Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-027117 on 29 April 2019. Downloaded from Descriptive, observational study of pharmaceutical and non-pharmaceutical arrests, use, and overdoses in Maine Kevin J Simpson,1 Matthew T Moran,1 Michelle L Foster,2 Dipam T Shah,1 Daniel Y Chung,1 Stephanie D Nichols,3 Kenneth L McCall,4 Brian J Piper1 To cite: Simpson KJ, Moran MT, ABSTRACT Strengths and limitations of this study Foster ML, et al. Descriptive, Objectives The Maine Diversion Alert Program grants observational study of healthcare providers access to law enforcement data on ► All arrests involving illicit or licit drugs reported to pharmaceutical and non- drug charges. The objectives of this report were to analyse pharmaceutical arrests, use, and the Diversion Alert Program of Maine in 2017 were variations in drug charges by demographics and examine overdoses in Maine. BMJ Open examined. recent trends in arrests, prescriptions of controlled 2019;9:e027117. doi:10.1136/ ► Controlled substance transactions reported to the substances and overdoses. bmjopen-2018-027117 Drug Enforcement Administration were evaluated. Design Observational. ► Drug-induced deaths (n=2432) reported to the ► Prepublication history and Setting Arrests, controlled prescription medication Maine Office of Medical Examiner were analysed. additional material for this distribution and overdoses in Maine. paper are available online. To ► These complementary results from Maine may not Participants Drug arrestees (n=1272) and decedents view these files, please visit generalise to larger states with younger or more di- (n=2432). the journal online (http:// dx. doi. verse populations. org/ 10. 1136/ bmjopen- 2018- Primary outcome measures Arrestees were analysed by 027117). sex and age. Substances involved in arrests were reported by schedule (I–V or non-controlled prescription) and into KJS and MTM contributed opioids, stimulants or other classes. Controlled substances is an electronic resource available statewide equally. reported to the Drug Enforcement Administration (2007– since 2013 and was developed to combat 2017) were evaluated. Drug-induced deaths (2007–2017) 2 Received 8 October 2018 drug diversion. Law enforcement agencies reported to the medical examiner were examined by the Revised 5 March 2019 report information on individuals facing substance(s) identified. Accepted 21 March 2019 charges for drug-related crimes to a data- http://bmjopen.bmj.com/ Results Males were more commonly arrested for base shared with healthcare providers.2 3 This stimulants and schedule II substances. More than two- thirds of arrests involved individuals under the age of 40. information is used to manage care plans so that further diversion of prescription drugs is Individuals age >60 were elevated for oxycodone arrests. 2 Over three-fifths (63.38%) of arrests involved schedule II– limited. Arrestee demographics, drug(s) and IV substances. Opioids accounted for almost half (44.6%) offence(s) are relayed to the DAP to support 2 4–6 of arrests followed by stimulants (32.5%) and sedatives prevention research and monitoring. (9.1%). Arrests involving buprenorphine exceeded those Variations in drug use by sex and by age are for oxycodone, hydrocodone, methadone, tramadol and of interest since women and the elderly have on September 25, 2021 by guest. Protected copyright. © Author(s) (or their morphine, combined. Prescriptions for hydrocodone 7–9 employer(s)) 2019. Re-use been overlooked. Drug misuse prevalence (−56.0%) and oxycodone (−46.9%) declined while permitted under CC BY-NC. No in the elderly may be underestimated due commercial re-use. See rights buprenorphine increased (+58.1%) between 2012 and to addiction being mistaken for dementia, 2017. Deaths from 2007 to 2017 tripled. Acetylfentanyl and permissions. Published by depression10 or so-called ‘pseudoaddiction’.11 BMJ. and furanylfentanyl were the most common fentanyl 1 Female gender was a risk factor for substance Medical Education, Geisinger analogues identified. 12 Commonwealth School Conclusions Although the overall profile of those arrested use disorders among the elderly. A higher of Medicine, Scranton, for drug crimes in 2017 involve males, age <40 and percentage of adult women in Maine received Pennsylvania, USA heroin, exceptions (oxycodone for older adults) were prescriptions for opioids, benzodiazepines 2 4 Diversion Alert, Houlton, Maine, observed. Most prescription opioids are decreasing while and stimulants than did men. However, men USA 3 deaths involving opioids continue to increase in Maine. in the USA generally report more illicit drug Pharmacy Practice, Husson 9 University, Bangor, Maine, USA use of almost all varieties. 