FLORIDA FRONTLINE: CHANGING PATTERNS OF PRESCRIPTION DRUG ABUSE AND EMERGING SYNTHETIC DRUGS

Transcription

1 FLORIDA FRONTLINE: CHANGING PATTERNS OF PRESCRIPTION DRUG ABUSE AND EMERGING SYNTHETIC DRUGS Presented by: James N. Hall, Epidemiologist Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University This product was supported by Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding

2 Learning Objectives Cite two key sources of prescription drugs diverted from legitimate medical use in Florida before 2011 Name two or more actions since 2010 that helped reduce the number of Florida deaths related to the non-medical abuse of prescription drugs Identify two factors in the rise of heroin use in Florida since 2011 Provide two or more street names used for synthetic cathinones sold and abused in Florida Describe the symptoms of the Excited Delirium Syndrome

3 Prescription Drug Abuse in Florida Responding to an Epidemic: 2000 to 2015

4 Part I: The Nonmedical Rx Epidemic 2000 to 2010

5 Number of Rx Opioids Detected in Deceased Persons # of Opioids Detected Among Decedents in Florida: Rx Opioids* All Opioids 3,246 *The 3 Rx Opioids are Methadone, Hydrocodone, and Oxycodone 6,608 4,282 SOURCE: Florida Medical Examiners Commission Reports

6 in Ft. Lauderdale Pill Mill.The doctor i

7 9,201,731 Dose Units 25 in Broward County

8 Sources of Oxycodone Dose Units Dispensed Annually in Florida ,000,000 Pills 440,000,000 Pills Dispensed by Practitioner Dispensed by Pharmacist or Hospital Source: Analysis of US Department of Justice 2009 and 2010 data by NSU Center for Study And Prevention of Substance Abuse

9 7,000 6,000 Numbers of Substances Identified among Decedents in Florida: 2010 Escambia Santa Rosa Okaloosa W alton Holmes W a s hington Bay Jackson Ca lhoun Gulf Libe rty Gadsden Le on Franklin Wakulla Je fferso n Nas sa u Ham ilton Ma dis on Ba ke r Duval Suwannee Ta ylo r Union St. Clay Johns Gilchrist Dix ie Alachua Putnam Flagler Lafayette Pinellas Le vy C olum bia Bra d fo rd Pasco Hillsborough Ma nate e Ma rion Citrus La k e Sumter He rna nd o Sarasota Polk Harde e De Soto Charlotte Le e Seminole Orange Osceola Highlands Glade s Collie r Monroe Volusia Hen dry B re va rd O ke e cho be e Indian River St. Lucie Ma rtin Palm Beach Broward Dade 6,188 6,608 All Rx = 13,549 Alcohol + Illicit Drugs = 6,757 5,000 4,000 3,992 3,000 2,000 1, , Source: Florida Department of Law Enforcement: Florida Medical Examiners Commission Report 2010

10 Numbers of Rx Drugs Identified among Deceased Persons in Florida Present 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 Cause 13,549 2,710 individuals died with at least one 8,420 5,129 prescription drug in their system that was, in the opinion of the medical examiner, the cause of death (Lethal Dose). 0 Rx Meds Source: FDLE Florida Medical Examiners Commission Report 2010

11 Number of Selected Lethal Rx Opioid Occurrences Among Deceased Persons in Florida Jan 2008 to Dec 2010 # Cause of Death Occurrences Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan Dec 2010 Reports H'08 2H'08 1H'09 2H'09 1H'10 2H'10 Oxycodone Methadone Morphine Hydrocodone Fentanyl

12 Number of Lethal Oxycodone Reports Detected Among Decedents by Age Groups in Florida: 2010 # of Oxycodone Reports State of Florida 1, <18 yrs yrs yrs yrs. >50 yrs. Source: FDLE Florida Medical Examiners Commission Report 2010

13 Rate of NMU Rx Opioid Emergency Department Reports Per 100,000 Miami-Dade, Broward and Palm Beach Counties, and USA: Rate per 100, Broward & Palm Beach USA Miami-Dade SOURCE: US Dept. HHS-SAMHSA, CBHSQ: DAWN Emergency Dept. Estimates

14 Rates per 100,000 of Rx Opioids Nonmedical Use Emergency Department Reports by Age Groups DAWN Ft. Lauderdale Division vs. USA: 2010 Rate per 100, yrs yrs yrs. Broward & Palm Beach yrs yrs yrs yrs. USA > 64 yrs 15 SOURCE: US Dept HHS-SAMHSA, CBHSQ: DAWN Emergency Dept. Estimates.

