Substance Abuse Trends: Old and New Drugs
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Transcript of Substance Abuse Trends: Old and New Drugs
Substance Abuse Trends:Old and New Drugs
Jane Maxwell, Ph.D.Addiction Research Institute
Center for Social Work ResearchThe University of Texas at Austin
3-6%
1-2%
11-14%
Percentage of Drug Items Identified as Heroin by Tox Labs: NFLIS 2010
7-10%
15-16%
<1%
30-44%
11-15%
16-19.%
5-9%
Percentage of Drug Items Identified as Cocaineby Tox Labs: NFLIS 2010
20-29%
<5%
5-8%
1-3%
17-24%
Percentage of Drug Items Identified as Methamphetamine by Tox Labs: NFLIS 2010
11-14%
25-34%
0%
Heroin34%
Heroin3%
Cocaine42%
Cocaine32%
Cocaine29%Cocaine
13%
Heroin9%
Cocaine6%
Cocaine3%
Heroin25%
Cocaine7%
Heroin10%
Meth8%
Cocaine17%
Heroin11%
Meth9%
Meth17%
Meth27%
Meth13%
Meth25%
Heroin16% Heroin
13%
Primary Drug of Abuse at Admission to Treatment: 2009
SISVEA & TEDS
Cocaine8%
Cocaine14% Meth
1%Meth2% Heroin
1%
Heroin8%
Meth4%
Meth1%
* ALCOHOL USE BY YOUNG WOMEN
* DRUGGED DRIVING
QUICK SNAPSHOT OF PROBLEMS TO BE ADDRESSED
Percentage of Texas Secondary Students Who Reported They Normally Consumed
Five or More Drinks at One Time, by Gender: 2000–2012
2000 2002 2004 2006 2008 2010 20120%
5%
10%
15%
20%
25%
30%
35%
22% 22%20%
18% 18% 17% 16%
32%30%
26%24% 23% 22%
20%
Girls Boys
Liu, L. Texas School Survey of Substance Use Among Students in Grades 7-12, DSHS.
Females and Drinking• Rates of STD higher for Texas females than males
until they reach age 45+ (DSHS).• Women who binge drink have higher rates of STDs
and more partners. Interventions should address binge drinking and risky sexual behaviors (Hutton, 2008, ACER).
• When women preparty or participate in drinking games, they consume fewer drinks than males but reach comparable BAC levels and experience same amount of consequences (Hummer et al., RSA, 2012).
Percentage of Texas Seniors Who Had Driven While Drunk or High from
Drugs: 1990–2012
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
0%
5%
10%
15%
20%
25%
30%
35%29%
15%
11%
16%
Driving While Drunk Driving While High From Drugs
Source: DSHS
Of those who drove 1+ times after drinking and 1+ times high on drugs, 50% did both
2007 National Roadside Survey: Prevalence of Drugs with Oral Fluid
Illegal BAC (alcohol)
THC
Narcotic Analgesics
Sedatives
Stimulants
Overall Drug Positive
0 10 20
0
2
2
2
2
11
2
6
2
1
3
14Night Day
PercentNHTSA Traffic Safety Facts, July & December 2009, DOT HS 811 175 & 249
Items Identified by Toxicology Laboratories: NFLIS 2004-2012
2004 2005 2006 2007 2008 2009 2010 2011 20120
5
10
15
20
25
30
35
40
CannabisCocaineMethamphetamineHeroin
Source: DEA NFLIS
Average Purity of Heroin Samples in the US: 2003-2011
Southeast Asian Southwest Asian Mexican South American0%
10%
20%
30%
40%
50%
2003 2004 2005 2006 2007 2008 2009 2010 2011
DEA’s Heroin Domestic Monitor Program
Mexican Black Tar Heroin
Mexican Brown Heroin
Mexican White Heroin
South American Heroin
Heroin• Almost all heroin in the U.S. is from Mexico or South
America. • East of the Mississippi, white South American heroin
and in West , Mexican heroin, but seeing Black Tar move eastward and into the South, while South American now seen in Chicago and St Louis.
