Proceedings of the Denver Epidemiology Work Group. Spring 2015 Report. Colorado Social Research Associates (Arapahoe House)

Transcription

1 Proceedings of the Denver Epidemiology Work Group Spring 2015 Report Colorado Social Research Associates (Arapahoe House)

2 Table of Contents DEWG Spring 2015 Attendees... 3 Purpose and Distribution... 4 Data Sources... 5 Executive Summary... 7 Colorado and Denver Demographics Alcohol Trend Summary Alcohol Prevalence Alcohol Indicators Cocaine Trend Summary Cocaine Prevalence Cocaine Indicators DEA Price, Purity and Trafficking Information Heroin Trend Summary Heroin Indicators DEA Price, Purity and Trafficking Information Marijuana Trend Summary Marijuana Prevalence Marijuana Indicators The Impact of Recreational and Medical Marijuana in Colorado DEA Price and Purity Information Synthetic Cannabinoids Methamphetamine Trend Summary Methamphetamine Indicators DEA Price, Purity and Trafficking Information Prescription Opioids Trend Summary Prescription Opioid Prevalence Prescription (Rx) Opioid Indicators Benzodiazepines Methylenedioxymethamphetamine (MDMA) Prevalence Bath Salts... 31

3 DEWG Spring 2015 Attendees Adam Shirey Amy Romero April Hendrickson Audrey Nottke Becky Helfand Bruce Mendelson Chelsey Clarke Clayton Gonzales Devi Grieser Don Mares Don Shriver Donald Bell Helen Kaupang Jack Reed James Henning James Warne Jason Schimschal Jodi Lockhart Jonathan Gray Kathryn Deyoung Laura Ginnett Leah Raffa Lisa Barker Mandy McCullen Mariah Coler Marie Gurrola Maureen Carney Meredith Silverstein Michel Holien Michelle Deland Nachshon Zohari Nanin Wongngamnit Nicole Berg Nicole Burrell Rob Valuck Robert Bellamy Robin Valdez Ron Gowins Sharon Liu Terri Wellman Toby Leroux Wendi Roewer Rocky Mountain HIDTA Arapahoe House Omni Institute Denver CARES Office of Behavioral Health Denver Office of Drug Strategy Rocky Mountain HIDTA Urban Peak Arapahoe House Denver Department of Human Services Denver Crime Lab Denver Medical Examiner DEA Colorado Division of Criminal Justice DPD (Denver Police Department) Arapahoe House DPD (Denver Police Department) Office of Behavioral Health Arapahoe/Douglas Mental Health Denver Public Health Denver Public Health Denver Office of Drug Strategy Colorado Department of Public Health and Environment Environment Omni Institute Peer Assistance Arapahoe House Peer Assistance Services Arapahoe House Denver Public Schools Arapahoe House Denver Office of Drug Strategy Denver VA Medical Center Arapahoe House Arapahoe House University of Colorado- School of Pharmacy Harm Reduction Action Center Denver Environmental Health ARTS Office of Behavioral Health DEA Denver Public Health DEA

4 Purpose and Distribution The Denver Epidemiology Work Group (DEWG) was 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 (Goal 5, Objectives 1 and 4 of the Denver Drug Strategy Plan). 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 illicit drug abuse, including misuse, diversion, and abuse of prescription drugs. However, alcohol use and abuse will also be examined by the DEWG on an ongoing basis. The DEWG members were selected by the Data and Evaluation Subcommittee of the DDSC 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. DEWG Spring

5 Data Sources Prevalence data for the Denver metro area is derived from the National Survey on Drug Use and Health (NSDUH) which 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, noninstitutionalized 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 substate levels. The current NDEWS report for the DMA uses , , and NSDUH data. The Healthy Kids Colorado Survey (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 captures Denver Public School (DPS) middles (6-8 th grade) and high school (9-12 th grade) students from the 2011 and the 2013 school years. Treatment data are provided by the Drug/Alcohol Coordinated Data System (DACODS) which is maintained by the Office 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 choice (as reported by the client at admission) unless otherwise specified. Annual figures are given for calendar years (CY) 2006 through Alcohol and drug-related emergency department (ED) visits for the City/County of Denver, the Denver metropolitan area, and Colorado were provided by the Colorado Department of Public Health and Environment (CDPHE) based on ICD-9-CM codes for 2011, 2012 and Alcohol and drug-related hospital discharges for the City/County of Denver, the Denver metropolitan area, and Colorado were provided by the Colorado Department of Public Health and Environment (CDPHE) based on ICD-9-CM codes for 2007 through Alcohol and drug-related mortality for the City/County of Denver, the Denver metropolitan area, and Colorado were provided by the Colorado Department of Public Health and Environment (CDPHE) based on ICD-10 codes for 2007 through Alcohol and drug-related mortality data for the City and County of Denver for CY 2007 through CY 2013 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 DEWG Spring

6 toxicology findings are part of the autopsy report. 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 2006 through National Forensic Lab Information System (NFLIS) data are presented for Denver, Jefferson, and Arapahoe Counties for 2014 with a comparison 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. Additional drug specific crime lab statistics for 2000 through the first half of 2013 were obtained from the Denver Crime Lab, Denver Police Department. Statistics on prescriptions filled for Denver residents by drug type from the 3 rd quarter 2007 through the 2nd quarter 2013 were obtained from the Colorado Prescription Drug Monitoring Program (PDMP), Colorado Department of Regulatory Agencies, Division of Registrations, Board of Pharmacy. Data on the number of medical marijuana applications and approved patients from December 2009 through September 2014 is from the Colorado Department of Public Health and Environment, Medical Marijuana Registry. Data on medical marijuana centers, retail stores, medical marijuana infused product manufactures, and medical marijuana grow sites are provided by the Colorado Department of Revenue. Data are presented through October Data on price, purity and trafficking comes from the Denver Field Division of the Drug Enforcement Administration with additional data from the Denver Police Dept. and the High Intensity Drug Trafficking Areas Program (HIDTA). Other anecdotal data comes from discussion during the May 6, 2015 meeting of the Denver Epidemiology Work Group. DEWG Spring

