1 MEDTOX Journal Public Safety Substance Abuse Newsletter August 2010 In This Issue Trends in Adolescent Drug Abuse: "Starter Heroin and the Smell of Cheese Non-medical Use of Opiates and Benzodiazepines Continue to Climb Junior High and High School Campus-Based Drug Testing Programs From the Hotline: Phenibut Update Thank you for reading the MEDTOX Journal. We hope that you find it interesting and informative. Please join our mailing list to receive the MEDTOX Journal monthly, at no charge. If you have questions or suggestions on articles you would like to see featured, please contact us at For a PDF Version of the newsletter click here: PDF Version of Newsletter. Buprenorphine and HIV Treatment
2 Name That Drug Trends in Adolescent Drug Abuse: "Starter Heroin" and the Smell of Cheese Non-medical Use of Opiates and Benzodiazepines Continue to Climb Prescription opiates (hydrocodone, oxycodone, codeine) and benzodiazepines (diazepam, alprazolam and lorazepam) have become some of the most popularly abused prescription drugs in America. A spate of celebrity overdoses and deaths has spotlighted this problem. Non-medical utilization of these drugs and the subsequent overdoses exceeds the carnage of fatal automobile accidents in some states, especially in adult populations ages Prescription opiate abuse is dominated by Calls to the DAR Hotline have increased in recent weeks in response to unusual changes in adolescent drug abuse. In particular, callers from Texas and Arizona have inquired about a drug called "cheese" or "mickey juice." This drug is a substance that we first reported on two years ago when it was alleged to be the cause of scores of overdoses and deaths in the Dallas- Ft. Worth area. Scroll forward to the present and we find that this form of "starter heroin" continues to plague communities in the southwest. It appears that Texas still bears the brunt of "cheese." Reports of its use in hydrocodone and oxycodone; the most common forms of these drugs are Vicodin and Oxycontin. Diazepam (valium) is a member of a separate classification of drugs called benzodiazepines. Included in this family of substances are Ativan (lorazepam) and Xanax (alprazolam). The benzodiazepines are frontline medications used to induce sleep and reduce anxiety. Frequently both classes of prescription drugs are combined to form "loads." The composition of "loads" varies from city to city and region to region. More often than not, alcohol is mixed with these prescription drugs. When this occurs, a pharmacological synergy ensues resulting in exaggeration of sedative symptoms and physiological loss of control. A trip to the emergency room often follows. The Drug Abuse Warning Network (DAWN) researchers evaluated a sampling of emergency room records from 231 hospitals. From 2004 to 2008, emergency room visits for nonmedical use of opiates increased from 140,000 to 300,000, a 111% increase over that period. The reason most cited for the emergency room visits was concern for patient overintoxication and/or overdose from use of oxycodone, hydrocodone, and/or methadone prescription drugs. The benzodiazepines experienced an 89% caused increase in ER visits as well over the same period of time. ER visitation rates peaked among people ages 21 to 24; nearly one quarter of those who visited the hospital were ultimately admitted. Not
3 other states have been sporadic. The impact of this problem is borne by young, oftentimes inexperienced drug using teenagers. The drug is priced squarely for use by young drug users; its purity is relatively low and led to the drug's designation as "starter heroin." "Cheese" is a compound made up of black tar heroin and Tylenol PM. Black tar is a potent, less refined form of heroin. It's typically found as a sticky and very black goo. The drug can be smoked or it can be injected intravenously. "Cheese" purveyors mix water, crushed Tylenol PM, and black tar heroin together. The mixture is then heated mildly to evaporate off the water and to create a crispy powdery appearance. The final dried product has the appearance of parmesan cheese, hence its name. The drug is packaged in ¼ to ½ gram bindles in wax or notebook paper. A bindle of "cheese" can cost anywhere from $5 to $10. Purity of "cheese" can range from 5%- 20%, substantially less than that of tar heroin alone. The drug is typically snorted, but there have been seizures of "cheese" crammed into gelatin capsules. captured in this data is the role that adjunct non-medical drug use plays in ER visits. Carisoprodol (Soma) and Zolpidem (Ambien) are popularly abused drugs that possess powerful sedative features. Soma in particular is a widely abused drug, one whose popularity goes well beyond its putative value as a muscle relaxant. This barbiturate-like drug is mixed with prescription opiates (Vicodin or Percocet) to create one of the most popular "loads" for America drug abusers. This dangerous and addictive phenomenon is poorly appreciated and infrequently monitored by judicial and medical professionals. Non-medical use of prescription drugs continues to climb. In 2008, the number of ER visits involving non-medical use of prescription drugs equaled the number of visits for illicit drugs (methamphetamine, cocaine, ecstasy, and GHB). Physicians assigned to emergency rooms, occupational medicine centers and other clinical settings should be sensitive to this development. Family physicians should also be vigilant for signs of non-medical prescription drug use in their practices. Urine drug testing is an effective means of monitoring this problem. In a recent publication of the American Family Physician , family doctors were encouraged to undertake regular, broad-spectrum urine drug screening for the purpose of detecting of both licit and illicit drugs. In the journal, urinalysis was touted as a valuable office procedure for physicians and other healthcare providers.  