15 25% Percent of Primary Addiction Treatment Admissions for Rx Opioids among all substances (including alcohol) in Florida: 1998 to % 20% 15% 10% 5% 0% 10.8% 7.3% 8.3% 5.4%5.4% 4.2% 2.1% 2.6%3.4%4.8%4.8% 16.1% Source: SAMHSA - Treatment Episode Data Sets Submitted by the Florida Dept. of Children and Families as of April 5, 2012

16 Number of Primary Addiction Treatment Admissions for Prescription Opioids in Florida by Age: 1999 vs Number of Primary Addiction Treatment Admissions for Prescription Opioids n= 2, % < 31 yrs. n= 11, % < 31 yrs & over ,127 3,092 1, SOURCE: US Dept. HHS-SAMHSA, CBHSQ: Treatment Episodes Data Set (TEDS) as reported by the Florida Department of Children and Families 04/05/2012

17 Number of Neonatal Abstinence Syndrome Diagnoses State of Florida: Number of NAS Diagnosis % Increase ,019 1, Source: Florida s State Epidemiology Work Group

18 # of Drugs Detected Among Decedents Number of Nonmedical Rx Opioid and Benzodiazepine Reports Detected among Decedents in Florida ,000 6,000 5,000 4,000 3,000 2,000 1, ,035 4,416 5,059 2,608 2,973 3,339 Opioids 5,454 6,006 6,608 4,167 4,340 6,188 Benzodiazepines

19 Percent of Other Drugs Detected in the 1,185 Lethal Oxycodone Deaths in Florida: % 70% 60% 50% 40% 30% 20% 10% 0% 72% 42% Source: Analysis of 2009 Florida Medical Examiner Commission Complete Electronic Database by Nova Southeastern University Center for Study & Prevention of Substance Abuse 12% 9% 7%

20 Escambia Okaloosa Holmes Bay Jackson Gadsden Calhoun Leon Liberty Wakulla Gulf Franklin Madison Hamilton Taylor Suwannee Union Baker Nassau Clay Duval St. Johns Florida Counties Ranked High in 2010 on Three or More of the Following Indicators: Rate of Rx Opioid Deaths Rate of Rx Benzodiazepine Deaths Rate of Overdose ED Visits/Hospitalizations Pain Clinics per 100,000 Treatment Admissions for Rx Drugs Number of high indicators: Dixie Gilchrist Alachua Levy Pinellas Pasco Marion Hillsborough Manatee Putnam Citrus Lake Sumter Hernando Polk Hardee Sarasota De Soto Charlotte Lee Flagler Seminole Orange Volusia Osceola Highlands Glades Hendry Indian River St. Lucie Martin Palm Beach Collier Broward Dade Source: Florida s State Epidemiology Work Group

21 Percent of those Age 12 & Above Who Report Nonmedical Use of Pain Relievers in Past Year USA 4.87 % Percent Range: 2.96 % to 8.11 % Source: NSDUH Substate Data

22 It s an Epidemic: An Epidemic of Deaths and Addiction Not so much an Epidemic of Number of Users Rx Rx Rx Rx Rx

23 Summary: The Rx NMU Epidemic in Florida From : Rx Opioid Medical Examiner Drug Reports increased 64-% Benzodiazepine Medical Examiner Drug Reports rose 58-% Treatment Admissions for Rx Opioids increased 347-% Neonatal Abstinence Syndrome cases increased 426-% The number of Rx drug deaths peaked at 2,710 persons in 2010, a 24-% increase since 2008 By 2010 there were 914 Pain Management Clinics in Florida

24 Part II: The Response 2009 to 2015

25 2009: FL Senate Bills 462 and 440 Florida joined thirty-four other states when it established a Prescription Drug Monitoring Program (PDMP) with the passage of Senate Bill 462 and companion Senate Bill 440 exemption of PDMP records from public records requirements. Yet, PDMP not funded or functional until the Fall of 2011

26 2010 July 2010 Senate Bill 2272 provided (1) legal authority for the Department of Health to shut down illicit pain management clinics; (2)includes improved standards of care that must occur at registered clinics; and (3) limited practitioner dispensing of CS Schedule II to 3-day supply. August 2010 New tamper-resistant reformulated OxyContin OP is shipped by manufacturer.

