Heroin, Meth, and Poly-Substance Abuse: Where We Are Now
Jane C. Maxwell, Ph.D. Research Professor The University of Texas at Austin No Relevant Financial Conflicts:
Relevant to the content of this educational activity, I do not have any relevant financial conflicts with commercial interest companies to disclose. Heroin Overdose Deaths: 2017
CDC Wonder & Kaiser Family Foundation Synthetic Opioid Deaths (fentanyl, tramadol)
CDC Wonder & Kaiser Family Foundation Opioid Overdoses Natural and Semisynthetic (oxycodone, hydrocodone): 2017
CDC Wonder & Kaiser Family Foundation Number of Drug Overdose Deaths Involving Opioids and Other Drug Types, Iowa Vital Statistics, 2010-2017 250 Other Opiates* Methamphetamine Heroin Cocaine 200 Other Opiates*
150
100 Methamphetamine Heroin 50 Cocaine 0 2010 2011 2012 2013 2014 2015 2016 2017
*Includes oxycodone, hydrocodone, synthetic narcotics (fentanyl) and other narcotics Mexican Black Tar Heroin
SWA Brown Heroin or “Cheese” Heroin
South American Heroin or “new” Mexican White Heroin Black Tar Heroin and Packaging Heroin Sources and Supply Routes TRANSITION IN HEROIN SOURCE AREAS (Heroin Source Area Distribution 1977-2016)
100
90 Inconclusive
80
70 South America 60
50 Southwest 40 Asia
30 Southeast 20 Asia 10
0 Mexico 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Source: DEA Heroin Signature Program Top Drugs Seized and Identified in Iowa
• July-Oct, 2019., 48% of all drugs seized were meth, 28% cannabis, 7% cocaine, 3% fentanyl 2.4% heroin. • Iowa DEA reports bi-weekly loads of 20# to 50# meth. • Increase in availability and demand for heroin and fentanyl. Heroin Is still more popular and most comes from Chicago. • Seeing meth coming up I-35 and merging with drugs on I-29 out of Kansas City. • Fentanyl not as popular as heroin but seeing fentanyl mixed with other drugs. Heroin and Fentanyl Deaths in Iowa: 2015-2019 (Death with heroin & fentanyl is counted in each drug category)
800 660 600 563 535 400 263 200 238 37 82 66 29 59 0 2015 2016 2017 2018 2019 Fentanyl Heroin Items Identified and Reported to DEA by Iowa Division of Criminal Investigation: 2010-2018 800 730 700 660
600 563 535 500
400 345 294 304 286 300 242 238 200 179
100 38 62 6 5 2 7 5 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 Fentanyl Heroin Powdered Heroin and Fentanyl Test Strips Fentanyl Items, Fentanyl Citrate, Fentanyl Hydrochloride, Fentanyl Salt Undetermined: US NFLIS 2008-2018
62067 54990
32898
13644 4233 569 623 668 661 693 938
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Fentanyl or Not?
Kilogram seizure of suspected black tar heroin that was fentanyl with no heroin present.
Fentanyl pills pressed to look like OxyContin
Fentanyl pills pressed to look like alprazolam ? BLACK FENTANYL ? • Fentanyl source? China and Mexico • Nationally 21% of fentanyl exhibits were mixed with heroin. • Since 2017, 37% of samples submitted to Utah DOR contained a form of counterfeit prescription pills. • Since September 2018, 15 submissions resembling black tar heroin but also contained fentanyl. • Jan. 2019, Arizona seized 12# fentanyl packaged like cocaine. • May 2019, Idaho submitted sample of black tar that contained heroin/fentanyl mix. • October 2019, black powder tested positive for fentanyl and methamphetamine. • Nov. 2019 Denver seized kilo for suspected black tar that was only fentanyl • Cross-country trafficking—identical fentanyl compounds found on east and west borders. Fentanyl Exposure Calls to Texas Poison Centers Identifying Patches, Sprays, or Sublingual Tablets (Medical Products) or Form Unspecified: 2016-2018
34% 43% 73%
66% 57% 27%
2016 2017 2018 % Medical Product Not Specified
DSHS Poison Centers The Iowa Prescription Monitoring Program Schedule CII or CIII Drugs
6000000
5000000
4000000
3000000
2000000
1000000
0 Total Prescriptions2013 2014 Dispensed 2015 Total Prescriptions2016 filled2017 2018 # Patients Filling CII or CIII ll includes OxyContin, Percocet, Dexedrine, Adderall, desoxyn; lll includes ketamine, Vicodin, steroids. Category of Drug Deaths and Mentions of Tramadol or Fentanyl on Death Certificates: Texas 2018
715 Psychostimulants 7 13 502 Benzodiazepines 29 32 706 Cocaine 8 12 547 Heroin 3 5 524 Other Opiates 105 176
Total Deaths Tramadol Fentanyl Tramadol Items Seized and Identified in U.S. Tox Labs: 1998-2018