Standridge JB, Adams SM, Zotos AP. Am Fam Physician Mar 1;81 (5): Junior High and High School Campus-Based Drug Testing Programs Fire Up for the Fall Semester Almost half of all people in grade 12 have used illicit drugs at one point or another. Many parents and school administrators are concerned with the effect that drugs and alcohol are having on students in terms of academic performance, dropout rates and disruptive behavior. One
4 As is the case with use of any opiate, chronic or frequent use of this drug will provoke addiction and dependency. Even though the purity of "cheese" is significantly less than other forms of heroin, it can quickly and easily overcome an adolescent user. The depressant effects of heroin in "cheese" are exacerbated by the additive effects of diphenhydramine; the antihistamine constituent of Tylenol PM. Diphenhydramine is the principle ingredient of Benadryl, a medication that is widely utilized as a sleep aid. When combined with the heroin in "cheese," users experience a profound sense of relaxation and calm. Non-tolerant users of "cheese" will display classic symptoms of opiate abuse: lethargy, somnolence, droopy eyelids, constricted pupils, dry mouth and slow speech. Because of the depressant effects of diphenydramine, "cheese" users will also display evidence of nystagmus and nonconvergence. Concentrated doses of diphenhydramine can cause frank hallucinations and a catatonic like affect. The more direct effects of this form of heroin will last for 3-6 hours. Signs of withdrawal from increasingly popular solution to these problems is voluntary school-based drug testing. What exactly is voluntary schoolbased drug testing? In collaboration with a number of large and small school districts, MEDTOX has created a highly affordable drug-testing program that has excited parents, school officials, and yes, the students themselves. This system is an all-encompassing program that is comprised of three interlocking sections: parent and student education, randomly sampled drug testing, and professional counseling and rehabilitation (if required). The program provides participating schools with educational seminars that are taught by some of America's most respected substance abuse experts. These free and frequent seminars empower parents and students by providing them with real life, no nonsense factual discussions about the dangers of alcohol and drugs. Program lecturers provide insight for parents into the Internet world where drugs sales are arranged and cabinet parties are scheduled. This experience is shocking for many of the parents who attend. You can hear a pin drop in the lecture halls when parents hear about how Facebook and social networking sites are exploited by students to organize and coordinate parties and other meetings where drugs and alcohol are used. In the end, students and parents find themselves on the same page in understanding the nature and the extent of their local drug scene. Seminar leaders provide tudents and parents with strategies for dealing with the various forces that tug at students to use drugs and alcohol. This school-based drug-testing program that is available for students in grades 7 through 12 is completely confidential and private. It is firewalled so that testing results are kept discreet; they're not shared with school officials. Positive test results are communicated to parents through the auspices of a medical review officer (MRO). Test results are treated as a private health care matter. These programs are completely voluntary with opt in forms necessary for each parent and student to sign and acknowledge. Either student or parent can verbally opt out of the program at any time. Once a student is enrolled in the program, he/she is then assigned to a pool that is subjected to random selection and collection. Professionally trained collectors operate at participating schools at discrete, out-of-the-way locations on the school grounds; collectors have access to a variety of onsite urine and oral fluid screening devices. Presumptive positive samples are sent to a lab overnight. Once a sample has been produced by a participating student, he/she is free to return to class. It takes a student less than 15 minutes. Positive screening results are confirmed at the SAMHSA certified laboratory utilizing gas chromatography/mass spectrometry (GC/MS) technology.