27 2011 February 2011 Operation Pill Mill: South Florida March 2011 Florida Law Enforcement Drug Strike Force created

28 2011 July 1, House Bill 7095 goes into effect. It Bans direct dispensing by medical practitioners, New permitting & inspection regulations for pharmacies, Shortening from 15 days to 7 days the PDMP dispensing reporting requirement, Codified new patient standard of care measures for physicians with enhanced penalties, $ 3 million for law enforcement Strike Force to close pill mills

29 # Cause of Death Occurrences Number of Selected Lethal Rx Opioid Occurrences Among Deceased Persons in Florida 2008 to CS-II Dispensing Limits & OxyContin Tamper Resistant Strike Force House Bill 7095 Takes effect Oxycodone Methadone Morphine Hydrocodone Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan Dec 2013 Reports

30 # of Drugs Detected Among Decedents 7,000 6,000 5,000 4,000 3,000 2,000 1,000 Number of Nonmedical Rx Opioids and Benzodiazepine Reports Detected among Decedents in Florida ,059 5,454 4,035 4,416 2,608 Opioids 2,973 3,339 4,167 6,006 6,608 6,333 6,188 4,340 CS-II Dispensing Limits and OxyContin Tamper Resistant 5,947 5,489 5,184 Strike Force 5,085 4,304 House Bill 7095 Takes effect Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan Dec 2013 Reports

31 Hydromorphone (e.g.., Dilaudid ) 2013 ARCOS Grams Sold Per 100/Population STATE TOTAL GRAMS GRAMS/ 100K POP 1 FLORIDA 270, , DELAWARE 10, , VERMONT 6, CONNECTICUT 34, VIRGINIA 67, MONTANA 8, NEW 7 HAMPSHIRE 10, MARYLAND 43, WASHINGTON 48, OREGON 27, # of Hydromorphone Occurrences Source: US DEA ARCOS 3 Report 4 March 5, Hydromorphone Related-Deaths in Florida Source: Florida Medical Examiners Commission

32 Number of Neonatal Abstinence Syndrome Diagnoses State of Florida: Number of NAS Diagnosis ,019 1,336 OxyContin Tamper Resistant 1,563 1, House Bill 7095 Takes effect Source: Florida s State Epidemiology Work Group

33 30% 25% 20% 15% 10% 5% 0% Percent of Primary Addiction Treatment Admissions for Rx Opioids among all substances (including alcohol) in Florida: 1998 to % 2.1% 2.6%3.4%4.8%4.8% 4.2% 5.4%5.4% 7.3% 8.3% 16.1% 27.5% 25.1% 23.9% Source: SAMHSA - Treatment Episode Data Sets Submitted by the Florida Dept. of Children and Families as of May 8, 2014

34 Number of Unique Patients Identified By Threshold Levels Number of Prescribers and Number of Pharmacies by Quarter ,000 5 Prescribers & 2,864 5 Pharmacies 51-% Decrease Level ,097 1,415 Level Level 7 Source: Annual Report Florida s Prescription Drug Monitoring Program (PDMP) Levels 9, Level 8 178

35 Summary: Response to Florida s Rx NMU Epidemic From : Rx Opioid Med. Exam. Drug Reports decreased 23-% Benzodiazepine Med. Exam. Drug Reports declined 30-% Rx Opioids Treatment Admissions declined 9-% Neonatal Abstinence Syndrome cases increased 22-% The number of Rx drug deaths declined to 1,916 persons in 2013, a 29-% reduction since 2010 By 2014 there were 376 Pain Management Clinics in Florida down 59-% since 2010 PDMP reduces Level 5 Doctor Shopping by 51-% from January 2012 to December 2013

36 May 15, 2013 February 19, 2013

37 Number of Heroin Deaths in Florida: # Heroin Deaths SOURCE: Florida Medical Examiners Commission Reports

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40 Metabolism of Heroin Heroin (diacetylmorphine) is metabolized to morphine. Heroin undergoes rapid deacetylation to 6-monoacetylmorphine (6- MAM), which is about 6 times more potent than morphine. 6-MAM is further deacetylated to morphine. The effects of heroin are attributed to the combined effect of heroin, 6-MAM, and morphine. Diacetylmorphine 6-monoacetylmorphine (6-MAM) Morphine

41 # Cause of Death Occurrences Number of Selected Lethal Rx Opioid Occurrences Among Deceased Persons in Florida 2008 to 2013 CS-II Dispensing Limits & OxyContin Tamper Resistant Strike Force House Bill 7095 Takes effect [VALUE] Oxycodone Methadone Morphine Hydrocodone Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan Dec 2013 Reports

42 Number of Deaths Heroin and Morphine Deaths in Florida Heroin Morphine Total Total 767 Morphine 568 Heroin 199 SOURCE: Florida Medical Examiners Commission Reports

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46 STRATEGIES TO PREVENT OVERDOSE DEATHS 1: Encourage providers, persons at high risk, family members and others to learn how to prevent and manage opioid overdose. 2: Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders. 3: Ensure ready access to naloxone. 4: Encourage the public to call : Encourage prescribers to use state Prescription Drug Monitoring Programs (PDMPs).

