Proceedings of the Denver Epidemiology Work Group (DEWG) The Denver Office of Drug Strategy The Denver Drug Strategy Commission

Transcription

1 Proceedings of the Denver Epidemiology Work Group (DEWG) The Denver Office of Drug Strategy The Denver Drug Strategy Commission Released July 24, 2012

2 Table of Contents Purpose and Distribution. 3 Membership and Attendance..4-5 April 12, 2011 Meeting Agenda.. 6 Denver CARES Detox Presentation Denver Mortality Presentation Denver Drug Trends Summary Report: Recent Drug Trends in the Denver Metro Area

3 Purpose and Distribution The Denver Epidemiology Work Group (DEWG) has been established in response to a need identified by the Denver Drug Strategy Commission (DDSC) and the community volunteers who have served on the Drug Strategy Subcommittees for an increase in the accessibility and sharing of comprehensive local data as it relates to ongoing community-level surveillance of drug abuse in the City & County of Denver and the Denver metro area. This report, which summarizes the quantitative and qualitative research data from the DEWG, provides current descriptive and analytical information regarding the nature and patterns, emerging trends, and social and health consequences of alcohol and drug abuse. The DEWG process is patterned after the National Institute on Drug Abuse s Community Epidemiology Work Group, and thus focuses for the most part on surveillance of alcohol abuse and illicit drug abuse, including misuse, diversion, and abuse of prescription drugs. The DEWG members were selected by the Data and Evaluation Subcommittee of the DDSC in 2008 based upon their expertise in substance abuse in the areas of treatment, law enforcement and intelligence, public health, research, and outreach. While all reports completed by the Denver Office of Drug Strategy (DODS) are open to the public, the distribution of this report is intended to alert the DDSC and its constituents to the current conditions and potential problems so that appropriate, timely action can be taken. This report will help to inform the efforts of the DDSC and its subcommittees during the implementation of the Denver Drug Strategy Plan and related campaigns to educate the community and, when appropriate, form policy recommendations. 3

4 Members participating in the sixth meeting of the DEWG convened on April 12, 2012 Candace Cadena Denver Office of Drug Strategy John Cohen Drug Enforcement Administration Chris Conner Denver s Road Home Kristen Dixion Colorado Division of Behavioral Health Andrea Donato Urban Peak Vanessa Fenley Denver Office of Drug Strategy Jonathan Gray Arapahoe House Ron Gowins Office of Behavioral Health, Denver Health April Hendrickson OMNI Institute Helen Kaupang, Drug Enforcement Administration Eric Lavonas Rocky Mountain Poison and Drug Center Jodi Lockhart Denver Office of Drug Strategy Amy Martin Denver Office of the Medical Examiner Bruce Mendelson Denver Office of Drug Strategy Katie Page OMNI Institute Linda Orr Denver Office of Drug Strategy Wendi Roewer Drug Enforcement Administration Don Shriver Denver Police Department Crime Laboratory Audrey Vincent Denver Cares, Denver Health Dale Wallis Denver Police Department Michelle Zucker Urban Peak Guests Present Todd Bunger Arapahoe House Maureen Carney Peer Assistance Services Kent MacLennan Colorado Meth Project Carol Martens Price Arapahoe House Liz Meade Phoenix Multisport Michelle Ponikiski Drug Enforcement Administration David Salinas Phoenix Multisport Julia Smith Centennial Peaks Hospital Kirsten Wall Research Projects, Denver Health Burvell Williams Denver Health Members Excused Kevin Dietrick Colorado Dept. of Transportation Mark Fleecs Denver Police Department Steve Hooper Division of Motor Vehicles Caitlin Kozicki Workplace Programs, Peer Assistance Charles Keep Colorado Dept. of Transportation 4

5 Laurie Lovedale Peer Assistance Services M.R. Marandi Colorado Dept. of Transportation Marcela Paiz IDEA Forum, Inc Allison Sabel Denver Health Jamie Sims CHIP, Children s Hospital Chris Thurstone Denver Health Michael Webster Drug Enforcement Administration Libby Whitmore University of Colorado, ARTS Stephanie Wood Harm Reduction Action Center 5

6 AGENDA Denver Epidemiology Work Group Meeting Thursday April 12, :30 a.m. to Noon Denver Police Dept. District 3 Bldg Community Room at 1625 South University Blvd. Denver, Colorado Welcome, introductions and packet review (8:30 to 8:40) Drug Roundtable (Data overviews and review of responses to questionnaires from law enforcement, treatment, street outreach, Medical Examiner s Office, emergency departments, Rocky Mountain Poison and Drug Center, etc.) o Alcohol Trends (8:40 to 9:15) Trends discussion Denver CARES Community Detox, a presentation on the non-hospital social detox model, by Audrey Vincent, RN, CAC III, Nurse Manager o Denver/Colorado Marijuana Trends (9:15 to 9:35) Regular Marijuana Medical Marijuana Synthetic Marijuana o Drug Markets in Denver: A presentation by Lt. Aaron Sanchez Denver Police Dept. (9:35-10:05) o Heroin Trends (10:05 to 10:20) o Other Opioids Trends (10:20 to 10:35) Break: 10:35 to 10:45 Drug Roundtable continuation: o A Closer Look at Drug Mortality in Denver-Amy Martin, MD and Bruce Mendelson, MPA (10:45-11:00) o Cocaine Trends (11:00 to 11:15) o Methamphetamine Trends (11:15 to 11:30) o Benzodiazepines Trends (11:30 to 11:40) o Bath Salts Trends (MDPV, Mephedrone, etc.) 11:40 to 11:45 Future Plans for the DEWG and Adjourn (11:45 to 12:00) 6

7 Denver CARES Community Detox A presentation on the non-hospital social detox model, by Audrey Vincent, RN, CAC III, Nurse Manager Denver CARES Community Detox Non-Hospital Social Model ASAM PPC 2R Level III.2D Denver CARES Mission Denver C.A.R.E.S is a State licensed 100 bed non-medical facility that provides a safe and humane environment for social detoxification and a 32 bed transitional residential treatment program from the drug of choice

8 History of Denver C.A.R.E.S. In 1976 Denver C.A.R.E.S. (Comprehensive Addictions Rehabilitation and Evaluation Services) was created as the designated place to take the publicly intoxicated. Colorado had adopted the Uniform Treatment Act in 1973 aimed at decriminalizing public intoxication. Establishing a safe place (Social Detox) to take public inebriates took the burden off the emergency rooms and jails. City Partnership with the Downtown business community (contributed largely to get the ESP van service running) Denver C.A.R.E.S. operated out of several locations prior to 1991 then found a home in the Golden Triangle Neighborhood Detox and Treatment Staff 30% Nursing, 30%Counseling, 30% Support staff 78 FTE s (Turnover 17.9% for 2011) Nurses 9 Counselors (CAC) 23 ESP (Emergency Service Patrol) 7 Behavioral Health Techs 18 Clerks 9 Housekeeping 9 Transportation Driver 1 Project Coordinator 1 Case Coordinator 2 Denver CARES does not have a physician on staff

9 Role of Clinical Personnel Nurses: Provide nursing assessment of clients at intake. Monitor vital signs on clients during stay. Assess for signs/symptoms of withdrawal. Obtain physician orders for withdrawal protocol. Dispense medication to clients on protocol and/or who come in with other prescription medications Triage/refer to higher level of care if indicated (ED). Behavioral Health Techs: Assist with intake process, monitor clients in milieu, obtain vital signs, refer clients to nurse or counselor as indicated. Counselors: Assess what stage the client is in his/her addiction and discusses treatment options Detox Referral Sources: High volume census days: 27,235 in 2011 Referral sources: Self: 2,026 ER: 372 Police: 7,417 ESP (emergency service patrol): 9,272 In 2011, 16,689 individuals who were brought in by the police or ESP that probably didn t come in voluntarily

10 Client Presentations at Intake: Intoxicated people display a range of behaviors: Angry, combative, challenging, threatening, yelling, spitting, clenching fists, kicking, screaming, accusing, cursing, swearing, name calling, pounding on desk/wall, refusing, belligerent, throwing things Anxious, frightened, crying, questioning, sad, quiet/not communicating, sobbing, self harming Happy, euphoric, talkative, friendly, jovial, enamored, cooperative, congenial, appropriate, oriented, insightful, thoughtful Intake Process Clients arrive at Denver C.A.R.E.S. brought in by: ESP, DPD, ER, SELF Security: Remove outer layers of clothing Pat down client Remove any contraband Inventory and secure valuables for safe keeping. Intake Triage: Assess vital signs & BAL No ability to test for other drugs Go by clinical presentation, orientation, cooperation Obtain medical-psych-social history Inventory and secure other property Nursing Assessment RN reviews intake & assesses client Makes determination of intoxication Accepts admission and assigns bed Occasionally Triage to ED

11 Typical Detox Stay: Most clients are assigned to a dorm for their stay: Male dorm, female dorm or quiet room (isolation) Vital signs monitored by tech (2-4-8) Abnormal vital signs reported to nurse Length of stay determined by level of intoxication: Assume alcohol 0.02/hour BAL = 8 hours in detox Average Length of Stay for 2011=31.6 hours (includes EC/IC) Withdrawal protocol initiated by nurse as indicated. Counseling staff meet with each client daily to discuss treatment options and completes assessment for discharge and referral. Some clients will be placed on an E.C. and/or I.C. (ALOS 26 days) (Emergency Commitment/Involuntary Commitment) Client is discharged when sober and finished detoxing and appears clinically stable Discharged to self, RTD, hospital, treatment program. By statute discharge no sooner than BAL Alcohol Withdrawal When a person with alcoholism stops drinking. withdrawal symptoms begin within 6-48 hours after the last drink (prior to sober time for chronic drinkers) inhibition of brain activity caused by alcohol is abruptly reversed stress hormones are overproduced the central nervous system becomes overexcited anxiety, irritability, agitation, insomnia, tremors, fever rapid heartbeat, changes in blood pressure, mental disturbances, seizures, delirium tremens (DTs)

12 Delirium Tremens (DTs) Shaking Frenzy DTs are potentially fatal progressively worsening altered mental status hallucinations confusion severe agitation generalized seizures Transfer to Intensive Care Unit for IV Sedation Why Treat Alcohol Withdrawals? To avoid hospitalization: assessing symptoms frequently and administering benzodiazepine doses as needed may reduce the incidence of withdrawal symptoms, delirium, seizures, and transfer to the intensive care unit. To avoid worsening withdrawals: repeated withdrawal episodes, even mild forms, that are inadequately treated may result in increasingly severe and frequent seizures with possible brain damage. In 2011, with 27,235 census days, CARES provided 2100 Tranxene protocols for Alcohol Withdrawal and there were 61 seizures

13 CARES Withdrawal Protocol Benzodiazepines inhibit nerve-cell excitability in the brain and are considered to be the treatment of choice. They relieve withdrawal symptoms, help prevent progression to delirium tremens, and reduce the risk for seizures. CARES Tranxene (clorazepate) protocol: 30 mg at onset of symptoms 30mg again in 2-4 hours 15 mg every 4 hours for 6 doses Total of 150 mg Tranxene given in hours Tranxene has a long ½ life Opiate Withdrawals Opiate Withdrawal Protocol: Tranxene (15mg every 8 hours for 4 doses) Hydroxyzine for 3 days if needed for severe agitation Clonidine in tapering doses for 6 days Over the counter medications: Tylenol or Motrin for pain Kaopectate Maalox Nicorette Very few people stay after the Tranxene is completed

14 Integrated Health Care for Detox clients ESP (Detox Van), Paramedics and the Police are all integrated into the 911 system and work closely with Denver C.A.R.E.S. to address the issue of public intoxication. Denver C.A.R.E.S. is part of The Department of Behavioral Health at Denver Health. Denver C.A.R.E.S. staff work closely with both Medical and Psych Emergency Departments. 385 patients were transferred to the ED in Inpatient and Outpatients referrals are made as needed (pregnant women are referred to women s services) women were offered pregnancy testing, 101 tests were given, 3 were positive in Treatment Referrals All clients are provided referrals at discharge: AA and other self-help groups Outpatient treatment (Traditional or Intensive) Outpatient education (DUI education) Residential programs: Transitional Residential Treatment Therapeutic Community Denver CARES has 32 Transitional Residential Beds RETURN= 10 beds Cherokee House (VA)= 14 beds (males only) CHaRTS= 8 beds in RETURN dorm

