December 2010MEDTOX® Journal
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Public Safety Substance Abuse Newsletter

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In This Issue
Whipped Lightning Causes Whipped Up Controversy
New Delivery System for Buprenorphine Holds Promise for Opiate Addicts
Stories on the Frontline from the DAR Hotline
Happy Holidays From MEDTOX

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Whipped Lightning Causes Whipped Up Controversy
 

2010 has given rise to a number of vexing drug and alcohol problems. From the explosion of synthetic cannabinoids, such as K2 and Spice, to experimentation with the smoking of nutmeg, modern American culture is awash in unusual drug use options. The situation is especially trying for parents of American children. With cell phones, social networking sites, and music television dominating contemporary adolescent communication, drug use trends quickly inflate and blow out in the turbulent adolescent world. Aside from the ubiquitous nature of marijuana, drugs used and abused by teenagers are oftentimes nothing more than experimentations with the drug du jour of Facebook or YouTube. But there are drugs that are more dangerous than others; drugs where a one-time drug use can lead to serious injury or death. For adolescents, alcohol is one of those drugs where calamity often follows experimentation, especially when experimentation leads to a drunk driving.

 

In recent yeAlcohol Whipped Creamars, there have been a variety of exotic beverages that target adolescents and young adults. These beverages have been alternately called natural stimulants, pick-me-ups, or relaxing potions described as "tranquility in a bottle". Whipped Lightning represents a new and potentially troubling direction in the growth of alcohol-infused food products. The product is whipped cream pasteurized and spiked with nearly 15% alcohol. Marketed and sold as a condiment for other alcoholic beverages and as a topping for pies, Jell-O, and pastries, Whipped Lightning is attractive to younger people. Producers of the alcohol-infused whipped cream have eluded FDA labeling requirements by an assertion that their product is not a foodstuff. The product is not even required to list the amount of calories it contains. Although a buyer must be at least 21 years of age, it does not take much effort for minors to get their hands on Whipped Lightning. Because of the high alcohol content, it does not take much Whipped Lightning to get whipped drunk. Because of kids' relatively low tolerance to alcohol and its inebriating effects, kids can become very drunk following the quick downing of this canned alcoholic whip cream. This is where trouble begins and ends.

 

In recent months, controversy has also swirled around an alcoholic beverage called Four Loko. A blend of stimulant herbs and chemicals along with alcohol, Four Loko contains a contradictory blend of stimulant and depressant drugs. The concoction immediately connected with young people. The product offered the traditional experience of drinking a malt beverage, but it added the attraction of an espresso-like jolt of adrenalin as a counterweight to the alcohol. The drink posed a distinct threat to teenage and young adult users. Four Loko is now banned from most store shelves in America. We believe that is an early holiday present for most readers.

New Delivery System for Buprenorphine Holds Promise for Opiate Addicts
Buprenorphine 

For generations now, methadone has been the mainstay treatment for heroin and other opiate dependencies. Methadone is a narcotic, not all that different than heroin, yet it has become the standard therapy for establishing opiate replacement therapy in addicted patients. Treating opiate addicts with methadone substitution or maintenance can be tricky. Patients have to be administered the drug on a daily basis. Methadone has to be carefully calibrated; doses have to be customized for each patient to prevent overdosing or causing the patient to become high or "loaded" on an excessive dose. Buprenorphine is another option for opiate addicts. The drug is a mixed property opiate that interacts with opiate receptors without triggering the sequelae of opiate effects. When properly administered to recovering opiate addicts, the drug mutes cravings and withdrawal. Like most drugs, buprenorphine is available in oral tablets and in sublingual lozenges. Although an effective drug, it requires daily self-administration. Like all drugs taken by mouth, adherence problems can cause cravings for opiates that reemerge and lead to new instances of opiate abuse. And although a Schedule IV drug, buprenorphine remains a problem as a drug of abuse and susceptible to diversion.

 

In a six-month manufacturer-funded study, researchers tested the safety and effectiveness of 80 mg buprenorphine in 163 opiate dependent patients.[1] Patients were implanted with 80 mg time-released depots of buprenorphine. Most patients received four implants.  In this study, patients were provided "rescue" doses of buprenorphine. When cravings or withdrawals started to burn through the base dose of buprenorphine, patients were allowed to request breakthrough buprenorphine-naloxone mixed sublingual tablets. If a patient requested frequent "rescue" doses, researchers would implant an additional fifth implant. A separate group of participants were treated with placebo implants. Placebo patients were allowed rescue buprenorphine-naloxone tablets as well.