7 Executive Summary The DEWG report provides trend data on prevalence, and indicators of problematic drug use which include drug treatment data, emergency department data, hospital discharge data, mortality data, and crime exhibits. This report provides the trends from for the following substances: alcohol, marijuana, prescription opioids, heroin, methamphetamine and cocaine. A limited amount of information is available for benzodiazepines and MDMA. The following graphs display the rates per 100,000 of all substances to demonstrate the highest and lowest treatment admission rates by substance from Treatment Admission Rates During 2014, the highest treatment admission rates involved alcohol, followed by marijuana. The lowest treatment admission rates were for cocaine and prescription opioids. Treatment Admission Rates: Denver Metro, Emergency Department Rates Emergency department (ED) visits from were highest among alcohol and marijuana use. Alcohol related ED visits were almost five times higher for alcohol compared to marijuana. Cocaine and heroin had the lowest ED during DEWG Spring

8 Mortality Rates In 2014, mortality was highest for heroin, followed by oxycodone. The lowest mortality numbers during this reporting period were for methamphetamine and cocaine. Human Exposure Calls Rocky Mountain Poison and Drug Center human exposure calls were highest for alcohol from , followed by marijuana and methamphetamine. The fewest calls were for cocaine and heroin. DEWG Spring

9 Summary of Individual Substances Alcohol According to the National Survey on Drug Use and Health (NSDUH), past 30 day alcohol use among people 12 years old and above declined slightly in both the Denver metro area (65.6 percent to 61.6 percent) and in Colorado (62.5 percent to 59.8 percent) from 2010 to Both Colorado and Denver metro showed substantially higher 30- day alcohol use than their national counterparts. The prevalence data from the Healthy Kids Colorado Survey (HKCS) demonstrated a slight decrease in past 30 day use when comparing 2011 and 2013 data. The high school average dropped slightly from 40% of students to 38% of students who used alcohol in the past 30 days. Decreases occurred among all grades except in 10 th and 11 th grade. In the Denver metro area, males years had the highest rate of alcohol related ED visits at 2,044.5 per 100,000. Males years old had the next highest rate of ED visits at 1,990.3 per 100,000. This rate is a 17% increase from The highest rate of alcohol related treatment admissions were by males (67.9%). The majority of admissions for alcohol were White (57.2%), followed by Hispanic (26%). The most common age for treatment admission for alcohol was years of age. Hospital discharge rates per 100,000 in the Denver metro area increased by 16.7% from 2007 to Alcohol related emergency department visits increased by 14.1% from 2011 to In the Denver metro, alcohol related mortality rates declined by 16% from 2009 to Cocaine Past year cocaine use among people 12 years and older remained fairly stable from Both Colorado and Denver metro respondents reported higher past year cocaine use than national respondents. In the Denver metro area, treatment admission rates for cocaine have decreased from 23.4% in 2006 to 9.8% in 2014 (excluding alcohol). In the Denver metro area in 2014, the majority of those admitted to treatment for cocaine were male (65.6%). Most were Hispanic (33.9%), followed by African American (30.8%), and White (30.1%).The most common age for treatment admissions for cocaine was (31.3%). In the Denver metro area, cocaine related hospital discharge rates per 100,000 decreased by 34.4% from 2007 to Mortality rates declined in Denver metro from from 5.8 to 2.2 per 100,000. Heroin Treatment admission rates in Denver metro has more than doubled from , from 10.5 in 2007 to 23.8% in 2014 (excluding alcohol). During 2014 in the Denver metro area, the majority of treatment admissions were male (65.6%). Most of the people admitted to treatment were White (67.3%), followed by Hispanic (23.6%), and other (6.2%). The most common age for treatment for heroin users was (37.9%). In Denver metro, the highest rate of ED visits for heroin poisoning was among males years old with a rate of 43.9 per 100,000. This rate increased 56% from 2011 to DEWG Spring