• Number of U.S. heroin treatment admissions under age 25 increased from 16,357 in 1992 to 57,060 in 2010.
• Reports of increasing heroin use among suburban youth and young users in Austin and in the US.
• Harm Reduction Kits and wound/abscess care
Average Age of Persons Dying with Mention of Heroin in Texas: 1992-2011
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
31
32
33
34
35
36
37
38
39
40
41
37
39 38 3838
40
3738
38
39 39 39 3940 39
37
40
3635
34
Age
(Yea
rs)
Source: DSHS
*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org **no data available for FY 2000-2001
1993-1994
1994-1995
1995-1996
1996-1997
1997-1998
1998-1999
1999-2000
2002-2003
2003-2004
2004-2005
2005-2006
2006-2007
2007-2008
2008-2009
2009-2010
0
20
40
60
80
100
120
140
160Naloxone distribution begins, 2003
Heroin-Related Deaths, San Francisco: 1993-2010
Other Opiates
•Shifting back and forth between Rx opiates and heroin. Which came first? More research needed.•Cost difference? In Texas, heroin cap is $10-$20 vs. $1/mg for 72 mg OxyContin and impact of “abuse resistant” formulations.•Some injection drug users report prescription opiate use predates heroin use and tolerance motivates them to try heroin. But other reports of those who became addicted to prescription opiates and when controls were tightened, then shifted to heroin.•Pollini et. Al., Problematic use of prescription-type opioids prior to heroin use among young heroin injectors. Substance Abuse and Rehabilitation 2011: 2 173-180, Lankenau SE, et al. (2012). Initiation into prescription opioid misuse amongst young injection drug users. Int J Drug Policy. 2012 Jan;23(1):37-44. Epub 2011 Jun 20.
Change in Rates of ED Visits for Misuse or Abuse: DAWN 2004-2011
Hydrocodone
Oxycodone
Methadone
Alprazolam
Zolpidem (Ambien, etc.)
Muscle Relaxants
Marijuana
Central Nervous System Stimulants*
0% 50% 100% 150% 200% 250% 300% 350%
96%
220%
74%
155%
152%
71%
86%
292%
*Increase in CNS Stimulants is among adults over 18 using ADHD stimulants
Texas Heroin and Other Opiate Admissions by Age Group: 2005-1/2 2012
Heroin
2005
2006
2007
2008
2009
2010
2011
2012
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
50+40s30s20sU20
Other Opiates
2005
2006
2007
2008
2009
2010
2011
2012
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
50+40s30s20sU20
Source: DSHS
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
2,000
4,000
6,000
8,000
10,000
12,000
Natural and semi-synthetic opioid analgesic Methadone
Cocaine Heroin
Synthetic opioid analgesic, excluding methadone
Num
ber o
f dea
ths
Number of Drug Poisoning Deaths: United States, 1999--2010
NOTES: Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm
Drug poisoning death rates by age: United States, 1999-2010
CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
5
10
15
20
25
30
15-24 years 25-34 years 35-44 years 45-54 years55-64 years 65 years and over
Dea
ths
per 1
00,0
00 p
opul
atio
n
BABY BOOMERS
1
2
3
4
5
6
Nonmedical Use of Pain Relievers: NSDUH 2011
All Ages 50-54 55-59 60-64 65 or Older
0
2
4
6
8
10
12
14
16
1314
12
6
34
3 21 1
2 1 1 1 0
LifetimePast YearPast MonthPe
rcen
t
“SYRUP” in Texas Codeine cough syrup
continues to be abused. Cut with Karo syrup, jolly
ranchers, and soft drink. Rap music on syrup continues. Prepackaged to introduce to
youths or ready to add the syrup?
