DRUGS OF ABUSE IN THE DIALYSIS POPULATION 2 0 1 4 H E A R T L A N D K I D N E Y C O N F E R E N C E
Jamie Killion, PharmD, BCPS MEDICAL I N FORMATION SPECIALIST
OBJECTIVES: Describe the magnitude of drug abuse in the general population and within the dialysis population. Know the extent that prescription drug abuse is an epidemic. Understand how ESRD and dialysis affect the pharmacokinetics and pharmacodynamics of drugs.
OBJECTIVES: Know which drugs are most likely to be abused by dialysis patients. Define drug addiction and physical dependency. Know how to identify patterns of abuse. Understand strategies to combat abuse and steer patients towards treatment.
DEFINING THE PROBLEM D R U G A B U S E
DEFINING THE PROBLEM Marijuana and opioid drug abuse are significant public health issues >1200% increase in sales of oxycodone prescriptions between 1997 and 2011 1.9 million or more new nonmedical pain reliever users each year since 2002
Source: SAMHSA 2012 NSDUH
DEFINING THE PROBLEM Substance abuse is costly! In the US over $600 billion annually
DEFINING THE PROBLEM In hemodialysis population, ~19% of patients are current or previous substance abusers Substance abuse is associated with decreased access to kidney transplantation
PHARMACOKINETICS & PHARMACODYNAMICS Majority of drugs, or their metabolites, are renally eliminated from the body Reduced clearance can lead to accumulation prolonged effects of drug! Some substances are directly nephrotoxic Continued renal insult promotes progression of ESRD
PRESCRIPTION MEDICATION ABUSE
Opioids Changes in ESRD patients Removed by Dialysis? PRESCRIPTION DRUG ABUSE Oxycodone Increased sedation Only by High Flux HD (KUf 48) Opioids & Morphine Derivatives Hydrocodone Unknown No data exist Hydromorphone Codeine Possible neuroexcitation from metabolite Increased narcotic effects and reports of narcolepsy Metabolite only by Conventional or High Flux Metabolites only by Conventional HD Fentanyl No clinically significant changes Methadone Few changes No No Morphine Possible prolonged analgesia from metabolite Only by High Flux HD (KUf 8.1, 10.1)
Depressants Benzodiazepines: alprazolam, clonazepam, diazepam, lorazepam, temazepam, Triazolam Changes in ESRD patients Removed by Dialysis? PRESCRIPTION DRUG ABUSE Increased CNS depression possible Opioids & Morphine Derivatives Zolpidem Changes unlikely No Zaleplon No data exists No data Eszopiclone Changes unlikely No data No Barbiturates: Secobarbital, Phenobarbital, Primidone Increased CNS depression possible Short-acting: No Long-acting: Yes
Stimulants Changes in ESRD patients PRESCRIPTION DRUG ABUSE Amphetamines (Mixed salts & Dextro-) Unknown Removed by Dialysis? No data exists in humans Opioids & Morphine Derivatives Methylphenidate Changes unlikely Unlikely Other Drugs Dextromethorphan Unknown No data exists Tramadol Increased sedation, dizziness, GI issues, and headache Only by High Flux HD (KUf 50)
Illicit Drugs Changes in ESRD patients Removed by Dialysis? RECREATIONAL DRUG ABUSE Marijuana (THC) Changes unlikely Unlikely Cocaine Heroin Amphetamines & Methamphetamines Possible increased rate of glomerulosclerosis, higher rate of cardiovascular events Possible increased rate of infections, amyloidosis, and CNS depression due to morphine metabolite Changes unlikely but unknown Not removed by Conventional HD and Unlikely by PD Unlikely No data exists LSD Unknown Unlikely MDMA (Ecstasy) Unknown No data exists Phencyclidine (PCP) Unknown Unlikely
DESIGNER DRUGS Synthetic cannabis Image from Kelley McCall/Associated Press
DESIGNER DRUGS Bath salts Image from US DEA
DESIGNER DRUGS Methoxetamine (MXE) Image from Thinkstock
DRUG EFFECTS IN DIALYSIS PATIENTS
COMMONLY ABUSED DRUGS IN DIALYSIS POPULATION Based on general population data: Marijuana Prescription medications Cocaine Historically cocaine is highly associated with drug abuse in dialysis population Bridging medications
WHAT IS DRUG ADDICTION?
