the 9-year interval, the vast majority of cases were upper middle-upper class Caucasians, mostly female, age 30-45 years, using liquid Talwin intramuscularly, most were under medical care in that they had prescriptions for complications such as lupus erythematosus discoides, chronic migraine, neck and shoulder pain, chronic post-operative discomfort, etc. The Talwin was not used in combination with other medications. The preferred treatment was hospitalization for detoxification which lasted fourteen to twenty-one days. By the end of 1976 and early 1977, referrals from our emergency room, telephone inquiries, and patients interviewed for admission were requesting services for Talwin abuse, overdose, and addiction. Admissions began to increase during the Spring of 1977 which also correlated to the first steady decrease of admissions for opiate abuse to our Drug Dependence Program. Talwin is a Benzomorphan derivative, one of the five main chemical classes of narcotic analgesics used in humans. As such, the addiction potential is present and the abstinence symptoms range between methadone and morphine. The clinical manifestations resemble partially that of both morphine and nalorphine; sweating, tremor, chills, muscle cramps, abdominal cramps, nausea, vomiting, itching, rhinorrhea, and is accompanied by marked drug seeking behavior. It can produce psychotomimetic reactions such as visual hallucinations, dysphoria, nightmares, and feelings of depersonalization. After a large intravenous dose epileptiform convulsions may occur. Note: With the small number of patients who self-administered Talwin orally and/or injected less than a total of 12 pills per week, the physiological abstinence syndrome was lacking. However, the patients complained of identical clinical withdrawal manifestations and believed and expressed their "addiction" as real. The sample size or patient population for this report, N=108 individual patients, have been referred from the Central Intake facility (N=36) under the direction of Dr. Edward Senay or were self-referred tor medically referred to Northwestern (N=72). The 109 individual patients were assessed, identified, and "worked up" in accordance with established procedures reflecting both state (IDDC) and federal (NIDA) standards and guidelines. The abuse potential for Pentazocine will be demonstrated by reviewing the patterns of use for the following reasons or conditions as presented by the 109 Northwestern patients; medical need, psychic effect, dependence and drug seeking behavior, or self-destruction. During these past 12 months, the Northwestern Drug Dependence Program has provided intake and assessment services and developed patient treatment plans, both inpatient and outpatient, for 109 individuals defined as primary Talwin abusers. That is to say that the primary drug of choice primary drug of abuse at the point of initial contact/intake and admissions to Northwestern had been Talwin. According to intake data, the overwhelming response by the majority of patients is that the Talwin, or T's, "can get you high every time you fix." The clear expectation and resulting self-stimulation by the abuser is for the intention of a euphorogenic effect. The Talwin abuser did not appear to be a multiple narcotic abuser, validated by monitored urine surveillance, but prefers to utilize the medication Pyribenzamine, or Blue's or PBZ, to “boost,” intensify the rapidity and duration of the euphorogenic effect. The abusers profess a belief that Talwin is in fact addicting, and reported an extremely high degree of accessibility of Talwin. This accessibility has been significantly reduced since the recent rescheduling of the drug and the patients now admitted to our program present somewhat of a "panicky" concern for future accessibility and imminent withdrawal complications. Patients report drug cravings, exhibit and report drug craving behavior. All the patients assessed (100 percent) were able to present the actual pills or vials or accurately identify the physical characteristics of the drug, Talwin (color, size, markings). Better than 70 percent of the abusers adjunctively use Pyribenzamine, PBZ, in combination with Talwin in the usual combination of three Talwin to one Pyribenzamine. Only 24 percent admit to having a legitimate prescription for Talwin and 15 percent state they are under current medical care and supervision with chronic back pain as the most recurring ailment. Thirteen percent of the patients stated that they have experienced convulsions and passed out from using Talwin without prior histories of seizure disorders, or have admitted overdosing on Talwin. It appeared that in 1977-78 until recently, that Talwin represented rather inexpensive, convenient, and accessible drug for novice drug abusers who quickly develop a pattern of dependence and resulting drug seeking behavior. For most of these individuals their first exposure to narcotics was with Talwin and was described as their drug of choice. The amount of illicit activity was described as minimal initially. There are recent indications, since rescheduling, among older street addicts that Talwin is a drug of preference even with the predictable antagonistic reactions to methadone and unpredictable hallucinogenic and psychotomimetic effects. In the recent months it is this group which has repeatedly presented themselves with larger Talwin habits. (Up to 48 Talwin tablets/day. Fewer use PBZ in conjunction with Talwin. Most express fear for the future and sought admission for inpatient detoxification and presented a greater incidence of cutaneous ulceration and soft tissue damage.) CURRENT PATIENT PROFILE The current population profile of Talwin abusers (N=108 for the past year) represents a mixed group, who use the drug, PBZ adjunctively in approximately 80 percent of the cases: Age: Range, 17 to 52 years; mode, 24 years; mean, 25 years. Sex: Male, 80 percent; female, 20 percent. Race: Caucasian, 28 percent; black, 70 percent; other, 2 percent. The primary mode of administration: Intravenous, 80 percent; intramuscular, 18 percent; and oral, 2 percent. In the past 12 months, 108 different individuals were assessed at initial contact or presented themselves as Talwin abusers. The length of time elapsed from the first use of Talwin was: Range, 3 months to more than 9 years; mode, 10 months; mean, 14 months. The average cost for each Talwin pill was $2 with a range from $1 to $3 based on quantity. The cost for the PBZ tabled averaged $1 per pill, also based on quantity. Since rescheduling, the cost per pill has doubled. Range, 3 to 48 Talwin pills per day; 0 to 18 PBZ pills per day. Mean, 21 Talwin pills per day; 8 PBZ pills per day. The average daily habit for using both Talwin and