Pharmacologic Treatments for Alcohol and Opiates
Naloxone/Narcan for opiate overdosesOpiates:
Naltrexone (Revia)-1 pill per dayDepo-Naltrexone (Vivitrol)-injected every 30 days. Methadone-daily oral doseBuprenorphine—daily pill or film
• Duo (Suboxone-film buprenorphine + naloxone• Mono (was Sububex but now generic)
Alcohol Naltrexone (Revia) 1 pill per dayDepo-Naltrexone (Vivitrol)-injected every 30 days. Acamprosate (Campral)-1 pill 3x/dayDisulfiram (Antabuse)-1 pill/day.
Drugs targeting cocaine and methamphetamine under development
Cocaine: What’s going on?• Poison control, treatment, deaths, & tox lab
indicators down nationwide; price up. • Amount of coca under cultivation in South America is
down 15%• Demand in Europe for cocaine.• Use of Levamisole as a filler with serious medical
consequences.• Users in Austin report it is so weak “not worth paying
for”.• Vitamin C vs. lemon juice & safe smoke kits
Global Cocaine Flows: 1998cocaine consumption in metric tons
26763
267
Global Cocaine Flows: 2009cocaine consumption in metric tons
157123
New Problems with Cocaine
• Levamisole is cancer medication also used in de-worming animals.
• Found in almost 100% of all cocaine now—added in South America.
• 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)
Marijuana
• Blunts--Impact of new way of using cannabis
• What will happen with medical marijuana and legalization?
% Texas Secondary Students Who Had Used Marijuana in the Past Month, by
Ethnicity: 1990-2012
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
0%
5%
10%
15%
20%
25%
Anglos
African Americans
Hispanics
Source: DSHS
Monitoring the Future Survey: 1991-2012: Marijuana Use by 12th Graders
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
0102030405060708090
100
% Used in Past Year% Great Risk in Using% Strongly Disapprove of Use% Easy or Very Easy to Get
Consequences of Marijuana AbuseAcute (present during intoxication)• Impairs short-term memory• Impairs attention, judgment, and other cognitive
functions• Impairs coordination and balance• Increases heart rate• Psychotic episodesPersistent (lasting longer than intoxication,
but may not be permanent)• Impairs memory and learning skills• Sleep impairment
Long-Term Cumulative Effects of Chronic Abuse
• Can lead to addiction• Increases risk of chronic cough, bronchitis• Increases risk of schizophrenia in vulnerable individuals• Age of onset of cannabis use directly associated with age at
onset of psychosis and age of first hospitalization.• May increase risk of anxiety, depression, and amotivational
syndrome• New finding suggesting neurotoxic effect of cannabis on the
adolescent brain and cessation did not fully restore functioning.
National Institute on Drug Abuse, Research Report Series, Marijuana Abuse, updated 9/2010.Galvez-Buccollini et al., Association between age at onset of psychosis and age at onset of cannabis use in non-affective psychosis. Schizophrenia Research, 139 (1), 157-160, 2012; Meier; Caspi, Ambler et al., Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences, published ahead of print, August 27, 2012.
www.nida.nih.gov/ResearchReports/Marijuana/default.html
Another Excellent Resource
National Cannabis Prevention and Information Centre
http://ncpic.org.au.
SPICE
SYNTHETIC CANNABIS
Cannabis vs. Cannabinoids: Clinical Cases
Most symptoms are similar to cannabis intoxication•Tachycardia•Reddened eyes•Anxiousness•Mild sedation•Hallucinations, acute psychosis•Memory deficits
Symptoms not typically seen after cannabis intoxication• Seizures• Hypokalemia (low potassium level) • Hypertension (high blood pressure)• Nausea/vomiting• Coma• Agitation, violent behavior• Acute kidney injury• Some batches may have longer half-lives leading to prolonged
psychoactive effect.
Schneir 2012 J Med Tox; Rosenbaum et al. 2012 J Med Chem; Forrester et al. 2011 J Add Dis; Hermanns-Clausen et al. 2012 Addiction; MMWR 62(06);93-98, 2/15/13.