15 Return- TRT Rehabilitation, Education, Treatment, United, Recovery, Now (Transitional Residential Treatment) day Treatment Program 80 Admissions / Year 10 treatment slots located at the Denver C.A.R.E.S facility. Focus is on detox clients who have 20+ admissions CHaRTS Comprehensive Housing and Residential Treatment Services (Case Management) day Treatment Program Supportive housing is up to 2 years 25 Admissions / Year 25 treatment/housing slots aimed at the top users (80+ admissions) of detox. 5-8 beds in RETURN dorm Two full time case managers A Collaborative project between Denver Health, CCH and Denver Department of Human Services

16 VA- TRT Veterans Administration-Cherokee House (Transitional Residential Treatment) 6 month Treatment Program 40 Admissions / year 14 treatment slots located at Denver C.A.R.E.S. specific to homeless veterans. A Collaborative project between Denver Health, Veterans Administration and Denver Department of Human Services Comments from the DEWG on Audrey Vincent s Presentation There was a discussion on the cost of treating patients with delirium tremens (DT s), a potentially fatal condition brought on by alcohol withdrawal. The discussion focused on 20 individuals who were treated for DT s at a cost of $800,000 (uncompensated as patients had no insurance). A further discussion focused on the homeless in detox (16,000 out of 27,000 detox admissions in 2011 involved homeless individuals). Concerns were raised as to whether or not homeless individuals may be taken to Denver CARES if shelter beds were full (particularly in connection to Denver s urban camping ban). However, Denver CARES already runs above budgeted capacity and is not licensed as a shelter facility. A discussion also ensued on the problem with putting chronic alcoholics (who are mostly pre-contemplative) through multiple cases of withdrawal which is not considered to be safe. Some wondered if wet housing would be a better option for these individuals. Wet housing are permanent housing facilities in which individuals can enter the facility intoxicated as well as drink alcohol on premise.. 16

17 Number Average age A Closer Look at Drug Mortality in Denver Presented by Amy Martin, MD, Chief Medical Examiner and Bruce Mendelson, MPA A Closer Look at Denver Drug Mortality DEWG Presentation April 2012 A Collaborative Study Denver Office of the Medical Examiner Amy Martin, MD, Chief Medical Examiner Denver Office of Drug Strategy Bruce Mendelson, MPA, Senior Data Analyst Alcohol and Drug Deaths in Denver: 2003 to 2010 Total and by Average Age Average Age of Decedents Alcohol and Drug Related Deaths 17

18 Number Avg. Drugs/Case Percent 60 Denver Alcohol and Drug Mortality by Gender- Race/Ethnicity: 2003 to White Male % Afr. Amer. Male % Latino Male % Asian/Other Male % White Female % Afr. Amer. Female % Latina Female % Asian/Other Female % 600 Alcohol and Drug Mortality in Denver: Total Deaths, Total Drugs Involved and Avg. Drugs Per Case Drugs/Case Deaths Total Drugs 0 18

19 Exhibit 22: Most Common Drugs in Denver Drug Related Decedents: Percent of All Cases Drug Contributing to Cause of Death n % n % n % n % n % n % n % Cocaine Morphine Alcohol Codeine Heroin Methadone Oxycodone Methamphetami ne Acetaminophen Diazepam Alprazolam Hydrocodone Dihpenhydramin e Clonazepam Fentanyl Decedents* A Closer Look at 2009 Denver Drug Mortality 207 total alcohol and drug related deaths 167 (81%) were overdoses, 21 (10%) were suicides, and 18 (9%) were undetermined %--involved at least one Rx drug %--involved a Rx narcotic drug Of the 207, 98 (47.3%) involved persons who died from ingestion of drug combinations that included at least one Rx drug Among the 98, there were 43 different combinations of drugs ranging from only two drugs to eight drugs. Among the 43 combinations, 30 included at least one opioid, 20 included alcohol in combination w/ other drugs, and 17 included at least one opioid and one tranquilizer 19

20 A Closer Look at 2010 Denver Drug Mortality 152 total alcohol and drug related deaths 127 (84%) were overdoses, 17 (11%) were suicides, and 8 (5%) were undetermined % involved at least one Rx drug %-- involved a Rx narcotic drug Of the 152 deaths, 65 (42.8%) involved persons who died from ingestion of drug combinations that included at least one Rx drug Among the 65, there were 38 different combinations of drugs ranging from only two drugs to twelve drugs. Among the 38 combinations, 30 included at least one opioid, 17 included at least one opioid and one tranquilizer and 13 included alcohol in combination w/ other drugs. Denver Alcohol and Drug Mortality for 2010: Age Group Comparison Rx vs. Non-Rx Involved 70.0% 64.6% 60.0% 50.0% 46.0% 54.0% 40.0% 30.0% 20.0% 10.0% 35.4% % Rx & over Non-Rx 20

21 Denver Alcohol and Drug Mortality for 2010: Rx vs. Non- Rx Race/Ethnicity Comparison 90.0% 80.0% 83.1% 70.0% 66.3% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 16.3% 12.3% 14.0% 4.6% 3.5% 0.0% White Afr-Amer Hispanic Asian/other Rx Non-Rx 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% Denver Alcohol and Drug Mortality for 2010: Rx vs. Non- Rx Gender Comparison 60.0% 40.0% 76.7% 30.0% 20.0% 10.0% % % Rx Male Non-Rx Female 21

22 Denver Drug Trends Summary Alcohol is the most used and abused drug in Denver as shown by both prevalence and indicator data. Alcohol indicators have stable or increasing over the past two to three years. Cocaine continues to be a major drug of abuse in Denver associated with high morbidity and mortality. Most cocaine indicators had been declining through However, the exceptions are small increases from 2009 to 2010 in cocaine s proportions of emergency department and drug mortality. Conversely, there is some evidence that the cocaine user population is aging. For example, the proportion of cocaine clients in treatment who are 45 and over has more than doubled in the last nine years. Most heroin indicators have been flat or trending upward recently which is likely related to a stable supply, and the anecdotal reports that some prescription opioid users are switching to heroin because of its cheaper cost. There is also evidence of subtle changes in the user population with increases in younger (34 and under), and white (non-hispanic) heroin users who are smoking the drug. Marijuana continues to be a major drug of abuse in Denver associated with high morbidity. Most marijuana indicators have been trending upward recently. In 2010, excluding alcohol, marijuana ranked first in treatment admissions and increased to its highest percentage for the past 8 ½ years. It remained close to this level in Marijuana (excluding alcohol) also ranked first in drug related emergency department visits, and hospital discharges; and second in exhibits analyzed in Denver metro crime labs. Marijuana is in large supply in Denver, as it comes from multiple sources (e.g., Mexico, Canada, and local growers). Decreases in perceived risk of marijuana in conjunction with increases in use are anecdotally related to the proliferation of medical marijuana dispensaries in the Denver metro area. Methamphetamine continues to be a substantial problem in Denver. However, almost all methamphetamine indicators had been declining from 2005 to 2008, but in the past three years most methamphetamine use indicators have increased including treatment admissions, emergency department visits, hospital discharges, and mortality. Other opioids (e.g., oxycodone, hydrocodone, methadone, etc.) are increasingly problematic in the Denver drug scene. Other opioid treatment admissions, hospital discharges, deaths, and emergency department visits have all recently shown mostly upward trends, with local law enforcement and intelligence reporting increases in other opioid availability. Data from the Colorado Prescription Drug Monitoring program show increases in prescriptions filled for opioids such as oxycodone and hydrocodone. 22

23 Recent Drug Trends in the Denver Metro Area Data Sources Alcohol and selected drug prevalence data for Denver, Colorado, and the US are provided from the following sources: 1) the National Survey on Drug Use and Health (NSDUH), 2) the Behavioral Risk Factor Surveillance System (BRFSS), 3) the Healthy Kids Colorado Survey (HKCS) and 4) the Youth Risk Behavior Survey (YRBS). The NSDUH is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The survey is the primary source of information on the use of illicit drugs, alcohol, and tobacco in the civilian, non-institutionalized population of the United States aged 12 years or older. The survey interviews approximately 67,500 persons each year. Data are available at the state and sub-state levels. The Colorado BRFSS is a system of telephone surveys sponsored by the Centers for Disease Control (CDC) to monitor lifestyles and behaviors related to the leading causes of mortality and morbidity. In recent years, health professionals and the public have become increasingly aware of the role of such lifestyle factors as binge drinking, cigarette smoking, excess weight, a sedentary lifestyle, and the nonuse of seat belts in contributing to injury, illness and death. In 1981, the CDC began using the BRFSS as a method of estimating the prevalence of high risk behaviors and lifestyle factors that contribute to death and disease. Colorado participated in this project with point-in-time surveys in 1982 and The Survey Research Unit of the Health Statistics Section of the Colorado Department of Public Health and Environment (CDPHE) began collecting data on a monthly basis in January The Survey Research Unit now completes over 300 BRFSS surveys a month with adult residents of Colorado (i.e., 18 and over). The HKCS was developed to monitor statewide and local trends for school-attending youth by surveying a representative sample of middle and high school students. The HKCS integrates items from the CDC s Youth Risk Behavioral Survey (YRBS), the Colorado Youth Survey (CYS), and additional items selected by Colorado state agencies. The HKCS contains a total of 142 items on the high school version and 127 items on the middle school version. The HKCS provides information on a wide range of youth attitudes and behaviors including substance use, violence and delinquency, mental health, and academic performance. The HKCS data used in this report embodies the first administration of the survey in the Denver Public Schools among a representative sample of 6 th, 8 th, 9 th, and 11 th graders during the spring and fall of The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health-risk behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors 23

24 the prevalence of obesity and asthma. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and local school-based YRBSs conducted by state and local education and health agencies. This report summarizes results from the 2009 national survey, 42 state surveys, and 20 local surveys conducted among students in grades Treatment data are provided by the Drug/Alcohol Coordinated Data System (DACODS) which is maintained by the Division of Behavioral Health (DBH) at the Colorado Department of Human Services. Data for this system are collected on clients at admission and discharge from all Colorado alcohol and drug treatment agencies licensed by DBH. Treatment admissions are reported by the primary drug of use (as reported by the client at admission) unless otherwise specified. Annual figures are given for calendar years (CY) 2003 through CY Drug-related emergency department (ED) reports for the Denver metropolitan area were provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) Office of Applied Studies (OAS) through its Drug Abuse Warning Network (DAWN Live!). This includes both unweighted (i.e., data for 2010) and weighted data (i.e., rates per 100,000) for CY 2004 through CY The un-weighted data were collected in August 2011, reflect DAWN cases for CY 2010, and are subject to change in future OAS quality reviews. Because these data were un-weighted, they cannot be used as estimates of the reporting area. Only weighted DAWN data released by SAMHSA can be used for population trend analysis. To that end, weighted ED trends for selected drugs from 2004 through 2009 were prepared by OAS and are included in this report. A full description of the DAWN system can be found at < Drug-related mortality data for the City and County of Denver for CY 2003 through CY 2010 are from the Denver Office of the Medical Examiner. Drugs associated with mortality are based on blood toxicology performed as part of the autopsy. The toxicology findings are part of the autopsy report. Hospital discharge data for the Denver metro area for * (based on data from the first nine months of 2011) were provided by the Colorado Hospital Association. Data included diagnoses (ICD-9-CM codes) for inpatient clients at discharge from all acute care hospitals and some rehabilitation and psychiatric hospitals. These data exclude ED care. Rocky Mountain Poison and Drug Center (RMPDC) data are presented for Colorado. The data represent the number of calls (human exposure only) to the center regarding "street drugs" from 2004 through National Forensic Lab Information System (NFLIS) data are presented for Denver, Jefferson, and Arapahoe Counties for the first half of 2011 with a comparison to Colorado and to the entire US. The NFLIS is a Drug Enforcement Administration program through their Office of Diversion Control that systematically collects drug identification results and associated information from drug cases analyzed by federal, state and local forensic laboratories. 24