47 Naloxone Nasal Spray

48 Naloxone Auto-Injector

49 Source: FL-DCF Florida Youth Substance Abuse Survey

50 Source: FL-DCF Florida Youth Substance Abuse Only increase was in Rx Amphetamine Use

51 Prevention Strategies Lock you Meds Rx Drug Return and Disposal Programs Promote only the appropriate use of all medications Proper Use can be Miracle Drug Misuse can be Poison

52 Emerging Synthetic Drugs FAKE DRUGS; REAL POISONS

53 Drugs Not spice, bath salts, nor incense Psychoactive Substances Change the Brain s Functions Complex Chemistry Complicated Neuropharmacology

54 Classes of Emerging Synthetic Drugs Phenethylamines Cathinones Cannabinoids Tryptamines Piperazines Opiates Benzodiazepine Analogs

55 32 Kinds of Synthetic Phenethylamines Stimulants/Hallucinogens Phenethylamines Amphetamines Methamphetamines 2-C Series ( NBOMe ) 5 types 3,4-METHYLENEDIOXYMETHAMPHETAMINE (MDMA) 12 Others PLUS 12 Cathinones

56 12 Kinds of Synthetic Cathinones Stimulants/Hallucinogens Cathinones Synthetic Khat MDPV Methylone Alpha-PVP Ethylone Butylone 7 Others

57 Cathinone Stimulants often have trendy names and slick packaging White lightening Zoom Cloud 9 Cloud 10 Red Dove Blue silk Moon dust NRG (4-MEC) Head trip Radiance Ivory Wave Power surge Sextasy Vanilla Sky

58 22 Kinds of Synthetic Cannabinoids JWH Series (John W. Huffman) 8 types in Florida AM 2201 UR-144 XLR-11 PB-22 AB-FUBINCA AB-PINACA And 8 Others in Florida

59 Toxicity: Potency and Efficacy Potency: Low dose strong effects Efficacy: Strong maximum effects. Many Cannabinoids show higher potency and more severe effects than Cannabis.

60 Other Synthetic Drugs Tryptamines Related to Psilocin, DMT, Serotonin Piperazines BZP TFMPP Opiates Benzodiazepine Analog -Etizolam

61 Whole New Pharmacopoeia? Synthetic Stimulants, Hallucinogens, and Marijuana Substitutes First wave were Not New Science 40 years of Pharmaceutical Research, but Rejected for Medical/Human Use More Recently: Molecular Manipulation

62 21 st Century: The Perfect Storm Cheap to make in China and elsewhere Easy to Market Worldwide via Internet Particularly to Drug Users Subculture International Delivery Services Legal Retailers Not for Humans The Mimic Drugs Fake Pot, Fake Ecstasy Motivation for use: Beat the Drug Test Highly Profitable Global Phenomena

63 The World Tour Europe Australia New Zealand

64 Tracking in Florida Crime Lab Analysis Medical Examiner Toxicology Testing Confirmed Chemical Content

65 35,090 Emerging Synthetic Drug Crime Lab Reports in Florida: Number of Crime Lab Reports Synthetic Cathinones Synthetic Cannabinoids Other Phenethylamines* *Other Phenethylamines than Cathinones 3,951 4, , , Source: Analysis of US DEA - National Forensic Laboratory System Data

66 # of Drug Occurrences 543 Emerging Synthetic Drug Deaths Present in Florida Cause of Death Cannabinoids Cathinones Other Phenethylamines* *Phenethylamines Other than Cathinones Source: FDLE Florida Medical Examiners Commission, November 2014

67 Florida Phenethylamine Deaths in 2013 Phenthylamines 9 Amphetamine Methamphetamine Other Source: FDLE Florida Medical Examiners Commission, November 2014

68 Source: US DEA National Forensic Laboratories Information System

69 Source: US DEA National Forensic Laboratories Information System

70 Palm Beach, Broward, & Miami-Dade

71 Methamphetamine Trends Related Deaths State of Florida Primary Treatment State of Florida Florida Crime Labs State of Florida vs Up 16 % vs % 2 % Up 25 % vs ,616 3,997 Up 10 %

72 Methamphetamine and Amphetamine Crime Lab Cases in Florida: Number of Crime Lab Reports All Other Phenethylamines Amphetamine 2C Series MDMA Methamphetamine Source: Analysis of US DEA - National Forensic Laboratory System Data

73 Number of Crime Lab Reports Phenethylamine (excluding Cathinones) Crime Lab Cases in Florida: Other Phenethylamines Amphetamine 2C Series MDMA Methamphetamine Source: Analysis of US DEA - National Forensic Laboratory System Data