PBA is $25 to $30 prior to rescheduling and $40 to $45 after rescheduling. Six Talwin pregnancies have been identified; four have delivered and two represent the most serious or unusual infant complications with mothers who were addicted in our Program. One case represented the most serious infant withdrawal syndrome and the other was a congenital complication involving the extremities of twins. However, these complications cannot be assessed as the result of Talwin addiction alone. These patients were registered in our perinatal addiction component and delivered in Prentice Women's Hospital. The overwhelming evidence for substantiating the ability to produce and maintain a psychological dependence as well as a physiological dependence is contained in the large percentage of patients who have not completed detoxification because of the stated availability and accessibility of Talwin and the euphoric effect it maintains. This group or cohort of Talwin abusers, more than any other group previously identified in my clinic, has been extremely difficult to engage in treatment and therefore represents the largest numbers of drop-outs and premature terminations at this time. Our evaluation is that the potency, cost factor, availability, etc. of the Talwin does not facilitate the treatment of Talwin addiction at this time. The issue of permanent health impairment cannot be adequately documented at this time. The congenital complications with the pregnant mother, the severity of the infant withdrawal syndrome, the hallucinogenic side effects, the identified convulsions, tissue damage, etc. can easily be quantified with follow-up monitoring. However, the false sense of security, the mechanism to monitor and regulate euphoria, the ease and availability of securing and abusing Talwin cannot begin to reflect the human wastage and suffering for individuals, families and community. The trend for the past year has reflected the use of Talwin as the primary drug of choice by young, first admission with no prior psychiatric care, Black, males. Approximately only one quarter of this patient group were able to complete a course of outpatient detoxification which averaged 15 to 29 days. Note: More recent admissions, since the rescheduling of Talwin, were older former primary heroin abusers who had returned to illicit drug use following a number of treatment failures with methadone clinics or who have been using Talwin parenterally for three to four years. These individuals were concerned with the scarcity of Talwin pills on the street and recent reluctance by their "legal connections" to continue prescribing. With little or no success in outpatient detoxification, these patients have been admitted to our inpatient psychiatric unit and detoxified using oral doses of Talwin on a q.i.d. schedule to alleviate withdrawal problems. We have also identified small numbers of housewives, neighbors, and friends who use low doses of Talwin, oral and parenteral, four to six pills per day. These women, some are grandmothers, have never had drug abuse histories or prior records of treatment or prior significant medical histories. These women have had the most extensive soft tissue reactions necessitating admission to our medical units for acute care. These women describe the psychologic effects of euphoria or tranquilization as the primary reason for continued use. Mild abstinence symptoms have occurred on discontinuing Talwin. An assessment of the current abuse pattern of Talwin merits a moderate to high abuse rating. The number of individuals displaying withdrawal symptoms, engaged in drug seeking behavior, reporting extreme difficulty in remaining abstinent, etc., provide basic evidence for this rating. CONCLUSION Our experience at Northwestern with Pentazocine abusers clearly support any measure which would restrict the availability and monitor the patterns of distribution of this drug. The alarming phenomenon is the significant number of adolescents and young adults, without prior addiction histories, who appear to be entrenched in the current and growing abuse of Talwin. In just this past year, we have not been able to identify more than a few individuals who have remained drug free since completing their course of detoxification. This fact is alarming in the sense that unlike the majority of our other opiate abusing patients who have remained in treatment following physiological detoxification, the Talwin addict returns to drug of choice quite readily and is not responsive to group or family therapy. Our assessment of this situation includes our own lack of expertise but more so the clear difference between the cohort populations. The Talwin group did not necessarily present or describe themselves in any crises nor did they experience their current drug seeking behavior as a means to avoid withdrawal and "sickness." The overwhelming pre-occupational thought is the anticipated "high," which is easily controlled, inexpensive, chemically pure, and not the same as who or what a "street heroin addict" is all about. The Talwin addict does not consider himself as having problems like a heroin addict. The current prevailing attitude among older Talwin abusers, the street folklore regarding the advantages and positive aspects of Talwin and the availability and cost of Talwin has easily precipitated a return to the use of drugs, specifically Talwin, by order and former active opiate addicts currently on methadone programs. This trend has been identified and reported to the writer by a number of clinics, including the V.A. network, within the past few months. Note: Recent inquiries generated from drug treatment units sponsored by the military on bases, camps, etc. have indicated the suspected and confirmed use of Talwin by military personnel which has been described as "problematic" in terms of diagnostic and treatment methodologies. This drug may represent the answer to many individuals who are looking for the first time around or for the hundred thousandth time, the guaranteed "high." PREPARED STATEMENT OF ROBERT STEIN, M.D., MEDICAL EXAMINER, COOK COUNTY, ILL. The information presented here today was accumulated through the efforts of the office of the medical examiner, County of Cook. Information concerning the presence of pentazocine ("T's") alone or in combination with tripelennamine ("blues") will be discussed. Since this represented a new pattern of drug related/associated deaths it is of considerable interest to persons outside the area of Cook County. This particular drug combination was first noticed in mid 1977. The appearance of pentazocine, a synthetic narcotic analgesic and tripelennamine and antihistamine was demonstrated through the analysis of tissue and body fluids for drugs. |