10 The next highest rate was among males, years old, with a rate of 28.3 per 100,000. The rate of heroin related emergency department visits in the Denver metro area increased from 5.4 to 7.89 from 2011 to The rate of heroin related hospital discharges per 100,000 increased from.97 to 2.3 from 2007 to The rate of heroin related deaths per 100,000 increased from 1.3 to 2.6 from 2007 to Marijuana According to NSDUH data, past 30 day marijuana prevalence among people 12 years and older in the Denver metro area increased from 9.6% in to 13.5% from Further, the perception of risk decreased from 26.8% to 19.6% for that same population and reporting period. The HKCS demonstrated that 30 day marijuana use increased among Denver students as they progressed from middle school through high school. The past 30 day marijuana prevalence remained stable from 2011 to 2013, with a high school average of 28% of students using marijuana in the past 30 days in 2011 and 27% in Treatment rates for marijuana have been decreasing in Denver County, Denver metro and in Colorado since Denver metro admissions declined from 38.7% in 2010 to 28.2% in 2014 (excluding alcohol). In 2014, The majority of treatment admissions for marijuana use were male (79.9%) in the Denver metro area. Most were White (39.8%), followed by Hispanic (35.1%), and African American (16.4%). The most common age for treatment admission was (31.6%). Emergency department marijuana visit rates increased by 67.8% in Denver County from Marijuana related hospital discharge rates per 100,000 for the Denver metro area more than doubled from 2007 to Marijuana related calls to the RMPDC increased more than five-fold (from 45 to 238) from Methamphetamine In the Denver metro area, methamphetamine treatment admissions decreased from 2006 to 2011 but have been increasing steadily since. In 2014, Denver metro methamphetamine treatment admissions were 24.7% of all admissions compared to 21.5% in 2006 (excluding alcohol). During 2014 in the Denver metro area, the majority of methamphetamine treatment admissions were male (57%). Most were White (64.5%), followed by Hispanic (23.8%), and other (9.4%). During this same period, the most common age for treatment admission for methamphetamine users was (41.5%). The rate per 100,000 of ED visits in Denver metro nearly doubled from 52.6 in 2011 to in The rate per 100,000 of hospital discharges in Denver metro rose from 31.1 in 2007 to 46.1 in Statewide methamphetamine related human exposure calls to the RMPDC increased more than four-fold from 29 to 131 calls from 2006 to DEWG Spring

11 Prescription Opioids According to NSDUH data, non-medical use of prescription opioid use for people age 12 and older decreased in Denver metro from 6.6% in to 5.7% in Both Colorado and Denver metro respondents reported higher past year non-medical use of pain relievers than national respondents. Treatment admission rates for prescription opioids have nearly doubled in the Denver metro area from 5.5% in 2006 to 10.3% in 2014 (excluding alcohol). During 2014 in the Denver metro area, slightly more than half (50.3%) of prescription opioid treatment admissions were female. The majority (63.8%) were White, followed by Hispanic (25.7%), and other (6.2%). The most common age for treatment admission for opioid users was (41.8%). In the Denver metro area, prescription opioid ED visits per 100,000 increased by 22.7% from 2011 to In the Denver metro, the rate of prescription opioid related hospital discharges increased by 58.4% from 2007 to Mortality rates decreased slightly in Denver metro between 2007 and DEWG Spring

12 Percent Colorado and Denver Demographics 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, 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); 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. Trend Summary Alcohol Alcohol ranks as the number one drug of abuse in the Denver metro area for prevalence and indicator data. Alcohol prevalence has remained relatively stable while indicators have shown mixed trends: treatment stable, hospital discharges and emergency department visits up, and mortality and RMPDC human exposure calls down slightly. Alcohol Prevalence Past 30-Day Alcohol and Binge Alcohol Use from the National Surveys on Drug Use and Health (NSDUH) Exhibit 1 to the right compares past 30-day alcohol Exhibit 1: Past Month Alcohol Use Among Persons 12 and Over: Denver use 1 for the Denver metro Metro vs. Colorado vs. US-- Based on , , and area, all of Colorado, and the NSDUH Surveys total U.S. for respondents 70.0% 65.6% 61.7% 62.5% who are aged 12 and older 60.1% 61.6% 59.8% 60.0% based on annual averages from the , % 2010, and % NSDUHs. For the Denver 30.0% metro area, alcohol use increased from to % 10 (61.7 to 65.6 percentsignificant at p<.05), but 10.0% decreased from to % Past Month Alcohol Use (%)-12 and Past Month Alcohol Use (%)-12 and 12 (65.6 to 61.6 percentsignificant at p<.05). For Denver Metro Area Colorado Total U.S. over Pop Over Pop Colorado, past 30-day alcohol use increased from to (60.1 to 62.5 percent-not significant): but decreased 51.2% 51.7% 51.8% Past Month Alcohol Use (%)-12 and Over Pop 1 At least one drink of alcohol in the past month. DEWG Spring

13 Percent Percent from to (62.5 to 59.8 percent- significant at p<.05). Both Colorado and Denver metro showed substantially higher 30-day alcohol use than their national counterparts. Exhibit 2 to the right compares past 30-day binge alcohol use 2 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, alcohol binge use increased from to (27.2 to 28.3 percent-not significant), but decreased from to (28.3 to 26 percent not significant). For Colorado, past 30-day alcohol binge use increased from to (26.2 to 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Exhibit 2: Past Month Binge Alcohol Use Age 12 and Over: Denver Metro vs. Colorado vs. US-Based on , , and NSDUH Surveys 27.2% 28.3% 26.2% 26.8% 26.0% 23.3% 23.4% 24.4% 22.8% Past Month Binge Alcohol Use (%)-12 and over Past Month Binge Alcohol Use (%)-12 and over Denver Metro Area Colorado Total U.S Past Month Binge Alcohol Use (%)-12 and Over Pop 26.8 percent-not significant): but decreased from to (26.8 to 24.4 percentsignificant at p<.05). Both Colorado and Denver metro showed higher 30-day binge alcohol use than their national counterparts. Denver Public Schools Healthy Kids Colorado Survey Data on Alcohol Use Exhibit 3 to the right compares any past 30-day alcohol use among Denver Public School (DPS) middle (6-8 th grade) and high school (9-12 th grade) students from the 2011 to the 2013 using the Health Kids Colorado Surveys (HKCS). As indicated, past 30-day alcohol use among DPS students ranged from 8 percent of 6 th graders to 51 percent of 12 th graders in 2011; and from 5 percent of 60% 50% 40% 30% 20% 10% 0% 8% 5% Exhibit 3: Prevalence of Past 30-day Alcohol Use: Denver Middle School and High School Students (HKCS): 2011 vs Surveys 13% 9% 23% 17% 34% 29% 37% 38% 42% 43% 51% 46% 40% 38% 6th 7th 8th 9th 10th 11th 12th HS Avg Males having 5 or more drinks and females 4 or more drinks on at least one occasion in the past month. DEWG Spring