5 "cheese" are likely to be noticeable within 8-12 hours of the cessation of direct effects. Peak withdrawal symptoms will occur between hours following last dose. At present, "cheese" is mostly a regional phenomenon of Texas. Isolated seizures of "cheese" in other border states have not been significant. Mexico is the source of nearly all tar heroin consumed in the United States. Texas's proximity to Mexico puts it in the crosshairs of smugglers and cartel operations. With Nuevo Laredo (MX) becoming a focus point of cartel controlled tar heroin smuggling, communities proximate to the border are likely to see continued abuse of "cheese." Parents, teachers and friends should be sensitive to sudden and inexplicable behavioral changes in adolescents. Poor performance in school, withdrawal from friends and from hobbies and an affect of exhaustion are all suggestive of a "cheese" abuse problem. Treatment of "cheese" addiction and dependency may require in-patient detoxification and enrollment in an intensive outpatient program afterwards. Early intervention in a student's inclination to use drugs and/ or alcohol has proven critical in deterring substance abuse problems later in life. Random drug testing programs also provide students with motivations and social "cover" in handling peer pressure directed at them to use drugs at parties and at other gatherings. Reducing the rates of student drug testing can save lives as well. With prescription drugs topping the list of junior high school and high school drug abuse tendencies these days, a random testing program is a means of slowing or even reversing the pace of abuse for substances such as Vicodin, Oxycontin and Percocet. Depending on the nature of a local drug problem, a schoolbased program may also screen for abuse of over-the-counter drugs and botanical hallucinogens, substances that are exceedingly popular with high school students. The programs are easy to customize and fit to the on-the-ground realities affecting a participating school or school district. These programs are endorsed by the California Narcotic Officer's Association (CNOA), the Coalition for a Drug Free California and the Partnership for Responsible Parenting. If you want more information about this new program, please contact a MEDTOX sales representative or a Drug Abuse Recognition (DAR) Program representative at  From the Hotline: Phenibut Update We've previously reported on widespread use of a noncontrolled sedative called Phenibut. The drug has been sold and traded on the Internet below the radar of law enforcement and regulatory authorities. Up to now, most U.S. phenibut has been sourced from the U.K. and Europe. But recently, an "over-the-counter" Internet marketed product containing phenibut has surfaced in America. Called "Tranquila PM," this compound contains 350 mg of 4-amino, 3-phenylbutyric acid (Phenibut) and an array of vitamins and herbs. The product is packed into a small 2 fl. oz., oneshot plastic bottle that's designed for fast, nohassle ingestion. Tranquila PM's marketing
6 MEDTOX Quick Links Our Website Products Services Contact Us Past Issues message states that the drug is a worthy alternative to traditional prescriptions and overthe-counter sleep aids. One online purveyor of Tranquila PM asserts that a single dose of the drug brings about a "general relaxation effect that leads to a sound and restful sleep." (http:// Phenibut is a chemical relative of the inhibitory amino acid transmitter, GABA. The drug possesses some of the sedative powers of gabapentin (Neurontin), Baclofen and gamma hydroxy butyrate (GHB). Its effects are mediated through its agonist actions at GABAB receptors; the drug exerts less of an effect at GABAA receptors. In some Internet drug cafes, phenibut is advocated as a means of weaning off of powerful drugs such as GHB and GBL. It's also advocated for those that want to avoid the withdrawals from other depressant drugs, such as alcohol and benzodiazepines. The drug is also alleged to be an aphrodisiac. In its early development stages, the drug was also thought to be nootropic (a memory enhancer). In fact, modern phenibut aficionados tout it as a "smart drug," something akin to the prescription drug Provigil and several other substances thought to be cognitive accelerants. The Russian space program even packed phenibut into the medicine chests of the Soyuz spacecraft. Phenibut is not known to cross-react or otherwise interfere with modern drug test systems. Someone who uses phenibut products will not yield a positive drug test for a controlled substance. But phenibut does pose challenges to readers who work in the drug rehabilitation industry. For patients in recovery, phenibut poses risks. In particular, patients with alcohol and central nervous system depressant addictions may get undesirable drug cravings from the sedating and euphoric effects of phenibut. For others working in residential programs and sober living homes, phenibut use by participants could threaten the safety and security of the house. Chronic phenibut use can lead to tolerance. There have been reports of withdrawal following extended periods of use. Tranquila PM contains a warning to users that following two weeks of continuous use of the drug, a 5-7 day drug holiday should be taken. That admonishment from a phenibut distributor sums up the dangers that a drug like phenibut poses to people in recovery and the people and programs that support them.