25 Additional drug specific crime lab statistics for 2001 through 2011 were obtained from the Denver Crime Lab, Denver Police Department. Denver Adult and Juvenile Arrest data from 2000 through 2011 were obtained from the Denver Safety Office of Policy Analysis. Statistics on seized drug items were obtained through CY 2008 from Colorado Fact Sheet Reports published by the Drug Enforcement Administration (DEA) Statistics on prescriptions filled for Denver residents by drug type from the 3 rd quarter 2007 through the 4th quarter 2011 were obtained from the Colorado Prescription Drug Monitoring Program (PDMP), Colorado Department of Regulatory Agencies, Division of Registrations, Board of Pharmacy. Data on tests for driving under the influence of drugs from 2009 through 2011 are from the Colorado Department of Public Health and Environment, Laboratory Services Division. Intelligence data (including price and availability) were obtained from the Denver Epidemiology Work Group including clinicians, outreach workers, researchers, medical examiner s office staff, public health, and regional and local law enforcement officials. Colorado and Denver Populations Census data from the Colorado Division of Local Government website place the 2010 Colorado population at 5,029,196, and the 2010 City and County of Denver population at 600,158. For Colorado 1, 50.4 percent are male and 49.6 percent are female; 70 percent are White (excluding White Hispanics); 4.0 percent are Black; 1.1 percent are American Indian/Alaskan Native; 2.8 percent are Asian; and.1 percent are Native Hawaiian/Pacific Islander. Of the total Colorado population, 20.7 percent are Hispanic of any race. For Denver, 52.2 percent are White (excluding White-Hispanic or Latino), 10.2 percent are Black, 1.4 percent are American Indian/Alaska Native, 3.4 percent are Asian/Pacific Islander, and 31.8 percent are Hispanic (of any race) 1 ; 50.6 percent are male and 49.4 percent are female; 23.9 percent are under 20, 18.9 percent are 20 to 29, 17.7 percent are 30 to 39; and 12.9 percent are 40 to 49, 11.6 percent are 50 to 59, 7.8 percent are 60 to 69 and 7.2 percent are 70 and over Census 25

26 Percent Percentage Alcohol Prevalence Past 30-Day Alcohol and Binge Alcohol Use from the NSDUH Exhibit 1 compares past month alcohol 2 and past month binge 3 alcohol use for the Denver metro area 4, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the NSDUHs. For the Denver metro area, 61.7 percent of respondents reported past month alcohol use, compared to 60.1 percent of their statewide counterparts. This is not a significant difference. However, both the Denver metro and Colorado respondents reported significantly higher past month alcohol use than national respondents (51.2 percent). As to binge use, 27.2, 26.2, and 23.3 percent in the Denver metro area, Colorado, and the U.S., respectively, reported past month binge alcohol use. None of these differences is significant. Past 30-Day Alcohol and Binge Alcohol Use Trends from the BRFSS Exhibits 2 and 3 present comparisons of adult (18 and older) past 30-day alcohol and binge alcohol use for the Denver metro area 5, Colorado and the US, using data from the BRFSS. For 30-day alcohol use (Exhibit 2), the Denver metro area showed a slightly higher rate than Colorado and a substantially higher rate % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Exhibit 1: Past Month Alcohol and Binge Alcohol Use Among Persons Aged 12 and Over: Denver Metro Area Compared to Colorado and the Entire U.S. Based on Averages from the NSDUH At least one drink of alcohol in the past month 3 Males having 5 or more drinks and females 4 or more drinks on at least one occasion in the past month. 4 In this case the Denver metro area refers to Adams, Arapahoe, Boulder, Clear Creek, Denver, Douglas, Gilpin, and Jefferson Counties. 5 For the BRFSS, the Denver metro area refers to Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, and Park Counties Past Month Alcohol Use (%) Past Month Binge Alcohol Use (%) Denver Metro Area Colorado Total U.S. Exhibit 2: Adult 30-Day Alcohol Use--Denver Metro, Colorado, and US: 2004 to % 62.2% 57.1% 65.0% 62.2% 56.2% 63.9% 61.6% 55.4% 66.2% 62.6% 54.8% 64.3% 65.1% 61.5% 60.4% 54.5% Year Denver Metro Colorado US 54.4% 26

27 Percent than the US for all six years shown. As to binge use (Exhibit 3), the Denver metro area again shows a slightly higher rate than 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% Exhibit 3: Adult 30-Day Binge--Denver Metro, Colorado and US 2004 to % 17.8% 17.3% 17.4% 17.3% 17.5% 17.1% 16.1% 16.2% 16.4% 16.0% 16.3% 15.8% 15.1% 15.4% 15.6% 15.8% 14.4% Colorado for five out of six years, and a somewhat higher rate than the US for all six years. 30-Day Alcohol and Binge Use from the HKCS 8.0% 6.0% 4.0% 2.0% 0.0% Exhibit 4: Past 30-Day Alcohol Use Comparison Denver HKCS to Colorado and US YRBS 100.0% 80.0% 60.0% 40.0% 20.0% As previously discussed, the Healthy Kids Colorado Survey was conducted for the first time in Denver Public Schools during the school year. The weighted sample of 6, 8, 9, and 11 th graders represents baseline data for the district. As indicated in Exhibit 4 (below), 15 percent of 6 th graders, 37 percent of 8 th graders, 40 percent of 9 th graders, and 61 percent of 11 th graders reported they had used alcohol in the past 30 days. Comparisons with the Colorado HKCS and the US YRBS are also shown with Denver 9 th and 11 th graders reporting higher 30-day alcohol consumption than their statewide or national counterparts. Exhibit 5 (following page) compares past30- day binge alcohol use (defined as five or more drinks in a row within a couple of hours) for Denver HKCS to the Colorado HKCS and to the US YRBS. As shown, 9 percent of 6 th graders, 22 percent of 8 th graders, 22 percent of 9 th Year Denver Colorado US 0.0% 6th 8th 9th 11th Total 2008 DPS HKCS 15.0% 37.0% 40.0% 61.0% 33.0% 2009 CO HKCS 28.2% 45.7% 2009 US YRBS 31.5% 45.7% 27

28 Number of Weighted Visits Rate per 100,000 graders, and 46 percent of 11 th graders reported binge alcohol use in the past 30 days. Denver 9 th Exhibit 5: Past 30-day Alcohol Binge Use--Comparison DPS HKCS to Colorado to US YRBS 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 6th 8th 9th 11th Tot al 2008 DPS HKCS 9.0% 22.0% 22.0% 46.0% 21.0% 2009 CO HKCS 14.7% 30.4% 2009 US YRBS 15.3% 28.3% and 11 th graders reported considerably higher binge use than their statewide or US counterparts. Alcohol Indicator Trends For the most part, Denver s alcohol indicators are stable or increasing. Alcohol Treatment Admissions Alcohol accounted for 32.2 percent of total Denver treatment admissions in 2011, higher than any other drug. Alcohol treatment admissions more than doubled from 2003 (747 admissions) to 2009 (1677), but declined slightly in 2010 (1635) and 2011 (1,497). Likewise, alcohol as a percentage of all treatment admissions in Denver increased from 22.9 percent in 2003 to 34.0 percent in 2009, but declined slightly to 33.5 percent in 2010 and to 32.2 percent in 2011 (Ex. 12). While the gender percentage for alcohol admissions remained essentially the same from 2003 through 2011, non-hispanic Whites, those between 25 to 34 and those over 45 increased slightly among alcohol admissions during that same time period (Ex. 13). Alcohol Emergency Department Visits In 2010, there were 4056 alcoholrelated emergency department visits in the Denver metro area, as reported through DAWN. These accounted for 40.0 percent of all alcohol and illicit drug-related visits in the unweighted DAWN Live! data, with the alcohol proportion being two times as high as the next closest Exhibit 6 Number and Rate of Weighted Denver Alcohol Emergency Department Visits Compared to the US Rate: Denver Rate Per 100,000 US Rate Per 100,000 Denver Alcohol Related ED Visits (weighted) 0 28

29 drug (i.e., marijuana at 2031 visits, or 20.0 percent of total (Ex. 14) 6. In Exhibit 6 (right), the number of weighted Denver alcohol ED visits are shown for 2004 (3624) to 2009 (7324). Also the Denver metro area rate for alcohol is compared to that of the entire US. The Denver rate per 100,000 more than doubled from 2004 (155.5) to 2008 (340.19), but then declined to 287 per 100,000 in The Denver rate was substantially higher than the US rate from 2005 to Alcohol Related Mortality Exhibit 7, below, shows alcohol-related mortality numbers (unduplicated) and rates per 100,000 population for Denver and Colorado from 2000 through For Denver, with some peaks and valleys, both the number and rate had been relatively stable from 2000 to However, from 2007 to 2008 the number of alcohol deaths in Denver increase from 250 to 300 with the rate per 100,000 increasing from 43.2 to This number and rate remained stable in Denver s alcohol-related death rate from 2000 through 2009 was 1.5 to 1.9 times higher than Colorado s rate. Exhibit 7: Number and Rate of Alcohol Related Deaths in Denver and Colorado: Total Denver Alcohol Deaths-Unduplicated Total Denver Alcohol Death Rate per 100, Total Colorado Alcohol Deaths- Unduplicated 967 1,130 1,094 1,141 1,052 1,171 1,190 1,224 1,383 1,476 Colorado Alcohol Death Rate per 100, Source: Colorado Department of Public Health and Environment Alcohol Related Hospital Discharges As shown in Exhibit 18, alcohol related hospital discharges in Denver are substantially higher than those of any other drug. From 2003 to , Denver alcohol hospital discharges increased from 9,812 to 12,876 while the rate increased from 1751 to 2128 per 100,000 population, or by 21.5 percent. 6 For DAWN Live!, alcohol-related ED visits are reported either in combination with other drugs (all ages) or alcohol alone for patients under the age of 21 7 All 2011 hospital discharges (i.e., alcohol, stimulants, cocaine, marijuana, and opioids) are extrapolated from data for the first 9 months of the year). 29

30 Number of Arrests Rate of Arrests Per 10,000 DUI Arrests Exhibit 8 on the right compares the number and rate of Denver and Colorado total Adult and Juvenile DUI arrests from to (through 2011 for Denver only Statewide data not yet available) Denver DUI s 5000 declined from to 2268 (or by 45.3 percent) from 2000 to 2005, doubled to 4531 by 2008; but then declined to 3106 by Exhibit 8: Comparison of Denver and Colorado Total Adult and Juvenile DUI Arrests: Denver s DUI arrest rate had declined from 74.6 to 39.7 per 10,000 from 2000 to 2005 but then climbed dramatically to 77.7 per 10,000 by However, the Denver rate declined to 52.2 per 10,000 by Also, Denver s rate exceeded Colorado s rate from 2007 to Alcohol Related Calls to the Rocky Mountain Poison and Drug Center (RMPDC) From 2004 to 2011, statewide alcohol related calls to the RMPDC were 6 to 12 times greater than those of any other drug. The 991 calls to RMPDC in 2011, related to human exposure to beverage alcohol, represented an 8.5 percent increase over 2010 (i.e., 913 calls), and also constituted the highest number of alcohol related calls to RMPDC in the eight year time period shown (Ex. 24) Denver Adult and Juvenile DUI Arrests Colorado Adult and Juvenile DUI Arrests 52.2 Denver DUI Arrests Per Colorado DUI Arrests Per Alcohol Qualitative Information Denver s high rate of alcohol use and abuse are corroborated by comments from a variety of treatment, public health/medical, research/data analysis, street outreach and law enforcement professionals. They all describe a culture that is friendly towards alcohol, especially at major entertainment and sporting events. Drinking is considered a rite of passage, and an ingrained social norm. Many parents have the attitude that kids are going to drink anyway which keeps them from getting involved with their kids when it comes to alcohol. Adolescents say it is easy to get alcohol. However, there is substantial evidence of an inverse relationship between binge use and perception of risk for youth. The Colorado Division of Behavioral Health (Department of Human Services) has released a statewide campaign called SpeakNow! which encourages parents 30

31 to talk with their kids about alcohol and underage drinking (this is also the central theme of the Denver Office of Drug Strategy prevention efforts including toolkits for parents). Clinicians describe a Front Range culture friendly to alcohol use, with a high density of alcohol retailers and advertising geared to the heavy drinkers. According to these clinicians, there are a lot of people turning up in detoxes and emergency departments who are not alcoholics, but people who are just partying too much. Clinicians also describe a Denver metro area with a large number of festivities built around alcohol (e.g., People s Fair, Oktoberfest). Also, the Colorado legislature recently passed a bill that will allow cities to establish entertainment districts with a maximum of 100 acres. Within these districts, bars, restaurants, and hotels can form a consortium to establish common consumption areas in which open container are permitted. Many see this as something that will impact alcohol trends and the alcohol culture to which we are exposing our young adults. Some in public health and in law enforcement perceive an increase in marijuana use among adolescents and young adults as going hand in hand with a likely increase in alcohol use (i.e., acceptability, accessibility and the idea the any substance use/abuse is okay). Cocaine Prevalence Cocaine Exhibit 9 on the right compares past year cocaine use for the Denver metro area, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the and NSDUHs. For the Denver metro area, past year cocaine use increased slightly from to from 3.08 to 3.47 percent (not significant). Both the Denver metro and Colorado respondents reported higher past year cocaine use than national respondents. Cocaine Indicators P e r c e Exhibit 9: Cocaine Use in the Past Year: Comparison of to National Survey on Drug Use and Health: Denver Metro Area vs. Colorado Vs. US Cocaine remains at the top of the list for most Denver indicators. While n t 1 0 most cocaine Denver Area Colorado US indicators had been declining through and 2010, in 2011 hospital discharges, percent of ED visits, mortality, new users in treatment and cocaine related calls to the Rocky Mountain Poison and Drug Center either stabilized or rose somewhat. 31