14 6 th graders to 46 percent of 12 th graders in The average high school use was 40 percent in 2011 and 38 percent in Alcohol Indicators Alcohol Treatment Admissions Alcohol was the most common drug reported by clients admitted to treatment in the Denver metro area from 2006 to Alcohol treatment admissions in the Denver metro area increased from 4,414 in 2006 to a high of 5,685 in 2012, decreased to 5,586 in 2013 and to 5,222 in Admissions have been decreasing slightly both in the Denver Metro area and in Colorado since As to percent of total treatment admissions in the Denver metro area, alcohol increased from 35.9 to 40.6 percent from 2006 to 2013, but decreased to 37.7 percent in 2014 (Exhibit 13, Appendix). Alcohol was also the most common drug reported by clients admitted to treatment across Colorado from 2006 to 2014 (Exhibit 14, Appendix). Alcohol treatment admissions in the state increased from 11,528 in 2006 to a high of 14,007 in 2012, decreased to 13,172 in 2013 and to 12,435 in As to percent of total treatment admissions in Colorado by primary drug type, alcohol increased from 40.6 to 42 percent from 2006 to 2009, but decreased to 38.4 percent in 2014 (Exhibit 14, Appendix). Alcohol Demographic data As stated above, alcohol was the most common drug reported by clients admitted to treatment in the Denver metro area. In 2014, 67.9 percent of those treated for alcohol were male, while 32.1 percent were female. Fifty-seven percent of those admitted to treatment for alcohol were White, 26.4 percent were Hispanic, and 8.7 percent were African American (Exhibit 15, Appendix). During 2014 in the Denver metro area, the most common age for treatment admission for alcohol was years of age (32.2%). The most common route of administration for alcohol in 2014 was oral (99.5%) followed by inhaling (0.3%), and smoking (0.2%). The most common secondary substance for alcohol users in 2014 was reported as none (54.2%), followed by those reporting marijuana (22.7%), and cocaine (8.0%) (Exhibit 15, Appendix). Alcohol Related Hospital Discharges As shown in Exhibit 16 (Appendix), alcohol related hospital discharges in the Denver metro area are substantially higher than those of any other drug. From 2007 to 2013, Denver alcohol hospital discharges increased from 14,465 to 18,645 representing an increase in rate of to per 100,000 population, or by 16.7 percent. Alcohol Related Emergency Department Visits As shown in Exhibit 17 (Appendix), the rate per 100,000 of alcohol related emergency department (ED) visits in the Denver metro area are substantially higher than those of any other drug. From 2011 to 2013, the Denver alcohol ED rate per 100,000 increased from to , or by 14.1 percent. Alcohol Related Mortality Exhibit 18 (Appendix) shows alcohol and drug related mortality numbers (unduplicated) and rates per 100,000 population for the Denver metro area from 2007 through As with ED visits DEWG Spring

15 Percent Number of Arrests Rate of Arrests Per 10,000 and hospital discharges, both the number and rate of alcohol related deaths are higher than for any other drug. From 2007 to 2009 the number of alcohol deaths increased from 706 to 882 representing an increase in rate per 100,000 of 26.3 to 31.8 (or by 20.9 percent). However, the number of alcohol deaths declined to 819 in 2010, and to 775 by 2012, increasing only slightly to 792 in The alcohol mortality rate per 100,000 declined from 31.8 to 26.6 from 2009 to 2012, remaining stable at 26.7 in 2013 (overall a decline of 16.3 percent). Exhibit 4: Comparison of Denver and Colorado Total Adult and Juvenile DUI Arrests: DUI Arrests Exhibit 4 to the right compares the number and rate of Denver and Colorado total adult and juvenile arrests from through Denver DUIs declined from ,145 to 2,589, or by percent during the time period shown. Denver s DUI 0 arrest rate declined from 74.5 to 40.9 per 10,000 population from 2000 through Denver and Colorado s rates were relatively similar from 2010 to Alcohol Related Fatal Crashes in Denver and Exhibit 5: Alcohol Related Fatal Crashes: Denver County Colorado vs. Colorado: Exhibit 5 shows the 70.0% 65.7% percentage of alcohol related 60.0% 54.8% 53.8% fatal crashes for Denver vs. 50.0% 44.4% 47.1% Colorado from 2007 to % Denver s alcohol related fatal 40.0% 41.1% 42.1% crashes declined from % 41.3% 40.6% 30.0% 34.5% percent of total fatal crashes in 2007 to 32.4 percent in 20.0% In Colorado, alcohol 10.0% related fatal crashes 0.0% remained relatively stable from 2007 (41.1 percent) to 2013 (32.7 percent). The Denver Percent Alcohol Related percentages of alcohol related fatal crashes in Denver were higher than that of Colorado for the entire time period shown except for Alcohol Related Calls to the Rocky Mountain Poison and Drug Center (RMPDC) % 32.7% Denver Adult and Juvenile DUI Arrests Colorado Adult and Juvenile DUI Arrests Denver DUI Arrests Per Colorado DUI Arrests Per Colorado Percent Alcohol Related DEWG Spring