8000 7000 6000 5000 4000 3000 2000 1000 0 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 Medication Safety for Persons on Other Opioids: Taking strong pain pills safely
• Do we need a prevention campaign to decrease deaths due to Other Opiates (oxycodone, hydrocodone, etc.)? Emphasis by prescribing physician describing mortality risks to family and patient, need for each patient to receive a naloxone kit (“Naloxone in the home like Fire Extinguisher in the home”). • Pharmacist working with patient and family on safe medication practices: write down time of taking pill; keeping pill away from recliner or bed where patient sleeps so will be wide enough awake to be aware of the time of the dose? Other safe prescription management? • Lock up these meds to prevent diversion by others, including teenagers. Indicators of Methamphetamine Trends in Texas: 1998-2018 - when PSE was limited 1000
100
10
1 # PCC Calls % Tmt Admits # Deaths % Tox Lab Items 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 DEA Methamphetamine Profiling Program: National Data 2006-2018
Production Routes Purity and Potency 100% 100%
80% 80%
60% 60%
40% 40%
20% 20%
0% 0% 2007 2012 2017
P2P Purity Potency PSE (Pseudoephedrine) *http://www.justice.gov/dea/resource-center/meth-lab-maps.shtml Domestic seizure counts, 2002-2018 Meth seizures now exceed marijuana
Major drugs: • Marijuana seizures declining, both along SWB and in legalization states. • Cocaine declined in 2006-07; remains suppressed since 2012 • Meth dramatically rising since 2009; now exceeds marijuana seizure counts
Opioids: • Heroin peaked in 2015, now declining (correlated to Quest trend). • Oxycodone peaked in 2011, continues to decline • Fentanyl commenced rising in 2014, and continues to rise
12/5/2019 25 Source: National Forensic Laboratory Information system (NFLIS), DEA, semi-annual reports A Ten-Year Lookback from UNODC ATS ATS includes non-plant based drugs such as methamphetamine, amphetamine, and MDMA
• The global quantity of ATS seizures increased more than four times, from 60 tons in 2008 to 261 tons in 2017 • ATS is the primary drug of concern, as quantities of the drug seized increased more than sevenfold and its global share of all ATS seizures increased from 41 per cent in 2008 to 71 per cent in 2017 • The global ATS seizures increased from 60 tons in 2008 to 261 tons in 2017. • North America and Asia are the 2 main trafficking hubs but trafficking is increasing in other subregions; crystal meth and its health risks are increasing. • Between 2008 and 2017, US price has dropped from $220/gram to $70 and purity has increased from 46% to 93%
The Global SMART Update Vol. 22 - “The ATS market – 10 years after the 2009 Plan of Action” 2017 Iowa Treatment Admissions
10080
7705 6767
936 1231 152 Items Identified and Reported to DEA by Iowa Division of Criminal Investigation: 2010-2018
10000 Fentanyl Cocaine Heroin Methamphetamine
8000
6000
4000
2000
0 2010 2011 2012 2013 2014 2015 2016 2017 2018 Methamphetamine-Related Treatment Admissions, by Age and Gender, IDPH, 2014-2018 1000
800
600
400
200
0 15-24 25-44 45-64 Female Male 2012 2013 2014 2015 2016 2017 2018
Iowa Substance Abuse Brief: Methamphetamine use and trends in Iowa, October, 2019. Increasing Size of Methamphetamine Seizures 2018-2019
Meth seizures on border on routes north: Feb 6, 2019—Pharr—1,005 pounds-bell peppers Feb 20. 2019—Pharr—906 pounds-strawberries
Iowa DEA reports bi-weekly loads of 20 to 50 pounds.
Western Iowa trafficking linked to Kansas City & Omaha. More meth in central Source: DEA & western parts of state. Characteristics of Meth Clients in Treatment in Central Texas in 2014
• N=222; 83% White; 54% female. • 46% injected, 34% inhaled, 19% swallowed, 60% smoked. • More females completed high school (83% vs. 76%). • Females had more children living with them. • Females scored 8 on Severity of Dependence Scale vs. 7 for males • 63% had seen a mental health professional; 67% had been given meds for depression and 60% meds for anxiety. • Over 89% said a family member had drug problem, 94% said a family member had a drinking problem, 90% said family had psychological problem, and 87% had a family member who had been in jail. • 41% as youths had drunk with family members and 34% had done drugs with family members.