32 As a primary drug, Cocaine accounted for 13.8 percent of Denver treatment admissions in 2011 behind marijuana and alcohol (Ex. 12). However, the 13.8 percent is a substantial decline from the nine year (i.e., 2003 through 2011) cocaine treatment admission peak of 20.7 percent in 2004; and is the lowest percentage during that time period. Males, Hispanics, and those 45 and older increased among Denver cocaine treatment admissions from 2003 to 2011 (Ex. 13). Also, those who inhale cocaine increased from 20.4 percent of cocaine treatment admissions in 2003 to 31.1 percent in The percentage of those who smoke cocaine declined somewhat from 2003 (68.9 percent) to 2011 (63.6 percent). However, that percentage had been declining in earlier studies. Those who inject cocaine declined from 10.1 percent in 2003 to 3.8 percent in Excluding alcohol, cocaine, at 29.9 percent of total illicit drugs, was the second most common drug (after marijuana) as a proportion of Denver metro area substance abuse related emergency department (ED) visits in CY 2010 (Ex. 14). In Exhibit 17, the Denver metro area rate for cocaine ED visits is compared to that of the entire US. The Denver rate more than doubled from 93.2 to visits per 100,000 from 2004 to 2006 but then declined slightly to in 2007, and then declined substantially to in 2008, and to in 2009 (a decrease of 46.8 percent from the 2006 peak). The US rate increased by only 13.4 percent from 2004 to 2006 (162.2 to per 100,000), but then declined to by 2009 (or by 25 percent). The Denver rate was higher than that of the US for all years shown, except 2004, and most recently, in After alcohol, cocaine had been the second most common drug reported in substance abuse related hospital discharges in Denver from 2003 to 2009 (Ex. 18). However, in 2010 and 2011 the cocaine hospital discharge rate fell to third behind alcohol and marijuana. In fact, after increasing steadily from 254 to 331 per 100,000 population from 2003 to 2006, the cocaine discharge rate declined to 235 per 100,000 by 2009 (or by 29 percent). Surprisingly, the cocaine rate increased slightly to 240 per 100,000 in 2010, but then declined to 228 per 100,000 in 2011, the lowest rate in the time period shown. Cocaine was the most common drug found in Denver drug related decedents from 2005 to 2007, and behind only alcohol in 2004, and 2008 to 2010 (Ex. 22). However, the percentage of cocaine among total drug decedents declined from a peak of 50.3 percent of decedents in 2006 to 25.6 percent in 2009, rising slightly to 27.0 percent of decedents in Cocaine in combination with other drugs (i.e., morphine, codeine, alcohol, and heroin) was among the most common combinations found in Denver drug related decedents in the 2003 to 2009 time period (Ex. 23). As previously described, some cocaine indicators showed a small resurgence in This includes cocaine related calls to the Rocky Mountain Poison and Drug Center (RMPDC). In fact, the 96 cocaine related human exposure calls to RMPDC in 2011 was a 50 percent increase over the 63 and 64 calls in 2009 and 2010, respectively; and only slightly behind the 104 calls in However, the 96 cocaine calls in 2011 were still far behind the peak of 129 in 2006 (Ex. 24). Cocaine was the most common drug submitted for testing by local law enforcement in the first half of 2011 in the Denver metro area (i.e., Denver, Arapahoe and Jefferson Counties Ex. 19). As shown, cocaine accounted for 34.2 percent of the samples analyzed in the Denver metro area compared to 26.6 percent for all of Colorado, and 20.1 percent for the entire US. In 2011, the Denver Crime Lab (DCL) analyzed 751 crack cocaine down from the 879 analyzed in 2010, and 32

33 down substantially from the peak of 1740 in As to powder cocaine, in 2011 the DCL analyzed 521 exhibits also down somewhat from the 626 exhibits in 2010 and from the 739 in 2009; and down substantially from the peak of 1240 in Federal drug seizures for cocaine across Colorado (Ex. 20), after decreasing from 65.5 kilograms (kgs) to 36 kgs from 2003 to 2004, increased substantially in 2005 (131.5 kgs) and 2006 (135.1 kgs), declined sharply in 2007 (44.0 kgs), and increased slightly in 2008 (52.6 kgs). Cocaine Price, Purity, Trafficking and Other Qualitative Information According to the Drug Enforcement Administration (DEA), Denver Division, cocaine continues to be supplied by the Mexican poly-drug trafficking organizations (DTOs) with loads transported from Mexico and the southwest border to Colorado and throughout the region. The DEA reports that between 2008 and 2010 the DTOs experienced difficulty in obtaining consistent cocaine supplies, with price and purity also fluctuating. However, the cocaine supply stabilized in 2011 along with price and purity. The DEA states that cocaine exhibits analyzed between July and December 2011 average 56.9 percent purity. Also, according to the DEA, cocaine prices continue to range from $ for ounce quantities with kilos at $25,000-26,000. The Denver Police report that cocaine kilos are selling for $26,000; with the Denver Crime Lab placing cocaine purity at an average of 70 percent. However, the DCL says that some kilo quantities were found to be 90 percent pure. The DCL still finds the cutting agent levamisole present in two-thirds to three-quarters of cocaine samples analyzed 8. Many see cocaine as generally out of favor in Denver at the current time. Clinicians and outreach workers describe an aging cohort of cocaine users with little use among younger clients. Many young people see cocaine as being too expensive with methamphetamine a cheaper stimulant alternative (one outreach worker says some meth users will use cocaine if meth supplies are low). A Denver clinician reports that cocaine is often used in combination with other drugs (especially alcohol) which can moderate cocaine effects allowing the user to party longer. Also, clinicians say that treatment clients often use cocaine to self-medicate a mood disorder like depression or bi-polar disorder. Some street outreach workers report that cocaine is less popular among noninjecting street users, but remains popular among street IDU s for speedballs (cocaine and heroin injected at the same time a common combination found in Denver drug mortality cases). 8 Levamisole is primarily used in veterinary medicine to control parasites in livestock. It had been used in the US for treatment in rheumatoid arthritis, and colorectal cancer; but is no longer available for human consumption in North America. In February 2009, cocaine adulterated with levamisole was identified as the likely cause of agranulocytosis in a man admitted to a Denver emergency department. Agranulocytosis is an acute disease marked by high fever and a sharp drop in circulating granular white blood cells. 33

34 Heroin Heroin Indicators Heroin indicators present a mixed picture in Denver with mortality proportions stable, ED and treatment percentages increasing, and new users in treatment decreasing. Heroin declined from the highest percentage of Denver treatment admissions in 2003 (24.9 percent-of primary drugs) to only 9.6 percent in 2008, behind alcohol, marijuana, cocaine and methamphetamine. However, the percentage of heroin treatment admissions increased slowly but steadily to 12.1 percent by 2011, substantially behind alcohol and marijuana, slightly behind cocaine, but ahead of methamphetamine (Ex. 12). The 564 Denver heroin treatment admissions in 2011 (and the 12.1 percent of total admissions) were the highest such number and percentage since Females, non-hispanic Whites, those 34 years old and younger, and those 55 and older increased among Denver heroin treatment admissions from 2003 to Also, those who smoke heroin increased from 5.4 percent of heroin treatment admissions in 2003 to 9.8 percent in Conversely, those who inject heroin declined from 87.7 to 85.5 percent of heroin admissions during the same time period (Ex.13). Excluding alcohol, heroin, at 13.1 percent, was a distant third (after marijuana and cocaine) as a proportion of total illicit drugs in Denver metro area substance abuse related emergency department (ED) visits in CY 2010 (Ex. 14). As shown in Exhibit 17, the heroin ED visit rate for the Denver metro area increased from 33.1 to 53.4 per 100,000 population from 2004 to 2007 (or by 61.5 percent). It remained at approximately the 2007 rate in 2008 and 2009, at 52.8 and 51.7 per 100,000, respectively. Heroin was found in 4.0 to 23.0 percent of Denver drug related decedents from 2003 to The reason for this discrepancy had to do with detection of 6-monoacetylmorphine (6-MAM) in the blood and/or urine toxicology of the deceased as part of the autopsy. Heroin is metabolized into 6-MAM then into morphine. Also, heroin typically contains codeine because codeine naturally occurs in the opium poppy plant (from which heroin is produced). The 6-MAM needs to be present to confirm that heroin was related to the cause of death. However, this metabolite has a very short half-life and may be undetectable by the time blood work is done as part of an autopsy; whereas morphine and codeine will very likely be present in the blood toxicology. Starting in 2008, the Denver Office of the Medical Examiner (OME) began efforts to more definitively diagnose heroin mortality due to changes in the lab testing they use (i.e., looking for 6-MAM in urine). As a result, more heroin deaths were identified in 2008 (N=27) and 2009 (N=49) and 2010 (N=35) than in any year from 2003 through Consequently, the number of morphine and codeine deaths has declined, especially in 2010 (Ex. 22). The combination of heroin and cocaine (typically called a speedball) was found among 1.3 to 6.8 percent of Denver drug related decedents from 2003 to 2009 (Ex. 23). The OME states they are still seeing deaths with both opiates (e.g., heroin) and uppers (primarily cocaine). However, frequently, when cocaine is involved in mortality there is only the benzoylecgonine metabolite in the toxicology. This suggests the use of heroin/opiate and cocaine is not simultaneous, with cocaine use prior to heroin/opiate. 34

35 Some Denver clinicians who are also involved in outreach and research emphasize that heroin related mortality is often a result of polydrug abuse, particularly heroin and benzodiazepines (this also shows up in the OME heroin mortality data). Additionally, many heroin overdoses are caused by decreased tolerance (e.g., addicts who have been in prison who use when released). Statewide, heroin/morphine human exposure calls to the Rocky Mountain Poison and Drug Center from 2004 through 2011 have mostly ranked far behind those of alcohol, cocaine, marijuana and methamphetamine. Such calls had also remained relatively stable from 2004 to 2010 with a peak of 29 calls in 2009 and a low point of 19 calls in However, in 2011 heroin/morphine related human exposure calls to RMPDC increased 2.5 fold to 47, the highest number of such calls in the eight-year time period shown (Ex. 24). At 9.9 percent of samples tested, heroin lagged behind cocaine, cannabis, and methamphetamine among drugs submitted for testing by local law enforcement in Denver in the first half of In comparison, heroin constituted 6.6 percent of drug samples analyzed in Colorado, and 7.5 percent of samples analyzed in the entire US (Ex. 19). The Denver Crime Lab reported analyzing 304 heroin exhibits in 2011, substantially more than the 253 heroin exhibits in 2010, and the 249 analyzed in It is also the highest number of heroin exhibits analyzed since As shown in Exhibit 20, only small quantities of heroin were seized in Colorado ranging from 2.5 to 4.6 kgs from 2003 to Heroin Price, Purity, Trafficking and Other Qualitative Information The DEA, Denver Division, reports that black tar and brown powder heroin predominate in the Denver metro area. There s been some pressure in Mexico for DTOs to produce/traffic white powder heroin, which is being seen in other areas of the US (but not yet in Denver). Brown powder commands $ an ounce and is typically higher purity than black tar which sells for $ an ounce. Most street level purchases involve $20 balloons. Also, street level heroin analyzed by the DEA was found to range from 15 to 25 percent pure (a few buys were found to be percent pure, but this was unusual). The DEA and Denver Police Department (DPD) report that heroin supply remains fairly stable, as it is not affected by cartel infighting. Mexican heroin distributors are smaller, generally tight knit family based organizations, largely independent of the well known poly-drug cartels. Heroin loads coming up from Mexico through Arizona and southern California are smaller and easier to smuggle across the border undetected by law enforcement. They also report that Denver is a prominent redistribution point for the Midwest and East Coast. The Mexican DTOs have been using street gangs, and Honduran and Guatemalan for low level distribution. The DPD reports an apparent connection between increased prescription opioid use and increased heroin demand, with some opioid users switching to heroin because it is cheaper. Some Denver clinicians and outreach workers confirm that this phenomenon is becoming an all too common occurrence. They say it often happens when prescription user complains to a street dealer that the prescription opioids are becoming too expensive and the dealer introduces the prescription user to heroin. One clinician describes seeing a number of year old white, upper middle-class suburban youth who may use up an opioid prescription in the first half of the 35