16 Percent From 2006 to 2014, statewide alcohol related calls to the RMPDC were at least 3.5 times greater than those of any other drug. However, the 890 calls to RMPDC in 2014 related to human exposure to alcoholic beverages, represented a 10.2 percent decrease from the 991 calls in 2011 (the peak number of calls in the time period shown - Exhibit 19, Appendix). Alcohol Meeting Recap It is important to note that alcohol indicator rates for hospital discharges, emergency department visits, and RMPDC calls are much higher than all of the major drugs of abuse (i.e., cocaine, heroin, methamphetamine, marijuana, and prescription opioids) combined. The alcohol mortality rate is equivalent to the sum of cocaine, heroin, methamphetamine and prescription opioid mortality rates for Colorado, and Denver specifically, have a higher past month use (12 years of age and older) than the rest of the United States, painting the picture that Colorado has a culture largely influenced by alcohol. As discussed by the DEWG, this can be seen as Colorado is one of the top 5 states in microbreweries per capita, conveying the idea of work hard and play hard. Finally, when it comes to seeking treatment, it was observed that the year old age range is increasing, perhaps due to increasing alcohol problems among baby boomers. Trend Summary Cocaine Cocaine continues to be a major drug of abuse in the Denver metro area associated with high morbidity and mortality. However, cocaine prevalence has declined and most cocaine indicators have been declining through 2014 (i.e., treatment admissions, mortality, hospital discharges, crime lab exhibits and calls to the Rocky Mountain Poison and Drug Center). Emergency department visits also declined from 2011 to 2012, but increased in 2013 back to the 2011 level. Cocaine Prevalence Past Year Cocaine Use from the National Surveys on Drug Use and Health (NSDUH) Exhibit 6 to 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 3.49 to 3.55 percent (not significant), but then declined to 2.95 percent from to (not significant). For Colorado, past year * 1.68 cocaine use rose slightly from 3.24 to 3.44 percent from to (not significant), but declined to 2.76 percent from to (not significant). During all reported years, the Exhibit 6: Cocaine Use in Past Year: Comparison of , & NSDUH: Denver Metro vs. Colorado vs. US Denver Metro Area Colorado US DEWG Spring

17 Denver metro area and Colorado reported higher past year cocaine use than their national counterparts. Cocaine Indicators Cocaine Treatment Admissions Cocaine has been steadily decreasing for the past 6 years. Cocaine was the second most common drug (excluding alcohol) reported by clients admitted to treatment in the Denver metro area from 2006 to 2008, third most common from 2009 to 2010, fourth most common from 2011 through 2013, and dropping to fifth most common in 2014 (Exhibit 13, Appendix). The number of cocaine treatment admissions in the Denver metro area increased from 1,848 in 2006 to a high of 1,910 in 2008, but then decreased to a low of 841 in As to percent of total treatment admissions in the Denver metro area (excluding alcohol), cocaine decreased from 23.4 percent to 9.8 percent from 2006 to Statewide, cocaine was the third most common drug (excluding alcohol) reported by clients admitted to treatment from 2006 to 2011, dropping to fifth most common from 2012 to 2014 (Exhibit 14, Appendix). The number of cocaine treatment admissions in Colorado area increased from 3,484 in 2006 to a high of 3,690 in 2008, but then decreased steadily to a low of 1,524 in As to percent of total treatment admissions in Colorado (excluding alcohol), cocaine decreased from 20.7 percent to 7.7 percent from 2006 to Cocaine Demographic Data As reported, cocaine was the fifth most common drug in which clients sought treatment for in the Denver metro area in 2014 (excluding alcohol). During 2014 in the Denver metro area, 65.6 percent of those treated for cocaine were male, while 34.4 percent were female. Of these, Hispanics represented the largest percentage of those seeking treatment (33.9%), 30.8 percent were African American, and 30.1 percent were White (Exhibit 15, Appendix). In the Denver metro area, the most common age for treatment admission for cocaine was years of age (31.3 percent). The most common route of administration for cocaine in 2014 was smoking (59.5 percent) followed by inhaling (32.6 percent) and injecting (5.5 percent). The most common secondary substance for cocaine users in 2014 was alcohol (32.6 percent), followed by those reporting none or no secondary drug use (30.0 percent), and marijuana (21.5 percent) (Exhibit 15, Appendix). Cocaine Related Hospital Discharges As shown in Exhibit 16 (Appendix), cocaine related hospital discharges in the Denver metro area ranked second (including alcohol) in 2007, but declined to fourth from 2008 through From 2007 to 2013, Denver cocaine hospital discharges decreased from 2,583 to 1,870 representing a decrease in rate per 100,000 of 96.2 to 63 per 100,000 population, or by 34.5 percent. Cocaine Related Emergency Department Visits As shown in Exhibit 17 (Appendix), Denver metro cocaine ED visits (including alcohol) ranked fourth in 2011 and 2012, dropping to fifth in The rate per 100,000 of cocaine related emergency department (ED) visits in the Denver metro area decreased from 84.4 to 73.5 from DEWG Spring