74 MDMA and Phenethylamine (excluding Cathinones) Crime Lab Cases in Number of Crime Lab Reports 1600 Florida: Other Phenethylamines Amphetamine 2C Series 600 MDMA Source: Analysis of US DEA - National Forensic Laboratory System Data

75 2C Phenethylamines 2C-B 2C-I N-BOMe

76 Synthetic Cathinone Crime Lab Cases in Florida: Number of Crime Lab Reports All Other Cathinones MDPV Alpha-PVP Methylone Ethylone Source: Analysis of US DEA - National Forensic Laboratory System Data

77 Looking for Molly She Makes Me Want to Dance

78 Methylone is beta-ketone MDMA Molly

79 Flakka Flaca Skinny Flaka Beautiful, elegant woman who charms all Elsewhere called Gravel alpha-pvp a-pyrrolidinovalerophenone

80 South Florida Crime a-pvp Lab Cases: Over 200 Toxic Effects: Tachycardia, Agitation, Psychosis, Violent behavior, Excited Delirium Hyperthermia Kidney failure Death

81 Excited Delirium Excited Delirium is a medical emergency that presents itself as a law enforcement problem. - Early and advanced coordination with EMS is key. Excited Delirium is not easy to recognize. - Training is important so that dispatch or other personnel recognize behavioral signs. Excited Delirium containment requires backup personnel. - Do not approach until it is safe to do so and always ensure several officers are present. Excited Delirium victims exhibit superhuman strength and are impervious to pain. - Do not Hog Tie Excited Delirium is a life-threatening emergency. - Get the subject into acute medical care quickly.

82 Fake Flakka Cocaine + Methamphetamine +Heroin = Addiction on steroids

83 Percent of Emerging Synthetic Cathinones ( bath salts ) Detected in Deceased Person in Miami-Dade County, FL: Source: Miami-Dade County Medical Examiner s Office

84 2014 NMS Lab Results for Bath Salts Detected in Blood Samples

85 The Changing Face of Ecstasy, Molly, Flakka, et al in Florida Crime Lab Reports Number of Crime Lab Reports Ethylone Methylone Alpha-PVP Other Cathinones MDMA (Phenethylamine) Cathinones Ethylone Methylone Alpha-PVP Other Cathinones MDMA Source: Analysis of US DEA - National Forensic Laboratory System Data

86 New Drugs of Abuse, New Regulations, New Drugs of Abuse, New Regulations

87 Synthetic Cannabinoids Crime Lab Cases in Florida: Number of Crime Lab Reports AM-2201 XLR-11 AB-FUBINACA PB-22 UR-144 AB-PINACA Various JWH All Other Cannabinoids 2,087 1,996 1, Source: Analysis of US DEA - National Forensic Laboratory System Data

88 Percent of Florida High School Students Reporting Having Used Synthetic Marijuana in the Past 30 Days 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 4.3 % 1.4 % Source: Florida Youth Substance Abuse Survey

89 Budder Beware: Dangers of Marijuana Wax Marijuana Wax Budder, or Butane hash oil, or even ear wax hash Produced by soaking marijuana plant material in a solvent such as butane which extracts various cannabinoids of the plant.

90 Question: What was the Oxford English Dictionary's 2014 Word of the Year?

91 Answer: The Oxford Dictionary 2014 Word of the Year was vape, the verb used to describe inhaling and exhaling vapors produced by an electronic cigarette or similar device. Vape originated as an abbreviation of vapor or vaporize, according to Oxford Dictionaries. Oxford explained: You are thirty times more likely to come across the word vape than you were two years ago, and usage has more than doubled in the past year.

92 Electronic Smoking Device

93 Disposable Hookah No Tar No Ash No Fire

94 Marijuana Pens

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96 known to cause: Cancer Birth Defects or Other Reproductive Harm

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98 Kratom: To Ban or Not to Ban? Photo Source: FoxNews.com

99 Large tree indigenous to Thailand and Malaysia Leaves are usually chewed but it can be found in a dried form to create powder, tinctures and resins and is sold in the US as a powder, or in capsules, and as liquid.

100 Kratom Commercial Packaging

101 The Future?? Synthetic Opiates Benzodiazepine-Analogs Etizolam Not Controlled in USA Order it on line

102 Dangers of Synthetic Drugs Excited Delirium, Kidney Failure, Death More Addictive and Deadly ever month Guinea Pig drugs Both Short and Long-term Psychosis Linked to Violent Behavior Legal Strategies Information Dissemination: it s not what they say it is

103 Questions