7 Buprenorphine and HIV Treatment In communities where intravenous use of drugs is rampant, so is HIV. When people with HIV are also addicted to opiates, treating both simultaneously helps improve outcomes and reduces the spread of HIV or other infections that are transmitted through needle sharing and/or risky sexual behaviors. Combining and coordinating care for the HIV-opiate addicted patient has been spotty. Treatment systems typically fail to integrate the care of one condition in coordination of the other. Patients with HIV and opiate dependencies have traditionally been unable to get coordinated treatment for their conditions in one clinical setting. With expansion of buprenorphine treatment into clinics staffed by HIV clinicians, patients now have the option of receiving treatment of both opioid addiction and HIV infection contemporaneously. With this development, a growing body of evidence suggests that patients and the state of public health will benefit. Since 2002, buprenorphine has been available in the U.S. as an office-based treatment for opioid dependency. This development represented a substantial realignment of drug treatment resources from the inpatient clinic environment to smaller outpatient offices where individual or small groups of physicians organize and manage drug treatment. Physicians who want to prescribe buprenorphine must undergo a training program and become certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). Buprenorphine has been a game-changing drug because of its ability to expand access to treatment for opiate addicts. Nearly 19,000 physicians are currently certified to prescribe buprenorphine; most are medical doctors and osteopathic physicians working general practices and family medicine. Studies suggest that patients with HIV infection and untreated opiate addictions often experience delayed treatment until the later phases of the disease. Delays in treatment of HIV result in extended period of risky behavior and I.V. drug use that puts them and their partners at risk for new infections. Treating affected patients for both HIV and opiate dependency can improve their outcomes on both counts. New research suggests that buprenorphine has several advantages over traditional methadone maintenance programs. A recent randomized trial found that office-based care can improve addiction related outcomes for patients with HIV and opioid dependency and may lead to more effective interventions.  The results of the trial indicated that patients randomized to
8 clinic-based buprenorphine therapy entered addiction treatment much more quickly than those who were assigned to specialty addiction treatment centers elsewhere. Retention in the clinic-based treatment programs was much better than it was in the more distant treatment centers. Patients receiving buprenorphine in the clinic environment also had fewer urine test results that were positives for other opiates or cocaine. These patients also visited their primary HIV physicians more frequently. These are all positive outcomes effecting treatment success rates. It may also be the case that buprenorphine has fewer interactions with antiretroviral drugs than methadone. Methadone is the more traditional opiate agonist used in narcotic replacement therapy regimens. Studies suggest that an antiretroviral can trigger withdrawals in some patients taking methadone; this does not seem to happen when buprenorphine is used. Trying to get HIV patients to abide by their treatment plans and take antiretroviral drugs is difficult when they're experiencing the gnawing pangs and pains of opiate withdrawal. Buprenorphine may well enhance compliance with HIV treatment regimens. As a mixed property narcotic analgesic, buprenorphine is less sedating than methadone and poses fewer side effects and interactions with HIV treatment. Buprenorphine is a drug that can be used in a variety of different settings to treat stubborn opioid addiction. With greater expansion of buprenorphine-trained physicians into community clinical settings, HIV patients and others with complicated medical histories may experience better healthcare outcomes and a more satisfying quality of life.  Lucas GM et al. Annals of Internal Medicine 2010, Clinic-Based Treatment of Opioid-Dependent HIV-Infected Patients Versus Referral to an Opioid Treatment Program. 2010; 152:
9 Name That Drug The subject of this month's "name that drug" is a substance of significant complexity and great potential. A relative newcomer to the mean streets of drug abuse, this substance has established itself as one of the most after prescription drugs in the world for reasons that you might not expect. This month's drug came into the pharmaceutical world as (2S)-2-[(-)-(5R,6R,7R,14S)-9α- cyclopropylmethyl-4,5-epoxy-6,14-ethano- 3-hydroxy-6-methoxymorphinan-7-yl]-3,3- dimethylbutan-2-ol. Embedded in the International Union of Pure and Applied Chemistry (IUPAC) nomenclature is a hard clue as to this drug's biochemical makeup. The drug is an opiate, a distillate of the minor opium constituent called Thebaine. This month's drug is one of a half-dozen notable Thebaine derivatives that includes oxymorphone (Opana), oxycodone (Oxycontin) and naloxone (Narcan). The drug is a semi-synthetic opioid controlled in the United States under terms of DEA Schedule III. This drug resembles the chemical actions and mixed characteristics of pentazocine (Talwin), the subject of July's newsletter "name that drug" column. The drug is available by prescription in several different forms and iterations. In addition to a transdermal patch application, the drug can be found in sublingual and tablet forms. There is a formulation for intramuscular injection and an even newer application that involves an implantable depot format designed for slow, even absorption into the bloodstream. Like Talwin, the drug has been compounded with naloxone to reduce the potential of intravenous injection and parenteral addiction. As a Schedule III medication, the potential for abuse of this drug is rather modest, viewed similarly to drugs like hydrocodone and the opiate cough syrups. In its early years as a prescription medication, the drug was assigned to the much less confining spaces of federal Schedule V. Recent reports and studies of this drug suggest that abuse of it is becoming widespread. This drug is a game changer however. Initially conjured as an opiate analgesic, the drug has since morphed into a powerful means for treating opiate dependency. It has transformed the way opiate addicted patients are now treated and managed. It is foreseeable that this drug may ultimately dispatch more traditional methods of treatment (methadone maintenance).