18 2011 to 2012, but increased to 83 in Cocaine Mortality Exhibit 18 (Appendix), shows cocaine mortality numbers and the rate per 100,000 population for the Denver metro area from 2007 through Cocaine ranked third (including alcohol) from 2007 through 2012, dropping to fourth in The number of cocaine deaths declined steadily from 155 in 2007 to 65 in 2013, while the rate per 100,000 also declined from 5.8 to 2.2 during the same time period. Cocaine Related Calls to the Rocky Mountain Poison and Drug Center (RMPDC) From 2006 to 2014, statewide cocaine related human exposure calls to the RMPDC declined dramatically from 129 to 46 (Exhibit 19, Appendix). Cocaine Related Crime Lab Exhibits Cocaine was the most common drug submitted for testing by local law enforcement in 2013 in the Denver metro area (i.e., Denver, Arapahoe and Jefferson Counties Exhibit 20, Appendix). As shown, cocaine accounted for 24.4 percent of the samples analyzed in the Denver metro area compared to 20.5 percent for all of Colorado (where cocaine ranked second behind methamphetamine), and 15.4 percent for the entire US. In 2014, the Denver Crime Lab (DCL) analyzed 700 crack cocaine exhibits, down slightly from 779 analyzed in 2013, and down substantially from the peak of 1,740 in As to powder cocaine, in 2014 the DCL analyzed 585 exhibits also down slightly from the 631 exhibits in 2013; but down substantially from the peak of 1,240 in DEA Price, Purity and Trafficking Information Although reporting during 2014 indicated that some distributors in the Denver metro area experienced difficulty in obtaining consistent supplies of cocaine from sources in Mexico, cocaine availability and prices remained stable. Prices were largely determined by the purported quality of the cocaine for sale. Many distributors cut the drug in order to extend their supplies. During this reporting period, most offices within the Denver metro area reported moderate cocaine availability. Cocaine transportation and distribution throughout the Denver metro area are controlled primarily by Mexican polydrug trafficking organizations. Cocaine loads are driven in private vehicles from Mexico, Arizona, Texas, and California to Colorado. From Colorado, some of the cocaine is distributed throughout the region. Additionally, cocaine loads are sometimes redistributed from Colorado to markets in the Midwest. Prices reported in Denver during this period ranged from $500-1,300 per ounce; $8,000 for a quarter-kilogram; and $32,000-36,000 per kilogram. Cocaine Meeting Recap The 2014 data represents a steady decline in the use of cocaine, and this was generally echoed by anecdotal evidence from the members of the DEWG. There has been a consistent decline in treatment admissions since However, the reason for these declines remains debatable. As discussed above, the availability of cocaine could be a driving factor. Other factors discussed within the group included: switch in younger generations to seek Adderall or prescription stimulants over cocaine and methamphetamine being an easier drug to traffic than cocaine. DEWG Spring

19 Trend Summary Heroin Heroin prevalence is not measured in the NSDUH. However, all other heroin indicators are increasing including treatment admissions, hospital discharges, emergency department visits, mortality, calls to the RMPDC, and crime lab exhibits. Heroin Indicators Heroin Treatment Admissions Heroin was the fourth most common drug (excluding alcohol) reported by clients admitted to treatment in the Denver metro area from 2006 to 2010, third most common in from 2011 to 2014, except for 2013 when it moved to second (Exhibit 13, Appendix). The number of heroin treatment admissions in the Denver metro area has more than doubled from 829 in 2006 to a high of 2,048 in As to percent of total treatment admissions in the Denver metro area (excluding alcohol), heroin more than doubled from 10.5 percent to 23.8 percent from 2006 to The statewide increase in heroin treatment admissions was just as dramatic. Heroin was the fourth most common drug (excluding alcohol) reported by clients admitted to treatment from 2006 to 2011, but, increased to third most common from 2012 to 2014 (Exhibit 14, Appendix). The number of heroin treatment admissions in Colorado area nearly tripled from 1,380 in 2006 to a high of 4,001 in As to the percent of total treatment admissions in Colorado (excluding alcohol), heroin more than doubled from 8.2 to 20.1 percent from 2006 to Heroin Demographic Data As reported, heroin was the third most common drug in which clients sought treatment for in the Denver metro area in 2014 (excluding alcohol). In 2014, 65.6 percent of those treated for heroin were male, while 34.4 percent were female percent of those admitted to treatment for heroin were White, 23.6 percent were Hispanic, and 6.2 percent reported other (Exhibit 15, Appendix). In the Denver metro area, the most common age for treatment admission for heroin users was years of age (37.9 percent). The most common route of administration for heroin in 2014 was injecting (74.2 percent), followed by smoking (20.6 percent), and inhaling (4.2 percent). The most common secondary substance for heroin users in 2014 was reported as none (23.0 percent), followed by those reporting cocaine (16.1 percent), and marijuana (15.2 percent) (Exhibit 15, Appendix). Heroin Related Hospital Discharges As shown in Exhibit 16 (Appendix), heroin related hospital discharges per 100,000 in the Denver metro area ranked sixth (including alcohol) from 2007 through 2013, but increased from 1 (n=26) to 2.3 (n=69) per 100,000 during that time period Heroin Related Emergency Department Visits As shown in Exhibit 17 (Appendix), Denver metro heroin ED visits (including alcohol) ranked sixth in 2011 through The rate per 100,000 of heroin related emergency department (ED) DEWG Spring