36 month and then use heroin in the remaining part of the month to maintain their habit. Another clinician reports seeing some shift in the heroin using population coming into treatment with an increase in young, white, heroin smokers. A few clinicians feel that there is an increased perception of heroin use as a social norm. An outreach worker reports seeing newer and younger injection drug users who are converting from prescription drug use (e.g., oxycodone and hydrocodone) to heroin. Specifically, this outreach worker said that within the last year 10 new IDUs ranging in age from 23 to 26 with 6 to 7 years of prescription opioid abuse have converted to heroin (most of these report that it was because of personal circumstances like a job loss). In any event, the use of prescription opioids with a subsequent switch to heroin can be extremely dangerous with one clinician reporting the deaths of two young clients who died within months of going through an initial treatment assessment, but who had begun their opiate habits recreationally. The National Institute on Drug Abuse s Community Epidemiology Work Group, which tracks drug trends across the country in major urban and suburban areas, recently discussed the issue of poly-prescription drug use which becomes more of a concern when prescription opioid users switch to heroin and still use it in combination with alcohol. As described by a Denver clinician, there is a proportion of users who are aware you can enhance the high by mixing alcohol with opioids, or benzodiazepines and opioids. Looking at the Denver mortality data, in 2009, of the 49 heroin deaths, 18, or 37 percent also involved alcohol. Similarly, in 2010, of the 35 heroin deaths, 10, or 29 percent also involved alcohol. Marijuana Prevalence Marijuana Exhibit 10a on the right compares past year marijuana use for the 20 Denver metro area, all of Colorado P and the total U.S. for respondents e 15 who are aged 12 and older based r on annual averages from the c and NSDUHs. For the Denver metro area, marijuana use increased from to from to percent (not significant). Both the Denver metro and Colorado respondents reported e n t 5 0 higher past year marijuana use than national respondents. Marijuana Indicators Exhibit 10a: Marijuana Use in the Past Year: Comparison of to National Survey on Drug Use and Health: Denver Metro vs. Colorado vs. US Denver Area Colorado US Marijuana continues to be a major drug of abuse in Denver associated with high morbidity. In the current analysis, almost all Denver marijuana indicators are increasing. Marijuana increased from 20.4 to 26.4 percent of Denver treatment admissions from 2003 to 2004, but since then has shown a relatively stable pattern with small increases and decreases through At 24.1 percent, marijuana was the most common drug among all Denver treatment admissions except 36

37 for alcohol in 2011(Ex. 12). Males, Hispanics, and those over 18 years of age increased among Denver marijuana treatment admissions from 2003 to 2011 (Ex. 13). Excluding alcohol, marijuana, at 33.4 percent of total illicit drugs, was the most common drug as a proportion of Denver metro area substance abuse related emergency department (ED) visits in CY 2010 (Ex.14). In Exhibit 17, the Denver metro area rate for marijuana ED visits is compared to that of the entire US. The Denver rate tripled from 50.5 to visits per 100,000 from 2004 to However, in 2009, the marijuana rate dropped sharply to only per 100,000. The US rate increased by only 28.0 percent from 2004 (96.1/100,000) to 2008 (123/100,000), but declined only slightly to percent from 2008 to The US rate was lower than the Denver area rate from 2006 through Marijuana was the third most common drug (behind alcohol and cocaine) reported in substance abuse related hospital discharges from 2003 to However, from 2009 to 2010 the marijuana hospital discharge rate jumped by a third from 220 per 100,000 to 292, and was second only to alcohol. Even though there was an estimated drop in marijuana hospital discharges in 2011, the marijuana rate has nearly doubled during the time period shown (Ex. 18). From 2004 through 2009 marijuana related calls to the Rocky Mountain Poison and Drug Center were ranked either third or fourth behind alcohol and cocaine or alcohol, methamphetamine, and cocaine. However, in 2010 (N=107) and 2011 (N=98), marijuana calls ranked second behind only alcohol (Ex. 24). At 24.2 percent, cannabis was the second most common drug submitted for testing by local law enforcement in the Denver metro area in the first half of 2011 (Ex. 19). In comparison, cannabis was the most common drug tested in both Colorado (33.4 percent) and in the entire US (i.e., 36.3 percent of drug samples analyzed). The Denver Crime Lab reported analyzing 776 marijuana exhibits in 2011, down somewhat from the 836 exhibits analyzed in 2010, but down substantially from 1259, 1232, and 1240 marijuana exhibits analyzed in 2006, 2007 and 2008, respectively. Federal drug seizures for marijuana across Colorado (Ex. 20), after being relatively stable from 2003 (444.1 kgs) to 2006 (656.8 kgs), nearly doubled to 1,149.5 kgs in 2007 and increased nearly 24-fold to 24,089.2 kgs in However, the dramatic difference in Colorado marijuana seizures between 2007 and 2008 was due primarily to one large-scale indoor marijuana growoperation seized by the DEA. Almost 20 grow houses and 25,000 plants were seized. It was the largest indoor marijuana seizure to date. In 2009, Colorado marijuana seizures were back down to 278 kilograms total weight (not shown in Exhibit 20). Total adult and juvenile marijuana arrests in Denver (both sales and possession) decreased from 3,235 in 2000 to 2,110 in 2004 but then climbed steadily to 3,212 by However, from 2007 to 2008, total marijuana arrests declined by 16.9 percent to 2,670, but then increased to 3,090 in 2009 (or by 15.7 percent). However, from 2009, total marijuana arrests have declined for two straight years to 2,416 in 2010 (a 21.8 percent decline) and to 1545 in 2011 (a 36.1 percent decline). The 1545 total marijuana arrests in 2011 represents the lowest arrest total in the twelve year time period shown (Ex. 21). The DEA reports that marijuana is widely available in Colorado and Denver with the supply impacted by a number of sources. Much of the marijuana is still Mexican grown and brought across the border by poly-drug trafficking organizations in passenger cars, commercial busses 37

38 and semi-trailers. A pound of Mexican marijuana typically sells for $ High grade marijuana from the Pacific Northwest is also available in Denver and ranges in price from $3,000-$4,000 a pound. This price range also holds true for some high grade, locally grown marijuana. Street outreach workers in Denver report that some marijuana is sold in gram quantities at $10 per gram our $15 for two grams. However, much of the high potency marijuana increasingly grown in Colorado, once available in abundance on the illicit retail market, is now sold to licensed care givers and is sold at high retail prices through dispensaries. According to the DEA, the Colorado medical marijuana phenomenon has given the state the reputation as having the best marijuana in the nation. In fact, the DEA reports that Colorado grown marijuana is transported to the Midwest and Eastern markets where it commands higher prices. Marijuana tourism is a recently derived term related to interdiction of high-grade Colorado-grown marijuana going eastward. The Impact of Medical Marijuana The Colorado Department of Public Health and Environment recently updated the information on their website related to the Colorado Medical Marijuana Registry. As of December 31, 2011, their website reports 163,856 new patient applications received since the registry began operating in June 2001, with 82,089 patients currently possessing a valid Registry ID card 9. Of these, 68 percent are male; with an average age of 42 (there are only 45 on the MMR who are under 18). Fifty-five percent of patients are in the Denver-metro area. Patients on the registry represent all the debilitating conditions covered under Amendment 20 (initiated the medical marijuana program in CY 2000). Severe pain accounted for 94 percent of all reported conditions, with muscle spasms second most reported at 17 percent, followed by severe nausea at 12 percent. More than 900 different physicians have signed for patients in Colorado. In general, Denver area law enforcement reports that the large number of Denver medical marijuana dispensaries 10, patients and growers has challenged law enforcement with more, higher quality marijuana reaching the illicit market. Local police (e.g., resource officers) report finding medical marijuana from dispensaries in schools and in hands of non-patients. Likewise, local clinicians and street outreach workers describe a Denver scene in which medical marijuana dispensaries have made marijuana more available with less of a stigma, and with a lowered perceived risk of use. One local clinician lamented that there seems to be a medical marijuana dispensary on every street. There are 16 states with medical marijuana laws. In 2009, Colorado was one of two states in which prescription overdose was the leading cause of accidental death. In 2010, Colorado was one of 15 states in which prescription drug overdose was the leading cause of accidental death. Of the 15 states, 12 have medical marijuana laws, which may speak to an increased acceptance of substance use and abuse. States which have legalized medical marijuana typically find that the 9 Personnel in the CDPHE Vital Statistics Unit describe the decline in the number of patients on the Medical Marijuana Registry (i.e., have a valid registry card) as being due to both attrition (e.g., patients who did not renew, are deceased, etc.) and to patients who are waiting for the price of registration renewal to come down. Registration renewals in January 2012 already show an increase. 10 There are currently 519 medical marijuana centers (i.e., 517 medical marijuana dispensaries and 2 medical marijuana infused product manufacturers) in Colorado. Of the 519, 316, or 61 percent are in the Denver metro area. 38

39 laws to accomplish this are fairly similar to other states (probably due to the same advocates drafting such laws). Despite this, only Rhode Island accepts medical marijuana cards from other states. Law enforcement is concerned that individuals who are helping to draft medical marijuana laws are mostly legalization activists. A clinician in a Denver metro area treatment program said that this seems to be good time for pot users with increased public availability and acceptability. Many other local clinicians agree with this general view that medical marijuana has brought about an overall normalization perspective of any marijuana use. Many clients in treatment talk about marijuana as being medicinal, and even beneficial, and downplay studies showing harmfulness. One Denver metro treatment program surveyed 144 treatment clients with 95 percent of those surveyed reporting they were using medical marijuana to get high, while only one-third of those surveyed thought that marijuana could be addictive. There is general agreement that medical marijuana dispensary advertising contributes to public perception of harmlessness. A clinician who works with adolescents in the Denver metro area reported that most of his adolescent clients obtain their marijuana from people with a medical marijuana license; and that medical marijuana dispensaries increase the availability and acceptability of marijuana among adolescents in general. Clinicians and street outreach workers point to increases in arrests for driving under the influence of drugs (and advances in technology for catching those driving under the influence see below). A physician from the Rocky Mountain Poison and Drug Center reports that since medical marijuana became legal there have been 17 admissions to Children s Hospital for marijuana exposure (ages infant to 15); while there were none leading up to legalization. All of the kids survived and are doing well. Marijuana and Driving 2500 Exhibit 10b: Blood Tests for DUIDs In Colorado from 2009 to 2011 Exhibit 10b shows positive 2030 tests for persons arrested 2000 for driving under the influence of drugs in Colorado from through These tests were conducted by the Colorado Department of Public Health and 529 Environment, Laboratory Services Division. Positive marijuana tests almost 0 doubled (i.e., up 88.2 Amps Benz Cocaine Methadone Opiates THC percent) from 2009 (n=791) to 2010 (n=1489), and increased by 36.3 percent from 2010 to 2011 (n=2030). Also, as indicated, positive tests for marijuana were substantially higher than any other drug for each year shown. Specifically, 39

