Epidemic November 29, 2018 Phases of a Drug Epidemic Plateau 35 30 25 Expansion 20 15 10 Users & Problems X Users 1000 & Problems X 5 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Yr 10 Incubation Incubation Expansion & Problems # of Users Plateau Decline James N. Hall, Senior Epidemiologist Center for Applied Research on Substance Use and Health Disparities Time Nova Southeastern University Components of Substance Use Disorder Epidemiology Contributing Factors of a Drug Epidemic • Host - The User • Agent – The Substances • Environment - Social, Economic, and Geographic Conditions Contributing Factors – Supply Vectors Contributing Factors – Demand Vectors • Production •Attitudes: • Perceived Harmfulness • Patterns of Trafficking • Perceived Wrongfulness • Price • Acceptance by others • Purity • Desired Effects • Profit • Withdrawal – “Dope Sick” • Public Consensus • Availability • Cost • Poisonous Contamination • Rapid Onset of Action • Access Jim Hall [email protected] 1 Epidemic November 29, 2018 Reoccurring Patterns of Opioid Epidemics: 1880 - 2018 Opioids 1990 - 2018 Reoccurring Heroin & Fentanyls Patterns of 1955 - 1970 Rx Opioids Substance Use 1880 - 1900 Disorder Heroin Epidemics Morphine & Heroin 1880 – 2018 # # of users and level of consequences 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2018 The Morphine Molecule DEFINITION OF OPIOID • Binding to and activating “Similar to opium” the opioid μ receptors in the brain and spine Morphine and similar drugs derived from opium • Principal effect on the central nervous system and gastrointestinal tract All substances, both natural and synthetic, that bind to opioid • Primary actions are receptors in the brain and body analgesia and sedation. History of Opioids TYPES OF OPIOIDS • Opium the first drug from early agricultural civilizations • Illegal Heroin • Assyrians invented slicing the poppy pod • Sumerians - The “Joy Plant” • Legal Prescription Opioid Pain Relivers • Egyptians first produced opium as a drug – Thebaine • Greeks (e.g., Oxycodone, Hydrocodone, Methadone, • Indian Subcontinent Morphine, Rx Fentanyl, et al) • Medieval Trade spread the drug • Illicitly manufactured Opioid Analogues • 1804 German pharmacist first isolated Morphine (e.g., Fentanyl, U-4700, et al sold as Heroin or • Named after the Greek god of sleep and dreams, Morpheus adulterants to Heroin, Cocaine or other drugs, and counterfeit prescription pills) • 19th Century 330 Wars forced production of Morphine • Heavily used in US Civil War • Leaving many addicted ??? Jim Hall [email protected] 2 Epidemic November 29, 2018 History of Opioids in the U.S. • In 1874, Heroin was created in Germany and sold in History of Opioids in the U.S. the United States as a “safe, non-addictive” substitute for morphine. • From the late 1800’s to the 1900’s, drug companies sold over-the-counter drug kits containing glass barreled hypodermic needles and vials of morphine or heroin. • Heroin, morphine and other opiates were sold legally in the U.S. until controlled by Harrison Narcotic Tax Act in 1914 and made illegal in the 1920’s •200,000 heroin addicts in the U.S. by 1925 ADDICTION RARE IN PATIENTS TREATED WITH NARCOTICS To the Editor: Recently, we examined our current files to History of Opioids in the U.S. determine the incidence of narcotic addiction in 39,946 hospitalized medical patients' who were monitored consecutively. Although there were 11,882 patients who received at least one • 1950’s – Drug Advertising and Direct Marketing to narcotic preparation, there were only four cases of reasonably Physicians – antibiotic Terramycin well documented addiction in patients who had a history of addiction. The addiction was considered major in only one • 1960’s – Valium becomes first $100 million drug instance. The drugs implicated were meperidine in two patients, • 1980’s – NEJM Porter and Jick Letter to Editor Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the Purdue Pharma releases MS Conti development of addiction is rare in medical patients with no WHO Ladder of Pain treatment history of addiction. • 1996 - Purdue Pharma releases OxyContin JANE PORTER Nation’s first Pill Mill South Shore, KY HERSHEL JICK, M.D. th Boston Collaborative Drug American Pain Society – Pain as 5 Vital Sign Surveillance Program Boston University Medical Center Waltham, MA 02154 Jim Hall [email protected] 3 Epidemic November 29, 2018 Symptoms of Opioid Withdrawal • nausea •mood swings • sweating •depression • cramps •anxiety • vomiting •muscle soreness • diarrhea •aching bones • insomnia •fever • loss of appetite •runny nose • agitation •twitching • irritability “Dope Sick” Addiction is the Affliction Total Opioid Users 11,963,000 Rx Opioids 11,077,000 