20 visits in the Denver metro area increased from 5.4 to 7.9 from 2011 to Heroin Mortality Exhibit 18 (Appendix), shows heroin mortality numbers and the rate per 100,000 population for the Denver metro area from 2007 through The number of heroin deaths increased overall from 34 in 2007 to 77 in 2013, with a rate per 100,000 from 1.3 to 2.6 during the same time period. Heroin Related Calls to the Rocky Mountain Poison and Drug Center (RMPDC) From 2006 to 2014, statewide heroin related human exposure calls to the RMPDC increased from 25 to 51 (Exhibit 19, Appendix). Heroin Related Crime Lab Exhibits Heroin was the 4 th most common drug submitted for testing by local law enforcement in 2013 in the Denver metro area (i.e., Denver, Arapahoe and Jefferson Counties Exhibit 20, Appendix). As shown, heroin accounted for 14.0 percent of the samples analyzed in the Denver metro area compared to 11.3 percent for all of Colorado (where heroin also ranked fourth behind marijuana/cannabis), and 10.2 percent for the entire US. In 2014, the Denver Crime Lab (DCL) analyzed 931 heroin exhibits, up from 875 analyzed in 2013, and up substantially from the 607 analyzed in 2012, and 304 analyzed in DEA Price, Purity and Trafficking Information Both Mexican black tar and brown powder heroin are encountered in the Denver metro area. Mexico-produced white heroin can be found but not in abundance. White heroin does not appear to be in high demand in this region compared to black tar and brown powder. Mexico-based suppliers of white heroin generally produce black tar/brown power as well, usually in greater quantities. Heroin distribution organizations operating in Colorado are generally tied to sources of supply in Sinaloa and Nayarit, Mexico. Most of the heroin is transported from sources of supply in Mexico to Colorado via Arizona; Las Vegas, Nevada; or southern California. From Colorado, some of the heroin is further distributed to markets in the Midwest. Several Mexicobased trafficking cells control the transportation and distribution of wholesale quantities of Mexican heroin in Denver. Wholesale quantities are transported to Denver from southern California or Arizona by Mexican organizations. The wholesale distribution of heroin in Denver is controlled almost exclusively by Mexican drug organizations. Likewise, street-level distribution of quarter-ounce to ounce quantities is dominated by Mexican and Honduran distribution cells. During this reporting period, most offices within the Denver metro area reported high or moderate heroin availability. Prices for brown powder in Denver during this reporting period ranged from $750-1,200 per ounce. Heroin Meeting Recap All heroin indicators are on the rise with the greatest concern focusing on heroin mortality. Also, the DEWG discussion emphasized that there are still many current heroin users who had started with prescription opioids and then switched to cheaper heroin when the cost of prescription opioids (sometimes as high as $.50 to $1 per milligram) became prohibitive. DEWG Spring

21 Percent Percent Trend Summary Marijuana Both the Denver metro area and Colorado respondents reported substantially higher past month Marijuana use and lower perception of risk, than national respondents. While treatment admissions went down in 2014, marijuana still ranks second to alcohol for treatment admissions. Other indicators including hospital discharges, emergency department visits, RMPDC calls, and crime lab exhibits continue to move in an upward trend Marijuana Prevalence Past 30-Day Marijuana Use from the National Surveys on Drug Use and Health (NSDUH) Exhibit 7 to the right compares past month marijuana 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 month marijuana use increased from to (9.62 to 12.2 percent-significant <.01) and from to (12.2 to percent- not significant). For Colorado, past month marijuana use increased from to (8.56 to percent-significant P<.001): and from to (11.18 to percent-not significant). Both the Denver metro area and Colorado respondents reported substantially higher past month marijuana use than national respondents. Perception of Great Risk of Past Month Marijuana Use from the NSDUH Exhibit 8 to the right compares perception of great risk of smoking marijuana once a month 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 Exhibit 7: Marijuana Use in the Past Month: Comparison of , , & NSDUH: Metro Denver vs. Colorado vs. US Denver Area Colorado US Exhibit 8: Perception of Great Risk of Smoking Marijuana Once a Month: Comparison of , , NSDUH: Denver Metro vs. Colorado vs. US Denver Area Colorado US DEWG Spring

22 2008, , and NSDUHs. For the Denver metro area, perception of risk decreased from to (26.8 to percent-significant at P<.01): and from to (21.99 to 19.6-not significant. Likewise, Colorado perception of great risk of smoking marijuana once a month decreased from to (28.8 to 24.2 percent-significant at P<.01): and from to (24.2 to 22.1 percent-not significant). Both the Denver metro and Colorado respondents reported substantially lower perception of risk of marijuana use than national respondents. Lifetime and Past 30 Day Use of Marijuana: Healthy Kids Colorado Survey Exhibit 9 to the right shows lifetime and past 30 day marijuana use based on the Healthy Kids Colorado Survey of middle and high school students in Colorado (statewide sample) for 2005, 2009, 2011 and 2013 (no weighted sample in 2007). As indicated, about two in five students report having used marijuana at some point in their lifetimes during 2005, 2009, and 2011, with a slight downward trend through Likewise, there was little change in past 30 day use across the four surveys, with about 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Exhibit 9: Healthy Kids Colorado Survey: Comparison of Lifetime and Past 30 Day Marijuana Use Statewide for 2005, 2009, 2011 and 2013 one quarter of students reporting past 30 day marijuana use in 2009, with slightly more than 1 in 5 reporting such use in both 2005 and 2011, and about 1 in 5 reporting 30 day use in Lifetime and Past 30-Day Marijuana Use among Denver Public School Students Exhibits 21 and 22 (Appendix) show reported lifetime (for 9 th through 12 th grade) and 30-day marijuana use (for 6 th through 12 th grade) by grade among Denver Public School (DPS) students with comparisons to students in Colorado and the US. As shown in Exhibit 21, lifetime marijuana use by DPS high school students ranged from 37 percent among ninth graders to 56 percent among twelfth graders with an average of 47 percent across all grades. In all instances from 9 th through 12 th grade and in the high school (HS) average, DPS students reported substantially higher lifetime marijuana use than their Colorado and US counterparts. In Exhibit 22 (Appendix), the range for past 30-day marijuana use for DPS students in 2013 was from 3 to 30 percent for sixth to twelfth grade, respectively; a HS average of 27 percent. As with lifetime use, DPS students reported higher use than their Colorado or US counterparts (Exhibit 21). 42.4% 42.6% 39.5% 36.9% Colorado Students Lifetime Marijuana Use % 22.7% 24.8% 22.0% 19.7% Colorado Students Past 30 Day Marijuana Use: % DEWG Spring