40 positive screens for marijuana were 56 percent of total drug screens in 2009, 69 percent of total drug screens in 2010 and 66 percent of total drug screens in Synthetic Cannabinoids There has been increasing concern among law enforcement, treatment, and street outreach personnel about the availability and use of synthetic cannabinoids including a variety of compounds with street names such as Spice, K2, and Black Mamba. However, most of the reports of use are anecdotal, as very few institutional data bases contain codes which can be used to identify the synthetic cannabinoids separately from marijuana (this may be due in part to the fact that urine screens for these synthetics are expensive and take longer for results). In fact there may be some agreement among DEWG members that synthetic cannabinoid use has peaked, due in large measure to the negative side effects experienced by users which have caused many to switch back to marijuana Recent data from the Rocky Mountain Poison and Drug Center (RMPDC) details the problems arising from synthetic cannabinoid use. In 2010, RMPDC received 44 human exposure calls related to synthetic cannabinoids (i.e., 36 from males and 8 from females). Symptoms reported by callers included tachycardia (abnormally rapid heart rate), confusion, agitation/irritability, dysphoria, hallucinations/delusions, nausea/vomiting, drowsiness/lethargy, tremors, mydriasis (pupil dilation), seizures, etc. Products mentioned by callers included THC Homolog, K2-herbal blend, Spice Gold-herbal blend, Spice Silver-herbal blend, and Spice Arctic Synergy-herbal blend. However, an RMPDC physician reports that they saw a spike in synthetics, but it seems to have died down (i.e., it seems like people who disliked it or ended up in the emergency room have stopped using it). This RMPDC physician reveals that the synthetic cannabinoid phenomenon is similar to that of designer amphetamines in the 1980 s where it was difficult to come up with federal standards for capturing all drugs of that type under legislation. The OME reports that they cannot screen for all of the synthetic cannabinoids compounds (urine screens for these synthetics are expensive and take longer for available results). If they think cannabinoids might be involved in a particular death, they can ask for a specific screen. However, the screen is based on what s been popular in the past. In June 2011, the Governor signed legislation making synthetic cannabinoids Schedule I drugs in Colorado (i.e., illicit). Denver law enforcement officers state that the Colorado law may be one of the few in the nation that s actually workable, as it covers any drug with a binding affinity similar to THC (there are over 600 such compounds that are known, but perhaps hundreds more that are unknown). However, Denver Crime Lab (DCL) chemists report that even though they may identify a compound, it is difficult to determine if it has a binding affinity similar to THC. Interestingly, the DCL analyzed 9 synthetic cannabinoid exhibits in 2011, up from 4 in However, these 13 synthetic cannabinoid exhibits analyzed in the last two years are the only ones analyzed by the DCL from 2001 through Don Shriver, the lead forensic chemist from the Denver Crime Lab, gave the following update on synthetic cannabinoids during the April 12 th meeting: 40

41 Regardless of what is happening on the street, synthetic cannabinoids are out of control from the crime lab s perspective. The federal government controlled the key 5 synthetic cannabinoids, but now the DCL is seeing things coming into the lab that are marketed as being federally compliant, but contain different compounds. The DCL is playing catch up figuring out if they can find a synthetic cannabinoid, identify the cannabinoid, and show that it meets the criteria of being a synthetic cannabinoid included under Colorado legislation. The DCL sees little continuity in synthetic cannabinoid manufacturing with different compounds found in the same brand. if you look at samples purchased in different stores or on different days. Some Denver metro treatment personnel report that adolescents assessed for drug use usually know about synthetic cannabinoids, but it rarely comes up unless a client is asked about it. Some adolescents claim that they are above using synthetics, and why do so when so much high quality marijuana is available. Street outreach workers more commonly see synthetic cannabinoid users among those on probation and/or who need a clean UA. Methamphetamine Most methamphetamine indicators in Denver had peaked in 2005 or 2006 and declined sharply through However, from 2009 through 2011, most of the methamphetamine indicators have either stabilized or shown some slight to moderate increases. In 2003, methamphetamine accounted for 8.0 percent of total alcohol and drug treatment admissions in Denver. By 2007 the percentage of Denver methamphetamine treatment clients had increased to 11.3 percent, surpassing heroin. However, in 2008 and 2009 the proportion of methamphetamine treatment admissions declined to 10.5 and 9.4 percent, respectively, staying at about that level (9.6 percent) in 2010 (Ex. 12). In 2011, methamphetamine treatment admissions increased slightly to 10.2 percent. In 2003, females constituted 49.2 percent of methamphetamine treatment admissions. However, this percentage decreased to 32.1 in 2011 (Ex. 13). Interestingly, race/ethnicity proportions changed little from 2003 to Clients 35 to 54 increased among Denver methamphetamine treatment admissions from 2003 to The route of administration for methamphetamine treatment admissions changed very little during the same time period (Ex. 13). Excluding alcohol, methamphetamine was fourth (behind marijuana, cocaine, and heroin) at 11 percent of total illicit drugs as a proportion of Denver metro area substance abuse related emergency department (ED) visits in CY 2010 (Ex. 14). In Exhibit 17, the Denver metro area rate for methamphetamine ED visits is compared to that of the entire US. The Denver rate more than doubled from 32.5 to the four-year peak of 76.2 visits per 100,000 from 2004 to However, from that point it dropped by 55.5 percent (to 33.9 visits per 100,000) by The Denver methamphetamine rate was higher than the US rate from 2005 to Similar to the Denver decline, the US methamphetamine ED rate dropped substantially during the six year time period. 41

42 Methamphetamine accounted for 14, or 9.2 percent, of the 152 drug related deaths in Denver in This is the highest such percent in the 2003 to 2010 time period shown (Ex. 22). Methamphetamine related calls to the Rocky Mountain Poison and Drug Center increased from 95 to 127 from 2004 to 2005, but then declined sharply to only 29 calls in 2006; and remained at that level in 2007 (31 calls). However, methamphetamine calls then increased steadily, more than doubling to 78 calls in 2011(Ex.24). Methamphetamine could not be identified separately, but rather was included in the stimulants category in hospital discharge data. Overall, Denver metro stimulant-related hospital discharges nearly doubled from 2003 to 2005 increasing from 73 per 100,000 to 132 per 100,000, but then dropped steadily to only 60 per 100,000 by However, in 2009 stimulant related hospital discharges increased slightly to 65 per 100,000 and increased again to 92 per 100,000, or by 41.5 percent, in The stimulant rate dropped to 76 per 100,000 in 2011, or approximately the same rate as in 2007 (Ex 18). At 12.2 percent of drug samples analyzed, methamphetamine was the third most common drug submitted for testing by local law enforcement in the Denver metro area in the first half of Likewise, methamphetamine ranked third among drug samples analyzed in both Colorado (14.7 percent) and in the entire US (10.8 percent) (Ex. 19). The Denver Crime Lab (DCL) analyzed 341 methamphetamine exhibits in 2011somewhat less than the 440 exhibits analyzed in 2010, and substantially less than the peak number of methamphetamine exhibits (i.e., 857) analyzed by the DCL in The DEA reports that most of the methamphetamine in Colorado is produced and supplied by Mexican DTO s via the larger laboratories in Mexico. A handful of organizations control the Mexican super labs. Methamphetamine purity is currently very high. Between July and December, 2011, the DEA analyzed 12 methamphetamine exhibits (obtained in Colorado), 8 of which averaged 96 percent purity, and 4 of which were all at 100 percent. DEA intelligence personnel posit that the rising methamphetamine indicators may not be as much a sign of increased use as a consequence of higher methamphetamine purity. The lead forensic chemist from the Denver Crime Lab stated that there had been only one case in the past year when the purity of a methamphetamine sample had been below 90 percent. The DEA reports methamphetamine prices at $900 to $1,300 per ounce and $14,000 to $17,000 per pound. Despite precursor laws, the Mexican DTOs are still able to get precursors (e.g., China is one current source of precursor supply) and/or to change methamphetamine recipes. In general, the precursor laws have not changed production in Mexico. Reports from other law enforcement agencies also point to increases in methamphetamine availability and decreases in price. Law enforcement has not seen an increase in local methamphetamine laboratories. Local clinicians and outreach workers report that there are a variety of reasons that the decline of methamphetamine use has stalled including methamphetamine s affordability in the context of an economic recession (some clinicians point to the fact that methamphetamine provides an energy boost for users who need to work more hours), increased supply from Mexico in over prior years, and increased use in the gay population (called a party and play drug with an associated increase in sexually transmitted diseases). Perhaps these factors are temporarily 42

43 overwhelming the considerable community prevention efforts that have correctly labeled methamphetamine a dangerous and addictive drug. Also, while methamphetamine treatment admissions have stabilized, the proportion of treatment admissions that are new users of methamphetamine (i.e., entered treatment within their first three years of methamphetamine use) has about doubled from 2009 through Other Opioid Prevalence Exhibit 11 on the right compares past year non-medical use of pain relievers for the Denver metro area, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the and Other Opioids NSDUHs. For the Denver metro area, past year non-medical use of pain relievers increased from to from 5.51 to 5.71 percent (not significant). Both the Denver metro and Colorado respondents reported higher past year non-medical use of pain relievers than national respondents. Other Opioid Indicators P e r c e n t Exhibit 11: Non-Medical Use of Pain Relievers in the Past Year: Comparison of to National Survey on Drug Use and Health: Denver Metro vs. Colorado vs. US Prescription opioids (e.g., oxycodone, hydrocodone, hydromorphone, meperidine, methadone, fentanyl, etc.) continue an increasing role in the Denver drug abuse scene. Such drugs as a category (i.e., Other Opioids) increased from 2.7 percent of total Denver treatment admissions in 2003 to 4.6 percent in both 2010 and 2011 (Ex. 12). Females, Hispanics and those between 18 and 34 years of age increased among Denver other opioid treatment admissions from 2003 to 2011 (Ex. 13). Though not shown in Exhibit 14, there were 3,261 narcotic analgesics Emergency Department (ED) visits in In Exhibit 15, narcotic analgesic ED visits are broken out by specific drug for CY As indicated, oxycodone accounted for 1448 ED visits, or 44.4 percent of all narcotic analgesic ED visits in The next closest narcotic was hydrocodone at 701 visits, or 21.5 percent of total. In Exhibit 17, the Denver metro area rate for narcotic analgesics ED visits is compared to that of the entire US. The Denver rate nearly tripled from 30.1 to per 100,000 from 2004 to The Denver narcotic analgesic rate was higher than the US rate from 2006 to Denver Metro Area Colorado US

44 Other opioids were among the most common drugs found in Denver drug-related decedents from 2003 to 2010 (Ex. 22). Morphine, codeine, methadone, oxycodone, hydrocodone and fentanyl accounted for 71 of the 152 drug related deaths in 2010 (i.e., 46.7 percent). Morphine was involved in 11.8 to 37.9 percent of Denver drug related deaths during the 2003 to 2010 time period, while codeine was involved in 2.0 to 21.3 percent during the same time period. However, based on the prior discussion of the short half-life of the marker for heroin deaths (i.e., 6- monoacetylmorphine) and that codeine and morphine are typically present in the body following heroin use, it is likely that a substantial proportion of morphine and codeine deaths are really heroin related deaths. In fact, as heroin deaths increased dramatically in 2009 and 2010 due to better identification of 6-MAM in urine, morphine and codeine deaths dropped sharply to their lowest levels in the 2003 to 2010 time period. Oxycodone accounted for only 8.6 percent of Denver drug related deaths in 2003, but increased to 23.2 percent by 2009, dropping somewhat to 15.8 percent (24 deaths) in Likewise, oxycodone in combination with any other drug accounted for only 7.9 percent of Denver drug mortality in 2003 (11 deaths), but increased to 20.3 percent in 2009 (42 deaths Ex. 23). Denver metro hospital discharge data from 2003 to 2011 combines all narcotic analgesics and other opioids, including heroin 11. The hospital discharge rate per 100,000 for all opioids increased overall from 146 per 100,000 in 2003 to 257 per 100,000 in This is a 76 percent increase (Ex. 18). Taken together, oxycodone and hydrocodone accounted for 3.1 percent of drugs submitted for testing by local law enforcement in the Denver metro area in the first half of In comparison, oxycodone and hydrocodone constituted 4.1 and 7 percent of drug samples analyzed in Colorado and the US, respectively (Ex. 19). Other opioid exhibits tested by the Denver Police Department crime lab increased four-fold from 46 in 2001 to 183 in 2006 (Ex. 25). They declined to 154 in 2007 and to 143 in While other opioid exhibits reached 202 in 2009, nearly a five-fold increase over 2001, they declined to 131 in However, in 2011, the DCL analyzed 162 other opioid exhibits, an increase of 23.7 percent over Overall, as shown in Exhibit 25, the trend for other opioid exhibits analyzed by the Denver Crime Lab (DCL) from 2001 through 2011 represents a statistically significant increase (p <.01). In 2011, among other opioid exhibits in the DCL, oxycodone and hydrocodone were most common, at 46.3 and 33.3 percent of total opioid exhibits, respectively (Ex. 26). Recent data from the Colorado Prescription Drug Monitoring Program (PDMP) show mostly overall increases in the number and rate of hydrocodone and oxycodone prescriptions filled for Denver residents 12. Exhibit 27 details hydrocodone prescriptions filled for Denver residents from the third quarter of 2007 through the fourth quarter of Hydrocodone prescriptions peaked at 48,039 or per 1000 population, in the first quarter of 2011, but declined to 45,128 (or per 1000 population) by the fourth quarter of Overall, from the third quarter of 2007 through the fourth quarter of 2011, the hydrocodone prescription rate increased from to per 1000, or by 10.6 percent. Oxycodone prescriptions dispensed in Denver increased from 27,501 to 43,332 from the 3 rd quarter of 2007 through the 4 th quarter of 2011, with the rate per 11 This is the only way opioid hospital discharge data are available 12 The Denver Office of Drug Strategy was notified in July 2010 by the Colorado Department of Regulatory Agencies, Board of Pharmacy that past data on prescriptions filled in Denver was incorrect. The corrected data was included in both the October 2010 and April 2011Denver Drug Trends reports. Please do not use prior data. 44