Maxwell, JC. A New Survey of Methamphetamine Users in Treatment Biggest Risks of Meth Use: Mental
% Paranoia 38 Depression 35 Anxiety/panic 35 Damage to brain function 28 Psychosis 17 Aggressive/violent behavior 16 Memory impairment 12 Cognitive impairment 4 Long-term physical problems 9 Lack of motivation 8
Maxwell, Substance Use and Misuse, 2014 Biggest Risks of Meth Use: Personal Problems & Drug Use Problems % Legal/police problems 29 Family & child social services 22 Financial problems 20 Social/relationship problems 20 Employment problems 18
Addiction/dependence 38 HIV/AIDS 16 Hepatitis 15 Overdose 11 Unknown strength/contents 8 Taking more than intended 5 Maxwell, Substance Use and Misuse, 2014 Biggest Benefits of Meth Use 0 10 20 30 40 50 60 70 80
Increased energy/stay awake Weight loss Do more housework/care of kids Enhanced sexual experience The high Fun/good time Female Feeling in control/focused Male More social To not be depressed Increased confidence Enhanced mood/euphoria Work more hours or jobs *p=.05 Enhanced closeness/bonding Relax/escape
Maxwell, Substance Use and Misuse, 2014 Suggestions for Sobriety Counselors Women are more likely to have higher unemployment, lower education level, engage in sex trade or other professions as source income. Encourage healthy body image. Living in a situation where the woman was exposed to alcohol or drug use was strongest predictor of not remaining abstinent. Need sober housing for women and their children. Males have different reasons for using meth. Emphasize safer sex while under influence of meth; limit participation in sexual marathons. Emphasize better adaptive coping skills such as seeking social support to lessen negative emotions that could encourage risky behavior. Emphasize damage to health and mental problems rather than bad teeth or skin problems. As clients learn about the addiction process, explain that with the cognitive damage they may have suffered, their mental health symptoms will decrease over time as they continued to recover. Maxwell, JC. A New Survey of Methamphetamine Users in Treatment, Substance Use and Misuse, 49:6, 2014. Available Behavioral Therapies for Methamphetamine or Cocaine
• No FDA-approved medications for methamphetamine craving • Contingency Management plus community reinforcement is the most effective and acceptable intervention for both short- and long-term treatment of individuals with cocaine and/or amphetamine addiction. (De Crescenzo F, et al. (2018) PLoS Med 15(12) and Rawson et al., Archives Paper CM vs. CBT in methadone (200), ARCH GEN PSYCHIATRY/ VOL 59, SEP 2002 n Cocaine • Poison control, treatment, deaths, & tox lab indicators for cocaine in Texas are increasing. • The acreage under cultivation in Columbia is up with peace treaty between government and FARC rebels (Revolutionary Armed Forces of Colombia— People's Army). • DEA reports price per pure gram decreased from $259 in 2012 to $160 in 2018 while purity increased from 39% to 85%. • Cocaine powder can be injected or sniffed/inhaled. Crack is cocaine to which baking soda or an other base chemical has been added and with water turned into crack “rock”. Acidic cocaine will flash and burn while basic cocaine will smolder so it can be smoked. • Prepare to see more powder cocaine. Preliminary analysis of Texas cocaine admissions 2012-2017 found more inhaling, more White and Hispanic users, more females, more employed, fewer problems with cj system. • Contingency management and community reinforcement are the most32 effective social-psychological approaches.
National Cocaine Indicators: 1994 - 2017
600000 16000
14000 500000
12000
400000 10000
300000 8000
6000 200000
4000
100000 2000
0 0 Calls Control or of Poison Number Deaths 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 Numbers for Cultivation, Treatment Admits, Tox Lab Admits, Tox Treatment for Numbers Cultivation, Coca Cultivation Overdose Deaths Poison Control Calls Treatment Admissions 313 • Levamisole is cancer Problems with medication also used in Cocaine Use de-worming animals. • Can result in agranulocytosis (discoloration of skin, beginning in ears—sign of skin cell death) • Results in neutropenia (bone marrow does not make enough white blood cells)
33 Available Behavioral Therapies for Methamphetamine or Cocaine
• No FDA-approved medications for methamphetamine or cocaine. • Contingency Management plus community reinforcement is the most effective and acceptable intervention for both short- and long-term treatment of individuals with cocaine and/or amphetamine addiction.