Cannabinoids Identified in U. S. NFLIS Toxicology Labs
JWH-018 64%JWH-073 ; 9%
JWH-081 ; 6%
JWH-250 ; 14%
19 variations reported in 2010
AM-2201 35%
JWH-01816%
JWH-081 6%
JWH-12213%
JWH-210 9%
SYNTHETIC CANNABINOID
7%
44 variations reported in 2011
AM-220141%
6%
SYNTHETIC CANNABINOID
MAM-2201 4%
UR-144 13%
XLR-1114%
55 variations reported in 2012
SOURCE: National Forensic Laboratory Information System, 2010, 2011, 2012
• JWH-018/073 arrived early and have come and gone.
• JWH-250 arrived a little later and has also cycled out.
• JWH-081 was part of a second wave that has already completed its cycle.
• JWH-122 was part of the same wave but has persisted in popularity and is part of the current scene.
• AM-2201 was part of the same second wave and has gained in popularity, probably currently the most prevalent.
• JWH-022 and JWH-210 are showing signs of increasing popularity.
• Recent emergent drugs are the adamantoyl (AM-1248) and tetramethylcyclopropyl (XLR-11 and UR-144) indoles which are ahead of the latest attempts to schedule these drug classes.
Source: B. K. Logan, Testing Strategies to Monitor Novel/Emerging/Designer Drug Use in At-Risk Populations, CPDD 2012
Timeline
Texas Poison Control Exposures and Effect of Controls
Synthetic Cannabis
0
20
40
60
80
100
Synthetic Cathinones
Jan 1
0Apr Ju
lOct
Jan 1
1Apr Ju
l Oct
Jan 1
2Apr
Ju
lyOct Ja
n0
20
40
60
80
100
SOURCE: Forrester, M.B. (2013). Synthetic Cannabinoids (Marijuana Homologs) 2013 and Synthetic Cathinones (Bath Salts) Reported to the Texas Poison Control Network Update, March 1, 2013.
Amphetamine-Type Stimulants:MDMA, Khat, Meth, Amphet, Synthetic
Cathinones
An Emerging Liking for Speedy or Upper Drugs?
Comparison of Amphetamine and Methamphetamine Indicators in Texas
2011
NFLIS Methamphetamine
NFLIS Amphetamine
Treatment Methamphetamine
Treatment Amphetamine
020
0040
0060
0080
0010
000
1200
014
000
11967
657
2441
2117
Source: DSHS and NFLIS
Median Methamphetamine Purity in the Continental United States (1985-2005)
Months
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Med
ian
Pur
ity
0
20
40
60
80
100
US ephedrine single ingredient
product regulation
US pseudoephedrineproduct regulation
US ephedrine andpseudoephedrine bulk
powder regulation US ephedrine combinationproduct regulation
Canada precursor import/export
regulation
Canada precursor domestic distribution regulation
Canada essential chemical regulation
US pseudoephedrine retail sales regulation
Overall
Impact of US and Canadian precursor regulation on methamphetamine purity in the United States. (Cunningham JK, Liu L-M, Callaghan R. Addiction; 104, 441-453, 2009.
Meth trends are cyclical
All Methamphetamine Purchases Domestic STRIDE Data
January 2007 –June 2012
Jan-M
ar07
Apr-Ju
n07
Jul-S
ep07
Oct-Dec
07
Jan-M
ar08
Apr-Ju
n08
Jul-S
ep08
Oct-Dec
08
Jan-M
ar09
Apr-Ju
n09
Jul-S
ep09
Oct-Dec
09
Jan-M
ar10
Apr-Ju
n10
Jul-S
ep10
Oct-Dec
10
Jan-M
ar11
Apr-Ju
n11
Jul-S
ep11
Oct-Dec
11
Jan-M
ar12
Apr-Ju
n12
$0
$50
$100
$150
$200
$250
$300
$350
0.00
20.00
40.00
60.00
80.00
100.00
$159
$227
$289$306
$245
$244
$199
$179$189
$139$140
$128$126$112$104
$98$105$93 $94 $86 $90
$81
59
45
41
4248
55 56
65 6772 74
77 82
88 88 90 90 92 90 91 92 93
76 66
64
7477 76 76
7580 83
88
Pric
e Pe
r Pur
e G
ram
Purit
y in
Per
cent
From July 2007 through June 2012, the price per pure gram of Methamphetamine decreased 72%, from $288.69 to $81.29, while the purity increased 128%, from 41% to 93%.
