Archive for the ‘Controlled Substances’ Category

New Opioids

I’ve blogged about states that have passed new laws addressing the prescribing of opioids, but the manufacturers of prescription opioids medications also have made changes to help reduce the potential for medication misuse. Of course, opioids will never be misuse-proof, but at least it’s a little harder to misuse some of the newer ones.

Oxecta is a new immediate-release brand of the drug oxycodone. It’s formulated so that it breaks into chunks when crushed, instead of a powder. When it’s mixed with water, it forms a gel so that it can’t be injected. This pill contains sodium laurel sulfate, a substance that irritates the nose if snorted.

Lazanda is a new delivery form of a very potent opioid, fentanyl. This brand is designed to be used as a nasal spray, which I would expect to be very addictive. The preparation itself has no anti-abuse features, but in order to distribute, dispense, prescribe, or be prescribed this medication, parties have to sign an agreement and be enrolled with the drug company. This extra scrutiny is hoped to deter diversion by distributor, pharmacy, doctor, or patient. Physicians must take a training program specific for this brand, and be enrolled with the drug company as a prescriber, or pharmacies can’t dispense to the patient.

Patients also need to complete a patient-prescriber agreement. Many people (like me) think doctors aren’t likely to jump through these extra hoops to prescribe this particular brand, when other brands of the same medication are already on the market, though not in the form of nasal spray.

Remoxy, another brand of oxycodone, hasn’t yet been FDA approved. Supposedly, it’s resistant to injection or snorting, and also has been formulated to be resistant to alcohol extraction.

Drug companies are now required by the FDA to have plans to evaluate and mitigate the risks associated with the opioid drugs they manufacture, particularly if they make sustained release or long-acting opioid preparations. This cooperation by drug manufacturers is a necessary part of turning the tide of opioid addiction in this country.

Last year, Purdue Pharma re-formulated OxyContin, making it more difficult to crush to snort or inject.  I noticed a sudden drop-off in patients entering treatment for pain pill addiction who said OxyContin was their drug of choice. During the years 2002 through 2007, nearly all of the opioid addicts I admitted to treatment said OxyContin was their preferred drug. It became obvious that the re-formulation made a big difference.

Addicts can and will still abuse these medications orally to get high, but the new formulations really do reduce abuse by making pills less likely to be snorted or injected.

So Long Soma

Soma, a well-known brand name of the drug carisoprodol, is prescribed by doctors in the U.S. as a muscle relaxant. However, it does have the potential to cause addiction. Soma is now a Schedule III or Schedule IV controlled substance in about twenty states, and the DEA may soon make it a Schedule IV drug in all states. Carisoprodol has been removed from the market in other nations, due to its potential for addiction.

 All potentially addicting drugs are scheduled, meaning the physician has to have a DEA number to legally prescribe them. Non-scheduled drugs (antibiotics, antidepressants, blood pressure or diabetes medication) aren’t addicting, and the doctor doesn’t need a DEA number to prescribe these. They aren’t tracked by the DEA. Drugs are scheduled I through V, depending on the potential for addiction and the degree of therapeutic usefulness. Schedule I drugs have very high potential for addiction, and very little therapeutic use. Other medications are more beneficial with less risk of addiction. Heroin and Ecstasy are two examples of Schedule I drugs. At the other extreme, Schedule V drugs have some risk of addiction, though fairly low. Examples are low-dose codeine and other low-dose opioids.

 I hate Soma. I can’t remember the last time I wrote a prescription for it. I see too many people who have become addicted to it, or who use it with opioids. There are other better and safer muscle relaxants.

Soma gets metabolized to meprobamate, an old-timey barbiturate. Doctors used barbiturates as sedatives before the safer benzodiazepines came on the market.

 Some addicts say they like the high that they get when they mix Soma with opioids. Since I treat opioid addicts, I see the dangers of mixing Soma with maintenance medications like methadone and buprenorphine. Just like benzodiazepines, Soma has a synergistic effect with opioids, causing more sedation than expected. This is how it can kill. The user takes opioids with Soma, it turns into a barbiturate, and the combination puts the person into a deep sleep. In fact, this combination can make them sleep so deeply that the respiratory center of the brain, which tells us to breathe when we sleep, turns off. The person stops breathing, and without oxygen, vital organs like the brain and heart die, and the person never wakes up.

 At the recent ASAM conference in Washington, D.C., one presenter reminded us of how addicting carisoprodol can be: in one study, around 65% of patients with a personal history of a substance use disorder misused carisoprodol when it was prescribed to them for over three months. And even worse, only 18% of the prescribing doctors knew that this medication is metabolized to meprobamate. (1)

 If you have a history of any sort of addiction disorder and your doctor is prescribing Soma, talk to her. It’s likely that another safer and more effective medication can be found. Soma is only FDA approved for two or three weeks of continuous use, anyway.

  1. Reeves, RR; Carter, S; Pinkofsky, HB; Struve, FA; Bennett, DM; “Carisoprodol (Soma) Abuse Potential and Physician Unawareness; Journal of Addictive Diseases, Vol. 18 (2), 1999, pp 51-56.