 

Compared to placebo, a significantly higher percentage of buprenorphine implant patients completed this study (65% vs. 34%). Clean drug tests were established as the primary outcome for this study. At 16 weeks, those participants in the placebo group were significantly less successful in maintaining negative urine tests than were those in the implant group. Placebo patients reported a much higher need for rescue medication, an outcome that was assured since they were not absorbing continual release medicine from the implant. What was most interesting perhaps was the fact that the six-month retention rate for implant patients was almost twice that of sublingual buprenorphine. Overall, the implants were much more successful than the oral forms of the drug. The time-release application significantly added to overall program compliance for this group of opiate dependent patients.

 

Nevertheless, the overall rate of positive drug tests for other drugs of abuse was still high at the endpoint. And it is still unclear how buprenorphine endpoint success compares up to methadone. Those studies are forthcoming. But at this juncture, it is pretty clear that this new format for buprenorphine holds promise. Buprenorphine is a complicated drug that is just now getting national exposure as a front line drug for treating opiate dependency. Studies like this one help practitioners understand how to best improve outcomes for the many patients who are struggling to overcome opiate dependencies.

 



[1]Ling W et al. Buprenorphine implants for treatment of opioids dependence: A randomized controlled trial. Journal of the American Medical Assn. 2010 Oct 13; 304:1612.

Stories on the Frontline from the DAR Hotline
Hotline 

On Thanksgiving eve, a county probation officer called the DARS Hotline at MEDTOX with a question about a problem that she was trying to deal with before wrapping up her work for the long holiday. The deputy probation officer was conversing with a client who had a lengthy drug use history. The client had demonstrated a penchant for alcohol and depressant drug abuse. In particular, the client was disposed to the use of Valium and Xanax; both are benzodiazepine central nervous system depressants. The client frequently mixed alcohol and Xanax. On many occasions the client would become thoroughly inebriated to a point where he was stumbling and falling down drunk. The client had at least two drunk driving convictions, one of which involved a traffic collision where a passenger in his own car was seriously hurt. For most of the preceding nine months on probation, the client appeared to be doing well. He went to work, he was making restitution payments, he was attending Alcoholics Anonymous meetings, and had reconciled with his estranged wife. But then the wheels came off of the cart. The client began to miss meetings; on several occasions he missed his mandated random drug tests. He was arrested for being drunk in public twice. On one occasion he was found passed out face down in a sandbox at a playground near his home.

 

After protracted efforts at getting the probationer into the office, the deputy finally succeeded. She now had the client sitting at a desk about three feet away from her. The client appeared drowsy. He was not drunk though. His words were slow.  He enunciated his words carefully but his sentences were incomplete. The deputy thought that the client was in a good mood and mostly affable. The deputy surmised that the client had probably been drinking; after all it was recent alcohol abuse that led to his drunken nap in the park. The deputy accused the client of drinking. He denied alcohol use.  He said that he had taken an over-the-counter allergy medication earlier in the day and that he was drowsy as a result. He then became indignant and loudly protested the accusation that he had been drinking. The deputy did not believe the allergy medicine. She compelled her client to provide a urine sample for an instant drug screening. The client got up and staggered as he followed an assisting male deputy to the restroom for sample collection. Five minutes later, the results were in. Negative. The client said, "I told you so, now can I go home?" There was still a breath alcohol test on a portable breath tester (PBT) to be conducted. That result was negative as well. Here was a client in the office late in the day on the eve before Thanksgiving. A client who was on probation for felony driving while under the influence (DUI, DWI) and his drug of choice was alcohol. He exhibited classic signs of alcohol intoxication or impairment by some other central nervous system depressant drug. But the client screened negative for evidence of benzodiazepine, marijuana, or alcohol use. What was the cause of his drunken symptoms?