Different Manufacturing ProcessesI. Ephedrine/Pseudoephedrine Based (d-form):
A. “Nazi Method”-lithium, anhydrous ammoniaB. Cold method-red phosphorus, iodine crystalsC. “One Pot” and “Shake and Bake” cooking using dry ammonia nitrite and cough syrup rather than liquid anhydrous ammonia.
II. P2P/Phenylacetone (Illegal in US-Schedule II, precursor legal in Mexico) (l and d,l-forms).
If drug is 100% potent, it’s all d-form. If 0% potent, is all l-form. Mexican chemists are refining their process to produce more potent P2P meth.
DEA Methamphetamine Profiling Program: 2010-4th Q 2012
3&4
2008
1Q-1
0
3Q-1
0
1Q-1
1
3Q-1
1
1Q-1
20%
20%
40%
60%
80%
100%
Purity and PotencyPurity PotencyMSM
3&4Q
-06 2008
1Q-10
3Q-10
1Q-11
3Q-11
1Q-12
3Q-12
0%
20%
40%
60%
80%
100%
Production RoutesP2PPhosphorus Iodine
Source: DEA
Meth in Austin Now• Crystal is back and easy to get.• Injecting meth is more socially acceptable
than in the past.• Seems more centered in a closed MSM
population.• Users reporting better highs, more
psychosis—IS METH PROBLEM GETTING WORSE?
Glimpses of MDMA Situation: 1999-1/31/13
1999
2001
2003
2005
2007
2009
2011
2013
0102030405060708090
Results of Pill Tests Containing MDMA*
Any MDMA MDMA Only
•Australian EDRS reports drop in MDMA use from 52% in 2003 to 27% in 2011 and up to 32% in 2012.•Both Australia and UK reported MDMA “drought”.•Shift from PMK to safrole to make MDMA.•Predictions of return of high quality MDMA but from China, not BeneLux sources.
*http://www.ecstasydata.org/stats_substance_by_year.php
Emerging Psychoactive Drugs in Texas
Psychedelics
Stimulants
Examples of Major Psychedelic Drugs
DRUG NAME DESCRIPTION2C-I Phenethylamine, via PiHKAL; stimulant and
hallucinogenSlow onset (1 hr); long duration of action (8-10 hr.)
2C-B Phenethylamine, via PiHKAL; visualsFaster onset (1 hr.); shorter duration than 2C-I
5-MeO-DMT Tryptamine; naturally occurring (toad, shamantic brews)Smoked: almost immediate, very intense, short effect (<30 min)
DMT Tryptamine; naturally occurringSmoked: almost immediate, very intense, short effect (<20 min)
SOURCE: Slide courtesy of R. Bruno et al., Emerging psychoactive substance use, DAD, 2011, with revisions by James Hall, 2012.
2C-Phenethylamine• A broad range of compounds
that share a common phenylethan-2-amine structure.
• Some are naturally occurring neurotransmitters (Dopamine and Epinephrine), while others are psychoactive stimulants (amphetamine), entactogens (MDMA), or hallucinogens (the 2C-X series of compounds).
• 2 C-X can be snorted or dissolved into a liquid and placed on blotter paper under the tongue.
• May last 6-10 hours; onset takes 15-120 minutes.
• Reports of seizures and renal failure.