45 1000 population increasing during the same time period from to This is an increase of 53.1 percent (Ex 28). Local law enforcement continues to see well organized and sophisticated prescription opioid trafficking including use of fake prescriptions that utilize fake phone numbers. They also believe the availability and quality of prescription opioids (i.e., pain management drugs) has led to greater popularity and use (which seems to be corroborated by all of the increasing indicators). Also, there is less of a stigma in using prescription medications compared to use of heroin. The most common ways illicit users obtain prescription opioids are doctor and emergency department shopping, and forgery. Law enforcement describes several investigations of organized groups writing or calling in fraudulent opioid orders. The internet is also a less commonly used method to illegally obtain prescription opioids. Law enforcement reports that prescription opioid prices on the street have remained fairly consistent with the following price ranges; Oxycontin at $.50 to $1.00 per milligram, Percocet at $5-10 per pill, Vicodin at $ 3-5 per pill and Fentanyl patches at $ each. The 30 mg dosage of oxycodone has become popular on the street and is referred to as a Roxy. With formula changes to Oxycontin making it harder to abuse, the potent narcotic analgesic, oxymorphone (i.e., brand name Opana) is now being more widely abused. Opana is cheaper than Oxycontin and is reported to produce a more intense high. The extended release tablets are formulated in a way that make them relatively easy to abuse (i.e., the 12-hour time-release coating can be removed which makes available the entire oxymorphone dose a potentially fatal amount). The OME reported three oxymorphone deaths in 2010 and two in 2009, which they said was unusual. In a related matter, the OME also stated that they were starting to see muscle relaxants in combination with prescription opioids (e.g., Soma and Opana).. Local clinicians still see prescription opioid use as a huge problem in Denver, especially among women because they generally access health care more often than men (see increase in the proportion of females in treatment listing prescription opioids as their primary drug of abuse Exhibit 13). One clinician describes pain killer abuse as a scourge with medical providers increasingly stressed by patients demanding ever more potent pain killers in increasing doses. Patients with legitimate pain often develop tolerance to and withdrawal symptoms from prescription opioids with many addicted before they even realize. Some patients may fabricate or exaggerate their symptoms to get pain killers and then sell them to family or friends. Often times a primary care patient may come back with a clean opioid drug screen when they should test positive, because they are selling rather than using prescription pain killers (hard for some low income patients to resist easy cash). Clinicians, law enforcement and street outreach workers see increasing prescription opioid use among adolescents because it is easy for them to obtain and sell at school, parties, or on the street. Some adolescents report that they can sell Percocet (oxycodone and acetaminophen) and Vicodin (acetaminophen and hydrocodonea) for up to $20 a pill. While some adolescents are just trying to make easy money, many develop an abuse or dependence problem, which requires treatment. Clinicians also report that younger users lack education about how addictive 45

46 prescription opioids can be and how dangerous they are especially when combined with other drugs. Some street outreach workers in Denver say that prescription opioids are not sold as often on the street, except between users. This business is not typically run by street gangs, but rather by doctor shoppers who are able to obtain large quantities of prescription opioids. Benzodiazepines Benzodiazepines (benzos) are a class of psychoactive drugs with varying sedative, hypnotic, and anti-anxiety (i.e., anxiolytic) properties. Most common are the benzodiazepine tranquilizers (e.g., diazepam or Valium, alprazolam or Xanax, lorazepam or Ativan, etc.). Benzos present a mixed picture in the Denver drug scene, with ED visits showing a stable trend; and mortality and crime lab exhibits showing an upward trend. This drug category is not shown as a separate breakout on Exhibit 12. However, from 2002 to 2011 benzos were infrequent among Denver treatment admissions accounting for a high of 23 admissions in 2002 (1.1 percent of total drug admissions excluding alcohol) to a low of 4 in There were 8 such admissions in There were 1799 benzodiazepene related Denver metro area ED visits in 2010 as shown in Exhibit 16. At 458 visits (25.5 percent of total benzos), alprazolam (Xanax) was the most common benzo followed by clonazepam (Klonopin) at 417 visits, 23.2 percent; lorazepam (Ativan) at 299 visits, 16.6 percent; diazepam (Valium) 211 visits, 11.7 percent, and Temazepam (Restoril) 56 visits, 3.1 percent. In Exhibit 17, the Denver metro area rate for benzo ED visits is compared to that of the entire US. The Denver rate tripled from 23.7 to 72 visits per 100,000 from 2004 to 2008, and dropped slightly in 2009 (69.8 per 100,000). The Denver benzo rate was lower than the US rate for all six years shown, but only slightly in The Denver Police Department crime lab analyzed 79 benzo exhibits in 2011 an increase from the 62 benzo exhibits analyzed in 2010, and slightly less than the 84 exhibits analyzed in Overall, as shown in Exibit 29, the trend for other benzos exhibits analyzed by the Denver Crime Lab (DCL) from 2001 through 2011 represents a statistically significant increase (p <.05). Most notable among these benzo exhibits, alprazolam (i.e., Xanax) nearly doubled from 24.3 percent to 43.8 percent of total benzo exhibits from 2001 through 2008 (Ex. 30). Alprazolam exhibits declined to 32.1 percent of total benzo exhibits in 2009, but increased to 37.1 percent of total benzo exhibits in 2010, and to 46.8 percent in 2011 (the highest total in the 11 year time period). Alprazolam has been more numerous than all other benzo exhibits from 2008 through the As to other benzos in 2011, clonazepam was second to alprazolam in percent of benzo exhibits (at 22.8 percent), followed by diazepam (20.3 percent) and lorazepam (8.9 percent). In Exhibit 32, PDMP data show almost steady increases in the rate of lorazepam, alprazolam, and diazepam prescriptions filled for Denver residents from the 3 rd quarter of 2007 through the 4 th quarter of As indicated, among the three benzos, lorazepam had the highest rate of 46

47 prescriptions filled for Denver residents for the entire time period shown, followed by alprazolam with diazepam third 13. Local clinicians state that benzodiazepines are popular with people using opioids because of the high it creates when taken together (especially heroin). Some opioid addicts may use benzodiazepines to manage the effects of opioid withdrawal (e.g., a Denver detox manager sees a number of heroin using clients self-admitting to detox seeking benzodiazepine medication when they are unable to get heroin). However, the synergistic effects of opioids and benzodiazepines (often in combination with alcohol as well) can be lethal. Clinicians say their clients who use benzodiazepines most commonly use alprazolam (Xanax) and/or clonazepam (Klonopin). Xanax acts more rapidly and carries more punch, but wears off more quickly. For someone who is using Xanax for chronic/severe anxiety, and uses the drug throughout the day, this can lead to more use and abuse. A Denver area clinician states that benzos are popular with methadone patients (i.e., their methadone dose is lowered if they use benzos). However, if someone is on suboxone (i.e., buprenorphine plus nalaxone) and uses benzos, the client is taken off suboxone and referred for methadone. The OME mainly sees heroin and benzos (mostly diazepam and clonazepam) in mortality toxicology, but not a lot of methadone and benzos. Law enforcement describes benzodiazepine trafficking as being organized similarly to prescription opioids, with doctor and emergency department shopping, and forgery, but that it mostly involves individuals getting benzodiazepine prescriptions and selling to other individuals. Benzo usually sell for $3-5 a pill, but can be as high as $10-20 per pill (e.g., one Xani Bar may sell for up to $15). Outreach workers in Denver say that many adolescents and young adults have prescriptions for benzodiazepines, which gives the impression of a benzo social norm. Methylenedioxymethamphetamine (MDMA) MDMA, or ecstasy, morbidity and mortality remain relatively low in Denver. There were only 20 club drug treatment admissions in 2010 and 29 in 2011(.6 and.9 percent, respectively, of total non-alcohol admissions), all were for MDMA in 2010 and 27 were for MDMA in 2011 (Ex. 12). In 2009, of the 7 club drug admissions (.2 percent of total non-alcohol admissions), 3 were for MDMA. Nineteen of the twenty club drug admissions in 2008 were for MDMA. In 2010, there were 165 ED visits for MDMA in the Denver metro area, or 2.7 percent of total visits (Ex. 14). In Exhibit 17, the Denver metro area rate for MDMA ED visits is compared to that of the entire US. The Denver rate more than tripled from 4.5 to 14.2 visits per 100,000 from 2004 to 2008, but declined to 11.6 in The US rate more than doubled from 3.5 to 7.4 visits per 100,000 from 2004 to The Denver MDMA rate was higher than the US rate from for the entire 2004 to 2009 time period. 13 The Denver Office of Drug Strategy was notified in July 2010 by the Colorado Department of Regulatory Agencies, Board of Pharmacy that past data on prescriptions filled in Denver was incorrect. The corrected data was included in both the October 2010 and April 2011Denver Drug Trends reports. Please do not use prior data.. 47

48 Exhibit 31 shows MDMA and MDMA substitute (e.g., MDMA and methamphetamine, MDMA and ketamine, etc.) exhibits analyzed by the Denver Police Dept. crime lab from 2001 through In 2001, nearly all (110 or 98.2%) of the 112 MDMA/MDMA substitute exhibits were pure MDMA. However, while total MDMA/MDMA substitute exhibits increased to 192 and 173 in 2007 and 2008, respectively; the percentage that were pure MDMA dropped to 52.6 percent in 2007 and 61.3 percent in In 2009, there were 156 MDMA/MDMA substitute exhibits with only 48 percent being pure MDMA; in 2010, 74 of 117 (or 63.2 percent) of MDMA/MDMA substitute exhibits were pure MDMA; and in of 2011, 45 of 74 (or 61 percent) of MDMA/MDMA substitute exhibit were pure MDMA. MDMA accounted for 2.4 percent of drugs submitted for testing by local law enforcement in the Denver metro area in the first half of 2011 compared to 2.4 and 0.9 of drug samples analyzed in Colorado and in the US, respectively (Ex. 19). Local law enforcement (DEA and Denver Police) reports that MDMA comes from a variety of sources including California, the Pacific Northwest, Europe and Canada. However, most MDMA in Colorado and the Denver metro area comes from Canada, trafficked by Asian gangs. Much of the MDMA is distributed in downtown Lo Do nightclubs catering largely to Asians. Clinicians also point out that a lot of MDMA use is situational, attached to the rave lifestyle. Clinical and law enforcement personnel say MDMA use has increased because it is not perceived as harmful (e.g., few prevention campaigns discouraging use). Also, the typical urine screen panels don t detect MDMA. MDMA in powdered form sells for $1000 to $1600 per ounce. MDMA tablets sell for $8-25 per dosage unit (e.g., tablet). Users can get lower price deals for higher quantity purchases. Undercover officers are encountering powdered MDMA in gel caps called Mollies that are approximately.2 grams and sell for $15/du. The Denver Crime Lab finds that most MDMA tabs are cut with other drugs (e.g., methamphetamine, benzylpiperazine, etc.) but sold as MDMA (see Exhibit 31). One MDMA sample analyzed by the DEA in 2011 was only 22 percent pure. The Denver OME rarely sees MDMA in drug screens as a cause of death, or even as an accompanying drug. Benzylpiperazine (BZP) and Trifluoromethylphenylpiperazine (TFMPP) In 2011 the Denver Crime Lab analyzed 18 BZP samples, and 1 BZP/MDMA combination; compared to 10 BZP exhibits, 14 BZP combinations (mostly with MDMA) and 1 TFMPP in all of However, this is compared to the DCL analysis of 33 BZP, 9 BZP combinations, and 2 TFMPP exhibits for all of In contrast, the DCL had analyzed zero BZP, BZP combinations, and TFMPP exhibits from 2001 through The DCL says the BZP combinations may relate to BZP recently being made a Schedule 1 controlled substance. CY 2010 was the first year that BZP was illegal in Colorado and cases could be prosecuted with less than 1000 tabs. Unfortunately, BZP is not reported (at least currently) in treatment, emergency room, mortality, or hospital discharge data. It seems only the crime labs are isolating this drug. Thus, it is difficult 48