De Crescenzo F, et al. (2018) PLoS Med 15(12) and Rawson et al., Archives Paper CM vs. CBT in methadone (200), ARCH GEN PSYCHIATRY/ VOL 59, SEP 2002 Iowa HIV Diagnoses by Exposure Category: 2008-2018
100
80 64% 65% 60
40
20
0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Men who have sex with men (MSM) Injection Drug Use (IDU) MSM and Injection Drug Use ( MSM/IDU) Heterosexual Contact Old Club Drugs Don’t Die: They Reappear
• “XO” is new term for ecstasy and oxycodone. • “G” is GHB (gamma-hydroxybutyric). • “Lean” or “DXM” is promethazine and codeine. • “Ecstasy” term used to refer to the old K-2 versions of synthetic cannabinoids. • Fentanyl is being cut into other drugs. • People who are out on the street are the best source of information: HIV outreach workers, STD workers, needle exchanges, tobacco stores, etc. Changes in Synthetic Drugs: Changes in Packaging Characteristics of Synthetic Cannabis Admissions to Public-Funded Texas Treatment: 2011-2018
2011 2012 2013 2014 2015 2016 2017 2018 80
60
40
20
0 % Black % Hispanic % White % Male Age Synthetic Drugs Identified in U.S. Tox Labs: 2010-2018 Includes phenethylamines, psychedelics, tryptamines, hallucinogens, cathinones, synthetic cannabinoids
80000 70120 70000 62467 60241 60000 53307 51943 47509 50000 44252 40234 40000 37826
30000
20000
10000
0 2010 2011 2012 2013 2014 2015 2016 2017 2018 Iowa Synthetic Drugs Identified by Year
1200 10000
1000 8000 800 6000 600 4000 400
200 2000
0 0 2013 2014 2015 2016 2017 2018 Tryptamines Synthetic Cannabinoids Synthetuc Cathinones Piperazines Psychedelics-- LSD, Psilocybine Hallucinogens Phenethylamines Phenethylamines include NBOMe, 2C-B What happens after treatment in ER? Courtesy of Dr. Carlos Tirado and Dr. Isela Werchan • After the ED visit, some are referred to psychiatric hospital to be stabilized due to suspected synthetic cannabinoid- related psychosis and aggression. May be persisting psychosis leading to involuntary commitment. • More serious cases in need of emergency medication and isolation are individuals with previously diagnosed psychotic disorders. Goal is to stabilize them to transition to outpatient care. • Those with higher premorbid functioning have greater likelihood of returning to baseline while those with prior psychotic disorders may have unclear baseline. • What are the care options for a population with psychotic disorders and experiencing homelessness? Cost to society? Marijuana
• Accurate labeling and standardized dosing have been problems in use of street-grade pot, medical marijuana and in purchasing edible products. • Increased potency but few studies on effects of potency and Impaired driving (and effects of medical marijuana on ailments). • Texas poison center data in 2017 found users of edible portions such as marijuana-laced candy were the youngest and more likely to have suffered moderate or major effects and one death. Change in Attitudes Toward Marijuana Legalization: 2018
Millennials-22-37 Gen X-38-53 Boomers-54-72
Silent 73-90
http://www.pewresearch.org/fact-tank/2018/10/08/ Pew Research Center Blunts Cone
36 Blunt Wraps Juuls Electronic Cigarettes that contain “pods” of nicotine, glycerol and propylene glycol, benzoic acid, and flavorants similar to flavors in blunt wraps (“Mellow Mango”). In states with decriminalized cannabis, can contain “pods” of cannabinoid oil.
Vitamin E Headlines from one web site on cannabis packaging • What you need to know about child resistant packaging • Unlicensed sale of CBD products in Iowa • 6 more cannabis pesticides available for use in Colorado • 4 Tips to create cannabis packaging that sells • Counterfeit cannabis vape cartridges and how to avoid them • 4 Pro Photography Tips for Your Dispensary Inventory • The emergence of luxury cannabis • The rise of craft cannabis • How to enter the cannabis extraction industry • Safety guidelines for cannabis cultivation business • Take your cannabis to the next level with premium packaging • The importance of automation in your marijuana grow operation STAYING UP TO DATE ON DRUG TRENDS
• Tracking drug trends involves using federal and state datasets such as NSDUH surveys, mortality and treatment reports, as well as law enforcement data such as DEA intelligence reports, toxicology identification of seized items, reports from local law enforcement, and NDEWS website and reports. • Use data from hospital emergency department, hospitalization rates for drugs, and characteristics of persons in drug treatment. • Also use information from public servants who work with substance users or people at risk of substance use, such as HIV outreach coordinators, STD workers, drug overdose prevention workers, and treatment professionals. • Monitor national trends such as overdose deaths to figure out why your numbers are higher or lower • Expand your knowledge about treatment methods and medication assisted treatment for different drugs Questions/Thoughts? • How do we continue to monitor all these different drug trends? • How do we provide the latest and most effective treatment? • How do we train staff in the latest knowledge and techniques? • Do we build stronger partnerships with other agencies and rely on them to fill some needs? • Are our services readily accessible as our population grows? • How do upgrade our epidemiological knowledge about impending drugs trends? We need to take advantage of what our staff knows. Jane C. Maxwell, Ph.D. Research Professor Addiction Research Institute Center for Social Work Research The University of Texas at Austin Austin, Texas 78712 512 656-3361 Google for 2019 Texas Drug Trends
57