 

The deputy knew that the client was intoxicated to the point of impairment. His sister was sitting in the lobby. She had driven him to his appointment. The deputy thought perhaps that the sister would be forthcoming about her brother's situation. But before the deputy could get up and go fetch the sister, the client began to relate the circumstances of a bad fall that he had experienced the week before. The fall occurred as he stepped up from the curb of his house after collecting the mail from the mailbox. He stumbled, fell, and collided with the paved driveway. He hurt his back and he had a nasty set of bruises on his arms and upper torso. The injuries were bad enough that a neighbor called for an ambulance. The paramedics arrived and rendered aid. Fearing a head injury, he was transported to the local hospital emergency room for treatment.

 

At the hospital, x-rays were taken and treatment was meted out. The client was released in short order. But the emergency room doctors provided the client with a prescription for tramadol (Ultram, Ultracet) for pain and carisoprodol (Soma) for back spasms. It seems that the client was very adamant about his need for Valium for back spasm related to his fall. The doctor was leery of prescribing the drug and chose to prescribe him Soma instead. Thirty Soma and thirty Tramadol tablets were prescribed with no refills. His fall occurred three days prior to his appearance at the probation office. Asked by the deputy if there was any tramadol left, the client said that he had taken two tablets earlier in the day. As to the Soma, well that bottle he said had been stolen from his backpack while he attended a nightly Alcoholics Anonymous (AA) meeting.

 

This client was high on Soma.It was likely a pretty high dose of the drug. The Soma acts as a barbiturate in the central nervous system and can cause alcohol-like symptoms at higher doses. In this case, the client finally admitted that he had taken three or four 350 mg Soma tablets a couple of hours before going to the probation office. He insisted that he did not drink alcohol, smoke marijuana, or take Valium. Testing for Soma can be conducted in the lab; there is no onsite test for the drug yet. Tramadol testing must also be done in the lab. And although tramadol works in large part like a narcotic, it is not a drug that causes gross symptoms of opiate intoxication. The drug is a synthetic with an analgesic effect that is slightly less than codeine. (With the withdrawal of propoxyphene (Darvocet and Darvon) from the American pharmaceutical register, the rates of tramadol prescribing will likely increase.)

 

This client is addicted to drugs that slow down the central nervous system. Alcohol, benzodiazepines, opiates, and barbiturates are all appropriate choices for the client. Soma is a widely prescribed and abused drug in America. Regular users of the drug can become addicted and physically dependent. Withdrawals can be very unpleasant. The drug is routinely combined with Vicodin or Oxycontin to create pharmaceutical equivalents to heroin. The drug is a serious public safety concern in that sense. Testing for Soma should be seriously considered as part of standard lab-based drugs of abuse testing. DAR symptoms of Soma intoxication will be traditional central nervous system presentations. Users will demonstrate horizontal gaze nystagmus, lack of convergence, and a slowed pulse and Romberg clock. Pupil size will remain normal and the reaction to direct light may be normal or a bit slowed. Speech and physical mannerisms will be similar to someone under the influence of alcohol, but absent the odor of course. Should Soma be combined with alcohol, a synergistic effect will occur and create impairment that is more powerful in sum than either of the two drugs taken alone. A small amount of alcohol mixed with Soma may result in very serious impairment. As with all drugs in its class, physical dependency and tolerance can occur with Soma abuse. Some regular Soma uses can tolerate several thousand milligrams of the drug a day.

 

Questions about Soma abuse and testing can be directed to the MEDTOX DAR Journal staff.

Wishing all of our readers Happy Holidays
Happy Holidays 

Substance abuse and treatment of substance abuse is a complicated and tricky affair. The MEDTOX DAR Newsletter stands as a source of information and expertise to assist our readers with that challenge. We are grateful for all of you who read our monthly newsletters and our intermittent "BOLO" advisories. For those of you wondering what a "BOLO" is, it is cryptic for "be on the lookout." All of us are serving a profession that strives to bring effective intervention and treatment to those who labor against drug addiction and dependency. A good portion of our readership is involved with drug enforcement and the policing of our streets for drunk and drugged drivers. For all of you we are grateful. From the Salvation Army's Adult Rehabilitation Command (ARC) to the Los Angeles County Probation Department, we are thankful for the work you do. You keep us safe; you facilitate the healing that the addicted need to become whole. We hope that you have a safe and successful conclusion to 2010. God speed and good luck to you all in 2011!

 

From the staff of the MEDTOX DAR Newsletter. See you in 2011.

 

For a detailed list of articles you may have missed or a specific drug you would like to read more about click here to view or archived newsletters from 2010.