4Pharmacy Practice, University Use of controlled substances is changing 4 5 13 of New England College of INTRODUCTION in the USA. Relative to their peak Pharmacy, Portland, Maine, USA Substance use disorders and overdoses are in 2011, there were decreases by drug important health issues facing the USA. weight nationally in oxycodone (−13.8%), Correspondence to Dr Brian J Piper; There were approximately 72 000 overdose morphine (−18.9%), fentanyl (−21.4%) and 1 5 bpiper@ som. geisinger. edu; deaths in 2017 with two-thirds due to opioids. hydrocodone (−28.4%) in 2016. A 25% psy391@ gmail. com The Maine Diversion Alert Program (DAP) production quota reduction of controlled Simpson KJ, et al. BMJ Open 2019;9:e027117. doi:10.1136/bmjopen-2018-027117 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-027117 on 29 April 2019. Downloaded from substances by the Drug Enforcement Administration Carfentanil, an agent approved for veterinary use, has (DEA) in 201814 may be anticipated to result in further been identified in Ohio fatalities.22 The vast majority of decreases. Buprenorphine, used to treat an opioid illicit fentanyl and analogue deaths were male.20 use disorder (OUD), showed a pronounced eleva- The primary objective of this report was to provide an tion (+75.2%).5 Although there are concerns about updated2 4 6 account of trends in drug charges as reported buprenorphine access, particularly in rural areas, 15 of to the DAP and analyse variations in drug charges by sex the 16 Maine counties has at least one physician and and age. A secondary objective was to obtain information one advanced-practice provider waivered to prescribe about how controlled substances and drug deaths have buprenorphine.15 been changing over the last decade in Maine. Overdoses are complex events that often involve multiple drugs of different classes (illicit, prescription, over the counter and alcohol) and pre-existing health vulnerabilities. Their incidence and reported origin METHODS should be interpreted with caution.16 17 The US Centers Subjects for Disease Control and Prevention (CDC) recognises Law enforcement personnel submitted information the varying quality of overdose determinations and regarding age, sex, town of residence, drug(s), offence, classified states into three different categories: very arrest date and reporting agency for persons with arrests/ good to excellent (25 states including Maine), good summons to the Maine DAP in 2017 who were age >18 (7 states), and other (presumably less than good, 18 (n=1272, 30.5% female, mean age=33.69, SD=9.68, states).18 Testing practices depend on priorities and min=18, max=67). resources with variability across municipalities, espe- The DEA’s Automation of Reports and Consoli- cially for the more expensive confirmatory testing.19 dated Ordering System (ARCOS) monitors controlled Unfortunately, the drug implicated in over one-third of substance transactions in the USA and territories. unintentional overdose deaths in five states was coded ARCOS is a comprehensive pharmacoepidemiology as ‘unspecified’.17 data source which tracks schedule II and III controlled The epidemic of opioid overdoses has transitioned substances provided to pharmacies, hospitals, emer- from prescription opioids to heroin to illicitly manufac- gency rooms, narcotic treatment programs (NTP), tured fentanyl.14 Although there are scores of known veterinarians and dentists at private and public (e.g., fentanyl analogues, WHO has paid particular attention to Veterans Affairs, Indian Health Services) facilities.5 acetylfentanyl, butyrylfentanyl, acryloylfentanyl, carfen- Maine has a centralised state medical examiner system tanil, furanylfentanyl and ocfentanil.20 Acetylfentanyl with the Office of the Chief Medical Examiner collecting 21 16 23 can be an artefact in the synthesis of illicit fentanyl. information. Maine received funding on 9/2016 for http://bmjopen.bmj.com/ on September 25, 2021 by guest. Protected copyright. Figure 1 Drugs reported to the Maine Diversion Alert Program by class in 2017. The Federal Controlled Substances Act schedule is in parentheses. LSD, lysergic acid diethylamide; MDMA, methylenedioxymethamphetamine; MDA, methylenedioxyamphetamine; PVP, alpha-pyrrolidinopentiophenone. 2 Simpson KJ, et al. BMJ Open 2019;9:e027117. doi:10.1136/bmjopen-2018-027117 Open access BMJ Open: first published as 10.1136/bmjopen-2018-027117 on 29 April 2019. Downloaded from Table 1 Drugs by class and sex reported to the Maine Diversion Alert Program in 2017 Males Females Female Class (N) (1128), % (486), % ratio Opioids (719) 69.26 30.74 2.25 Stimulants (524) 73.85 26.15 2.82† Sedatives (146) 69.18 30.82 2.24 Misc pharmaceutical 60.19 39.81 1.51‡ (108) Hallucinogens (47) 68.09 31.91 2.13 Other (70) 64.29 35.71 1.80 *χ2 p<0.05 versus †non-stimulants