Heroin 886,000 Total Opioid Initiates 2,081,000 Rx Opioids 2,000,000 Heroin 81,000 Jim Hall [email protected] 4 Epidemic November 29, 2018 Sources of Origin for Wholesale-Level Heroin Seizures In the United States: 2000 -20016 Percent of Heroin Seizures of Percent Source: DEA Jim Hall [email protected] 5 Epidemic November 29, 2018 Numbers of Drug Overdose Deaths by Drug or Drug Class and Year in the United States 1999-2017 Synthetic Opioids (includes Fentanyls) 29,406 Heroin 15,958 Other Opioids 14,958 Cocaine 14,556 Methamphetamine 10,721 Methadone 3,295 Source: National Center for Health Statistics, CDC WONDER Source: NIDA and National Vital Statistics System, Mortality File, CDC WONDER Epidemic of Opioid Addiction and Deaths The Perfect Storm Or For For Pain Tolerance Pleasure Rx Need More OUD Pill Mills “Dope Sick” Street Mexican Heroin Fentanyl Analogues el al IM Opiates Polysubstance Abuse Xanax Cocaine Counterfeit Pills Marijuana In 10-state study, almost 57% of people who died from an overdose Alcohol Abstinence which tested positive for fentanyl and/or fentanyl analogs Whatever Relapse also tested positive for cocaine, methamphetamine, or heroin. Overdose Number of Crime Lab Reports of Fentanyl Alone and Fentanyl-Contaminated Cocaine Headlines In Combination with Other Drugs in the USA: 2016 Ft. Lauderdale Fentanyl Alone 22,278 DEA warns of deadly contaminated cocaine in South Florida Fentanyl & Heroin 8,017 Philadelphia Fentanyl & Opioids 1,341 Number of USA Crime Lab Reports Fentanyl & Cocaine 496 Fenanyl & Other 577 New Jersey Substances Fentanyl & Heroin & Cocaine 492 0 5000 10000 15000 20000 25000 Source: DEA – National Forensic Laboratory Information System Data Queried August 2017 This Photo by Unknown Author is licensed under CC BY-ND Jim Hall [email protected] 6 Epidemic November 29, 2018 Reoccurring Patterns of Stimulant Epidemics:1880 - 2018 Cocaine – The Origin • Since 15th Century – Andean South American native people 1975 - 2018 chewed coca leaves to relieve hunger and dispel fatigue Cocaine • 1859 – Alkaloid cocaine isolated by German pharmacist, Albert Niemann • Dr. Theodore Aschenbrandt - Bavarian Army cocaine water solution for exhausted collapsed solider who cheerfully 1880 - 1920 resumed the march • Dr. Sigmund Freud: “a magical drug” * recommended to friends and colleagues • Because of numbing effects became a standard treatment for # # of users and level of consequences eye disorders and local anesthetic for minor surgery and dentistry 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2018 • By 1863 Vin Mariani – coca leaves and Bordeaux wine The First Cocaine Epidemic 1880 -1920 Introduction Phase - the Drug Rapidly Gains Acceptance • 1884 – Purified cocaine commercially available in USA • Wholesale cost very high $5-10 per gram but fell to 25 cents a gram until WW I compared to average wage at 20 cents per hour. Retail price $2.50 per gram • Popular in the US: sold from drug and grocery stories, saloons and patent-medicine vendors “Fortifies and Refreshes Body and Brain” Old Town Saloon Restores Heath and Vitality Jim Hall [email protected] 7 Epidemic November 29, 2018 The First Cocaine Epidemic 1880 -1920 The First Cocaine Epidemic 1880-1920 Introduction Phase Middle Period - Use Spreads, Adverse Effects Revealed • Freud published 5 papers about Cocaine • 1885 – John Pemberton registers a trademark for: “French Wine • Some physicians believed cocaine Coca - Ideal Nerve and Tonic reduced cravings for opiate addicts Stimulant” and alcoholics • 1886- Renamed as “Coca-Cola” • 1887 – Noted neurologist William • Encouraged by medical authorities and entrepreneurs as an elixir for the masses Hammond’s cocaine wine 2 grams/pint instead of ½ gram in Vin Mariana • Touted as a panacea for melancholia, neuralgia, hysteria and nervous afflictions 2 grams The First Cocaine Epidemic 1880-1920 The First Cocaine Epidemic 1880-1920 Middle Period - Use Spreads, Adverse Effects Revealed The Repressive Stage 1900 -1920 • 1890s – Decade of Hedonism and Creativity Cocaine Becoming Most Feared of All Illicit Drugs • Reports of cocaine addiction becoming common in medical literature • 1903 - Commission on the Acquisition of the Drug Habit • Late 19th and early 20th Century – Era of Bacteriology declared cocaine, once favored by upper-class professionals, Allowed prescribing of specific medications for more illnesses was being used mostly by "bohemians, gamblers, prostitutes, burglars, racketeers, and pimps." Thus, fewer general elixirs with cocaine and opioids • As use of cocaine increased so did abuse. • Chronic abuse led to paranoid delusions, insomnia, malnutrition and nasal septum ulcerations. The First Cocaine Epidemic 1880-1920 The First Cocaine