazolam (the active
ingredient in Xanax
and other anti-anxiety
drugs) and
 benzoylecgonine (a
cocaine byproduct) in
exhaled breath
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Journal of Breath Research (April 25, 2013)
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“Molecular Roots of Cocaine Addiction in
Brain Uncovered: Promising New AntiAddiction Drug Revealed”
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“Scientists Identify Compound That May
Block Cocaine Craving in Animal Study”
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Johns Hopkins, May 22, 2013
Treatment is an effective intervention for drug
abusers, including those who are involved with
the criminal justice system.
 One of the goals of treatment planning is to
match evidence-based interventions to
individual needs at each stage of drug
treatment.
 Pharmacotherapy, one viable treatment option,
can help normalize brain function and facilitate
abstinence.
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