Source: Michigan Department of Community Health, Weekly Imminent Danger Notification Update Briefing-August 23, 2012
52
Examples of Major Stimulant Drugs/Synthetic Cathinones
DRUG NAME DESCRIPTIONMephedrone 4-methyl-methcathinone; “Miaow”
Similar to cocaine and MDMA (ecstasy)Methylone β-MDMA: 3,4-methylenedioxy-methcathinone;
“Explosion”Similar to cocaine and MDMA (ecstasy)
MDPV 3,4-methylenedioxyprovalerone; MDPV; “NRG-1” (Brandt, 2010); “Ivory Wave”Stimulant with rapid onset; 2-4 hour duration of action
BZP 1-benzyl-piperazoneSimilar to amphetamine1/10 potency of d-methamphetamine
SOURCE: Slide courtesy of R. Bruno et al., Emerging psychoactive substance use, DAD, 2011, with revisions by James Hall, 2012.
• Cathinone mimics the effects of the Khat Plant.• Could be 4-MMC, mephedrone, orover 37 other varieties.• Sold on-line with little info on ingredients, dosage, etc.• Advertised as Legal Highs, Legal Meth, Cocaine, or Ecstasy.• Taken orally or by inhaling.• Serious side-effects include tachycardia, hypertension,
confusion or psychosis, nausea, convulsions.*• Labeled “not for human consumption” to get around laws
prohibiting sales or possession.• Austin outreach workers report bath salt use declined
quickly among injecting drug users*Wood & Dargan, Novel Psychoactive Substances: How to Understand the Acute Toxicity Associated with the use of these substances, Therapeutic Drug Monitoring, 34: 363-367, 2012.
Synthetic Cathinones:Bath Salts
Clinical effects of bath salts in patients admitted to ED (N=236)
Agitation 82%Combative/Violent behavior 57%Tachycardia/Racing heart 56%Hallucinations 40%Paranoia 36%Confusion 34%Myoclonus/Movement disorders 19%Hypertension 17%Chest pain 17%CPK elevations 9%
Source: Spiller et al., 2011
Synthetic Cathinones Identified in U. S. NFLIS Toxicology Labs
4-MEC
4-MEC
BUTYLONE
ETHYLCATHINONE
FLUO-ROMETH-
CATHINONE
METH-CATHINONE
NAPHYRONE
SOURCE: National Forensic Laboratory Information System, 2010, 2011, 2012 .
8 varieties identified in 2010
4-MEC
BUTYLONE
FLUORO METH-
CATHINONE
PENTEDRONE
SUBSTITUTED CATHINONE
25 varieties identified in 2011
4-MEC
ALPHA-PVP
BUTYLONE
PENTEDRONE
37 varieties identified in 2011
Chromatography - Screens• Challenges with Identification
• Do not give colored reaction with Marquis field test• Variable quality and availability of reference standards• Immunoassay field tests for methamphetamine give
false positive reactions for some cathinone derivatives.
• Some items may contain ketamine, cocaine, or piperazine derivatives.
• We know little about thedetailed pharmacology andthey are constantly changing.
Source; B. K. Logan, Testing Strategies to Monitor Novel/Emerging/Designer Drug Use in At-Risk Populations, CPDD 2012
http://www.uclaisap.org/slides/synthetic-drug-training-package.html
Other Club Drugs (that won’t go away)
• PCP, ketamine, dextromethorphan (dissociative drugs & specific dosing)
• GHB is still around and still some mentions of sexual assault with it. Immediate need for rape kit.
• LSD and other hallucinogens still around but in lower doses so not as obvious.
• Rohypnol is still present along the Texas-Mexico border.• Kratom-opioid-like effects from plant in SE Asia• Salvia divinorum-hallucinogenic herb with intense effects;
unpleasant & won’t use again.• BZP & TFMPP are combined to be an alternative to MDMA.• Will they ever go away or just cycle back again?
www.utattc.net