WHAT IS PHYSICAL DEPENDENCY? Addiction, Dependence,... Semantics right? http://www.youtube.com/watch?feature=p layer%20embedded&v=sp4vakl9ej8
COMMON ADDICTION BEHAVIOR Evidence of being high Evidence of withdrawal symptoms Persistent drug seeking behavior
COMMON ADDICTION BEHAVIOR Patient s family member expresses concern. Patient exhibits unexplained wasting, dirty clothes, and poor nutrition. Patient has a pattern of skipping treatments. Patient has drug paraphernalia or other evidence of drug abuse.
HOW TO HELP
HOW TO HELP
HOW TO HELP Common comorbidities: Depression Pain Dialysis center staff should consistently ask about medication and drug use Screen patients using National Institute on Drug Abuse (NIDA) tools http://www.drugabuse.gov/nidamed/etools/sharenidamed-resources
HOW TO HELP Brief Intervention: Ask Advise Assess Assist Arrange NIDA s Principles of Drug Addiction Treatment
GOVERNMENT PROGRAMS TO HELP State Prescription Monitoring Programs DEA Drug Take-Back Initiatives Affordable Care Act provisions for substance abuse treatment
OBJECTIVES: Describe the magnitude of drug abuse in the general population and within the dialysis population. Know the extent that prescription drug abuse is an epidemic. Understand how ESRD and dialysis affect the pharmacokinetics and pharmacodynamics of drugs.
OBJECTIVES: Know which drugs are most likely to be abused by dialysis patients. Define drug addiction and physical dependency. Know how to identify patterns of abuse. Understand strategies to combat abuse and steer patients towards treatment.
REFERENCES Jaffe JA, Kimmel PL. Chronic nephropathies of cocaine and heroin abuse: a critical review. Clin J Am Soc Nephol 2006; 1: 655-667. Unruh ML, Evans IV, Fink NE, Powe NR, Meyer KB. Skipped treatments, markers of nutritional nonadherence, and survival among incident hemodialysis patients. Am J Kid Dis 2005; 46(6): 1107-1116. Crowe AV, Howse M, Bell GM, Henry JA. Substance abuse and the kidney. Q J Med 2000; 93:147 152. O Neil MG. Trends in prescription drug abuse: bridging medications. Medscape. May 28, 2012. Dahl F. Lure, variety of desinger drugs in alarming: U.N. Agency. Medscape. June 26, 2013. National Institute on Drug Abuse. Commonly abused drugs. Revised March 2011. National Institute on Drug Abuse. Commonly abused prescription drugs. Revised October 2011. Volkow ND. Substance abuse among older adults. National Institute on Drug Abuse Director s Perspective. December 19, 2011. Sandu GS, Khattak M, Woodward RS, Hanto DW, Pavlakis M, Dimitri N, Goldfarb- Rumyantzev AS. Impact of substance abuse on access to renal transplantation. Transplantation 2011; 91(1): 86-93. Degenhardt L, Hall W. Extent of illictit drug use and dependence, and their contribution to the global burden of disease. Lancet 2012; 379(9810): 55-70. Cassels C. Opioids front and center in first global picture of illicit drug use. Medscape. August 28, 2013. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage 2004; 28:496-504.
REFERENCES Bailie GR, Mason NA. 2013 Dialysis of drugs. Renal pharmacy consultancts. Santos PR, Arcanjo FPN. Social adaptability and substance abuse: predictors of depression in hemodialysis patients? BMC Nephrology 2013,14:12 Micromedex Healthcare Series. DRUGDEX System. Greenwood Village, CO: Truven Health Analytics, 2013. http://www.thomsonhc.com/. Accessed October 3, 2013 Clniical Pharmacology. Tampa, FL: Gold Standard, Inc.; 2013. http://www.clinicalpharmacology.com. Accessed October 3, 2013. National Institute on Drug Abuse. Screening for drug use in general medical settings. NIH Publication No. 11-7384. December 2011. U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013. Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. American College of Physicians. 10 questions to identify drug-seeking patients. American College of Physicians-American Society of Internal Medicine. 2002. www.acpinternist.org/archives/2002/04/drug_seeking.htm Carrns A. Understanding new rules that widen mental health coverage. The New York Times: Jan. 11, 2014: B4. (Online version ahead of print on Jan. 9, 2014 http://nyti.ms/1gn7vb8)
QUESTIONS? T H A N K Y O U F O R A T T E N D I N G