10 The drug is one of the most powerful opiates in the modern pharmaceutical armamentarium. It possesses affinity for opiate receptors that bests all other modern narcotics, a broad class of medications that includes other powerful drugs such as morphine, fentanyl, methadone and heroin. But what sets this drug apart from other drugs of the opiate class is the binding strength that it demonstrates at opiate receptor sites in the brain. The drug is classified as a mixed property narcotic, and although it possesses unparalleled affinity for opiate receptor sites, it performs as an agonist at some and an antagonist at others. These characteristics make the drug complicated to deal with. Physicians who prescribe the drug must undergo specialized training and certification before they can begin treating patients. This is the only drug of its type where specialized medical instruction is required before utilization. Because of the drug's mixed properties at opiate receptors, someone under the influence of the drug will not experience a traditional opiate euphoria. In fact, some users of the drug describe the effects of this drug as more of an edgy dysphoria. Because of its exclusive action at opiate receptors, the drug can effectively reverse the effects of other opiates that may be present in the bloodstream; this drug competitively preempts other narcotics from opiate receptors in the brain. This effect can be dramatic. For instance, someone who is abusing and is physically dependent on heroin would be put into instant opiate withdrawal if this month's drug were taken. The drug would act similarly and interrupt the action of any other opiate were it to be inadvertently mixed in to a patient or addict's narcotic regimen. Because of this drug's unique chemistry, it acts in blockade at opiate receptor sites, making it important in the practice of drug treatment and rehabilitation. For nearly two generations, methadone has been the go-to therapy in the treatment and management of opiate dependency. Addicted patients who failed in therapy or those who experienced multiple relapses, methadone (dolophine) represented a fairly safe and reliable means of managing the problem. "Methadone maintenance" has been the standard of care therapy in treatment of patients with chronic opiate abuse histories. Methadone substitution therapy crafted a pharmacological solution whereby opiate addicts could pull back from their lives on the street, pull the needles from their arms and transition to a medically supervised therapy that provided them with the necessary narcotics to stave off withdrawals. But in the end, methadone is one of a slew of very potent narcotic analgesics itself, not all that different than the abused opiates it replaces. Methadone is frequently abused too, sometimes fatally. Heroin addicts "chip" and add bits and pieces of other narcotics on top of
11 their methadone therapy to get high. Some methadone patients take to the abuse of drugs like Xanax to create a super methadone cocktail that is uniquely stupefying. This month's mystery drug may dislodge methadone from its primacy in narcotic replacement therapy and become the standard of care for the treatment of narcotic addicts. When utilized in the roll of narcotic replacement therapy, this month's drug can be tricky to use. Physicians have to follow a strict set of protocols to bridge heroin and methadone addicts over to short acting narcotics, such as morphine, before the substitution therapy with this drug can begin. In fact, an addicted patient must actually descend into a mildly acute withdrawal before therapy can begin. Once those withdrawals are evident, the drug is administered. Withdrawals stop shortly afterwards. The dose is adjusted over the course of several days of trial and error. Once sufficient concentrations of the drug are present to suppress withdrawals and a patient has become stable, he/she can then be titrated down off the drug. Becoming more vogue however is the utilization of the drug in the roll of substitution therapy. As is the case with methadone maintenance, affected patients are weaned down to as small a dose as possible and then maintained on a low dose of it over and extended period of time. As an analgesic, this month's drug does not hold a great deal of promise. Its mixed property status makes it a poor candidate to treat most types of moderate and serious pain. But there are some patients where the drug may be an appropriate fit. To that end, physicians have options that include the transdermal patch, a product not to be confused with a fentanyl transdermal patch. As a drug of abuse, there have been sporadic reports of "outbreaks" in communities where the drug is commonly used in treating narcotic dependency. In the club scene, the drug has been found in the possession of those who tend to use ecstasy, GHB and hallucinogens. Many people who use the drug to get high are often disappointed with their purchase. The mixed agonistantagonist properties of this drug often cause it to be a dud on the party scene. And although this drug may come off a little flat for those looking to get high, its real value is in the stabilization, detoxification and maintenance of the addicted opiate patient. For the narcotic dependent and the addicted, this month's drug may be nothing short of a miracle. August 2010 Mystery Drug: Buprenorphine (Suboxone, Subutex, Buprenex)