49 to determine actual BZP usage levels. However, local law enforcement report somewhat of a resurgence in BZP (BZP is often sold as ecstasy). According to a recent DEA review, BZP was first synthesized in 1944 as a potential antiparasitic agent; and was subsequently shown to have amphetamine-like effects. Though much less potent than amphetamine, BZP acts like a stimulant in humans producing euphoria, and increased heart rate and blood pressure. It appears that 1996 was the first year BZP use was initiated by drug abusers in the US, as measured mostly by encounters with law enforcement. BZP is usually taken orally as a powder, tablet or capsule. BZP street names include A2, Legal E, or Legal X. BZP is often taken in combination with a substance known as TFMPP (1-3- trifluoromethylphenylpiperazine), which is touted as a substitute for MDMA. Though probably not a significant problem in Denver in terms of user numbers, recent research 14 points out that BZP and TFMPP, when taken together, have a synergistic effect on certain neurotransmitters (i.e., dopamine and serotonin) which may lead to seizures. The Denver Crime Lab has reported seeing some methamphetamine mixed with TFMPP to boost the psychedelic effect. Bath Salts A class of drugs recently appearing on the scene in the Denver metro area and in Colorado is the synthetic stimulant called bath salts. Marketed with such benign sounding names as Cloud Nine, Vanilla Sky, Bliss and White Dove, these stimulants have effects similar to methamphetamine and ecstasy. The actual names for these drugs include mephedrone, methylone and MDPV. In 2011, the Denver Crime Lab (DCL) reported 3 mephedrone, 1 mephedrone- in-combination with other drugs, 1 MDPV-in-combination, 3 methylone, 3 methylone-in-combinations, 1 ethylone and 2 butylone among the total samples analyzed. This is the first time; the DCL has reported analyzing this drug in the past 11 years. However, these drugs do not typically appear in any other institutional data sets at this point, with the exception of the Rocky Mountain Poison and Drug Center. According to the RMPDC, based on data from January through April, 2011, there were 9 exposures to bath salts (8 males and 1 female). These bath salt users reported twenty-one different symptoms including slurred speech, seizures, hypertension, excessive sweating, acidosis, chest pain, confusion, agitation and irritability, and tachycardia. Though as mentioned above, bath salts are not in the treatment data set, one Denver area treatment program reports an increase in bath salts use, mainly males in their late 20 s to early 30 s (and actually had one client who had injected bath salts). The National Institute on Drug Abuse s, Community Epidemiology Work Group, considers these synthetic cathinones to be an emerging threat (including MDPV, mephedrone, methylone, 4- FMC 4-fluoromethcathinone- and 3-FMC 3-fluoromethcathinone). This class of drugs has been huge in Europe since 2007 with horrific stories of psychotic episodes. Any information 14 Bauman, et al. N-Substituted Piperazines Abuse by Humans Mimic the Molecular Mechanism of 3,4 Methylenedioxymethamphetamine. Neuropsychopharmacology, 2005, 30:

50 on the effects and consequences of this class of drugs is anecdotal. The DEWG will continue to monitor these drugs to try and determine their effects within the Denver metro area. 50

51 Exhibit 12: Numbers and Percentages of Treatment Admissions by Primary Drug Type in the City and County of Denver: CY Drug Total Alcohol n 747 1,003 1,114 1,489 1,363 1,542 1,677 1,635 1,497 12,067 % Marijuana n 665 1,038 1,067 1,086 1,162 1,341 1,207 1,223 1,119 9,908 % (excluding alcohol) % Methamphetamine n ,855 % (excluding alcohol) % Cocaine n ,021 % (excluding alcohol) % Heroin n ,171 % (excluding alcohol) % Other Opioids 1` n ,373 % (excluding alcohol) % Depressants 2 n % (excluding alcohol) % Other /Stimulants n % (excluding alcohol) % Hallucinogens 3 n % (excluding alcohol) % Club Drugs 4 n % (excluding alcohol) % Other 5 n % (excluding alcohol) % Total N 3,267 3,928 4,206 4,603 4,589 5,177 4,938 4,882 4,652 40,242 (excluding alcohol) N 2,520 2,925 3,092 3,114 3,226 3,635 3,261 3,247 3,155 28,175 1 Includes non-prescription methadone and other opiates and synthetic opiates. 2 Includes barbiturates, benzodiazepine tranquilizers, clonazepam, and other sedatives. 3 Includes LSD, PCP and other hallucinogens. 4 Includes Rohypnol, ketamine (Special K), GHB, and MDMA (ecstasy). 5 Includes inhalants, over-the-counter and other drugs not specified. SOURCE: Drug/Alcohol Coordinated Data System, Alcohol and Drug Abuse Division, Colorado Department of Human Services 51

52 Exhibit 13: Demographic Characteristics of Clients Admitted to Treatment in the City and County of Denver-- Percents: CY 2003 compared to CY 2011 Alcohol Cocaine Heroin Methamphet. Rx Opioids Marijuana Year Total N by Year Gender Male Female Race/Ethnicity White African- American Hispanic Other Age at Admission Under to to and older Route of Ingestion Smoking Inhaling Injecting Oral/Other Secondary Substance Alcohol Cocaine Heroin 1, Methamphetamin Marijuana Rx Opiates Hallucinogens Sedatives Other None , SOURCE: Drug/Alcohol Coordinated Data System, Alcohol and Drug Abuse Division, Colorado Department of Human Services 52

53 Exhibit 14: Number and Percentage of Reports in Drug-Related ED Visits in Denver by Drug Category (Unweighted 1 ): CY 2010 Amphet & Other Stim 5.1% Methamphetamine 11.0% DAWN Live! Unweighted Data: CY 2010 Heroin 13.1% Hallucinogens 2.1% MDMA 2.7% Other 1.6% Cocaine 29.9% Other Club 0.4% Synth. Cannabinoids 0.6% Marijuana 33.4% DRUG 2010 % Alcohol % Non-alcohol illicits % Cocaine % Heroin % Cannabinoids % Marijuana % Synthetic cannabinoids % Stimulants % Amphetamines % Methamphetamine % Other Stimulants 4 ** MDMA (Ecstasy) % GHB 9 ** Flunitrazepam (Rohypnol) 6 ** Ketamine 10 ** LSD 47.46% PCP 15 ** Miscellaneous hallucinogens 64.63% Inhalants 71.70% Combinations NTA 25.24% Total Illicit Drugs & Alcohol Unweighted data from 7 Denver area hospital EDs reporting to DAWN. All DAWN cases are reviewed for quality control. Based on this review, cases may be corrected or deleted. Therefore, these data are subject to change. 2 Misuse cases only, which exclude adverse reaction and accidental ingestion cases ** Too small to show SOURCE: DAWN Live!, OAS, SAMHSA, updated 9/22/2009 Exhibit 15: Number and Percentage of Narcotic Analgesic Reports in Drug-Related ED Visits in Denver, by Specific Drug (Unweighted): CY N % Oxycodone/combinations % Hydrocodone/combinations % Morphine/combinations % Methadone % Fentanyl/combinations 162 5% Codeine/combinations % Buprenorphine/combinations % Other % Total % SOURCE: DAWN Live!, OAS, SAMHSA, updated 9/22/

54 Exhibit 16: Number and Percentage of Benzodiazepene Visits Reported in Drug Related ED Visits in Denver, by Specific Drug: CY 2010 (unweighed) 2010 N % Alprazolam (Xanax) % Clonazepam % Benzos (NOS) % Lorazepam (Ativan) % Diazepam (Valium) % Temazepam (Restoril) % Clorazepate (Tranxene) % Chlordiazepoxide (Librium) 9 0.5% Other % Total % SOURCE: DAWN Live!, OAS, SAMHSA, updated 9/22/2009 Exhibit 17: Denver Metro vs. US Rate per 100,000 Population for Selected Drug-Related ED Visits Involving Misuse/Abuse of Illicit Drugs and Non-Medical Use of Pharmaceuticals: ED Visit Rates per 100, Cocaine: Denver Metro Rate US Rate Heroin: Denver Metro Rate US Rate Marijuana: Denver Metro Rate US Rate Methamphetamine: Denver Metro Rate US Rate Narcotic Analgesics: Denver Metro Rate US Rate MDMA Denver Metro Rate US Rate Benzodiazepines Denver Metro Rate US Rate

55 Exhibit 18. Number and Rates of Denver Drug-Related Hospital Discharge Reports per 100,000 Population for Selected Drugs: *(2011 extrapolated from data for the first 9 months of the year) Drug * Alcohol (n) 9,812 10,560 10,060 10,288 10,116 11,361 11,750 12, Rate Stimulants (n) Rate Cocaine (n) Rate Marijuana (n) Rate Opioid (n) Rate Population 560, , , , , , , , ,959 SOURCE: Colorado Department of Public Health and Environment, Colorado Hospital Association Discharge Data Program Database Exhibit 19. Denver Area and US NFLIS Samples: Top 10 Most Frequently Identified Drugs of Total Analyzed Drug Items: First Half 2011 Drug Denver Area Colorado Total US N % N % N % Cocaine , Marijuana/Cannabis , Methamphetamine , Heroin , MDMA Oxycodone , Psilocybin/Psilocyn/Psilocybine * * Hydrocodone , Benzylpiperazine (BZP) * * Alprazolam , Other , Clonazepam * * * * Buprenorphine * * * * Total , Source: National Forensic Lab Information System Note: Denver Area in this comparison includes Denver, Jefferson and Arapahoe Counties * Not among the top ten in Denver ** Not among the top ten nationally 55

56 Exhibit 20: Federal Drug Seizures in Colorado: Quantity Seized Drug Cocaine 65.5 kgs 36.0 kgs kgs kgs 44.0 kgs 52.6 kgs Heroin 3.9 kgs 4.6 kgs 3.0 kgs 4.0 kgs 2.5 kgs 3.2 kgs Methamphetamine 14.8 kgs 28.8 kgs 34.4 kgs 50.3 kgs 8 kgs 26.4 kgs (Meth labs) Marijuana kgs kgs kgs kgs Ecstasy 1 kgs=kilograms 2 NR=Data not reported. 3 du=dosage units 1,128 tablets 0 tablets 1,149.5 kgs 24,089.2 kgs kgs/1,103du 0.0 kgs 0.0 kgs kgs/2,104du Source: Denver Safety Office of Policy Analysis 56

57 Exhibit 22: Most Common Drugs in Denver Drug Related Decedents: Percent of All Cases Drug Contributing to Cause of Death n % n % n % n % n % n % n % Cocaine Morphine Alcohol Codeine Heroin Methadone Oxycodone Methamphetamine Acetaminophen Diazepam Alprazolam Hydrocodone Dihpenhydramine Clonazepam Fentanyl Decedents* Source: Denver Medical Examiner s Office Autopsy Reports *Drug totals won t sum to decedents because more than one drug may be found in individual s toxicology Exhibit 23: Most Common Combinations of Drugs in Decedents by Percent of All Cases: 2003 to 2009 Combinations n % n % n % n % n % n % n % Morphine and Codeine % % % % % % % Cocaine and Morphine % % % % % % 5 2.4% Cocaine and Codeine % % % % 8 4.2% 7 3.3% 2 1.0% Morphine and Alcohol % % % % 9 4.8% % 7 3.4% Cocaine and Alcohol % % % % % % % Cocaine and Heroin 7 5.0% 2 1.3% 8 4.7% 9 5.3% 5 2.6% 8 3.8% % Oxycodone & any other drug % 4 2.6% 0 0.0% 1 0.6% % % % Total Decedents Source: Denver Medical Examiner s Office Autopsy Reports Exhibit 24: Number of Statewide Drug-Related Calls to the Rocky Mountain Poison and Drug Center: 2004 to 2010 (human exposure calls only) Drug Alcohol Cocaine/Crack Heroin/Morphine Marijuana Methamphetamine Club Drugs Note: Club Drugs includes Gamma Hydroxybutyrate and MDMA 57

58 Source: Denver Crime Lab Source: Denver Crime Lab 58

59 Source: Colorado Prescription Drug Monitoring Program Source: Colorado Prescription Drug Monitoring Program 59

60 Source: Denver Crime Lab 60