23 Marijuana Indicators Marijuana Treatment Admissions In the Denver metro area (Exhibit 13, Appendix), marijuana admissions were second only to alcohol for the entire time period shown. This was also the case for marijuana admissions in all of Colorado, except for 2014 when the methamphetamine admission percentage moved ahead of marijuana (Exhibit 14, Appendix). In the Denver metro area, marijuana treatment admissions increased from 2,903 in 2006 to a high of 3,295 in 2008 (or by 13.5 percent) and remained at about that level in 2009 and 2010, 3,289 and 3,229 admissions, respectively. In 2011, marijuana admissions declined by 10.5 percent to 2,891. They declined slightly to 2,856 in 2012, or by 1.2 percent, and declined to 2,544 in 2013, or by 10.9 percent. In 2014, Denver metro marijuana admissions totaled 2,431, slightly less than In Colorado, marijuana treatment admissions also increased from 5,668 in 2006 to a high of 6,874 in 2009 (or by 21.3 percent), declining somewhat to 6,347 in In 2012, statewide marijuana admissions increased slightly to 6,405, but declined to 5,999 in 2013 (or by 6.3 percent), and to 5,529 in Interestingly, both Colorado and Denver metro area marijuana admissions as a percentage of total admissions have declined from a peak in 2010 (37.8 and 38.7 percent, respectively) through 2014 (27.8 and 28.2 percent, respectively). Marijuana Demographic Data As reported, marijuana was the second most common drug in which clients sought treatment for in the Denver metro area in 2014 (including alcohol). In 2014, 79.9 percent of those treated for marijuana were male, while 20.1 percent were female percent of those admitted to treatment for marijuana were White, 35.1 percent were Hispanic, and 16.4 percent were African American (Exhibit 15, Appendix). The most common age for treatment admission for marijuana users in the Denver metro area was years of age (31.6 percent). The most common route of administration for marijuana in 2014 was smoking (93.1 percent) followed by inhaling (3.7 percent) and oral/other (3.2 percent). The most common secondary substance reported after for marijuana (for those with marijuana as a primary substance) in 2014 was none (38.2 percent), followed by those reporting alcohol (36.7 percent), and methamphetamine (7.9 percent) (Exhibit 15, Appendix). Marijuana Related Hospital Discharges In the Denver metro area, marijuana was the fourth most common drug (behind alcohol, cocaine, and prescription opioids) reported in substance abuse related hospital discharges in However, from 2008 to 2013, it ranked third behind only alcohol and prescription opioids 3. Overall, from 2007 through 2013, the marijuana hospital discharge rate per 100,000 for the Denver metro area doubled from 77.9 to (Exhibit 16, Appendix). 3 Prescription opioids is a category and not a single drug. DEWG Spring

24 Marijuana Related Emergency Department Visits As shown in Exhibit 17 (Appendix), Denver metro marijuana ED visits (including alcohol) ranked second in 2011 through The rate per 100,000 of marijuana related emergency department (ED) visits in the Denver metro area increased from to 256.5, or by 67.8 percent, from 2011 to Marijuana Related Calls to the Rocky Mountain Poison and Drug Center (RMPDC) From 2006 to 2014, statewide marijuana related human exposure calls to the RMPDC increased more than five-fold from 45 to 238 (Exhibit 19, Appendix). Marijuana Related Crime Lab Exhibits Marijuana was the 3rd most common drug submitted for testing by local law enforcement in 2013 in the Denver metro area (i.e., Denver, Arapahoe and Jefferson Counties Exhibit 20, Appendix). As shown, marijuana accounted for 15.4 percent of the samples analyzed in the Denver metro area compared to 17.8 percent for all of Colorado (where marijuana it ranked second), and 31.4 percent for the entire US (ranked #1). In 2014, the Denver Crime Lab (DCL) analyzed 942 marijuana exhibits, up from 756 analyzed in 2013, and but down substantially from the 1,259 analyzed in Cannabis Related Motor Vehicle Crashes and Fatalities in Colorado Exhibit 23 (Appendix) shows cannabis related motor vehicle fatal crashes and fatalities among total motor vehicle fatalities in Colorado from 2008 through As indicated, the number of cannabis related fatal crashes increased from 30 in 2008 to 52 in 2011, declined to 35 in 2012, but rose to 44 in Also, the total number of fatalities in those crashes increased from 36 in 2008 to 59 in 2011, declining to 45 in 2012, but increasing to 52 in Likewise, the percentage of cannabis related fatalities doubled from 6.6 percent in 2008 to 13.2 percent in 2011, declining to 9.5 percent in 2012, but increasing to 10.8 percent in It is important to note that these crashes may include other drugs and alcohol. Thus, cannabis itself may not have been the main contributing factor in the fatal crash. The Impact of Recreational and Medical Marijuana in Colorado Exhibit 24 (Appendix) shows the number of new medical marijuana registry (MMR) patient applications compared to medical marijuana patients with a valid registry ID (i.e., patients). The number of applications increased more than six-fold from December 2009 through September 2014 (43,769 to 274,766). The number of patients, which had also grown substantially from December 2009 through June 2011 (41,039 to 128,698), declined during the next six months to only 82,089 (or by 36.2 percent). However, by the September 30, 2014, the number had increased to 116,287, or by 41.7 percent. Medical marijuana dispensaries or centers (hereinafter referred to as MMCs) and marijuana infused product manufacturers are regulated by the Colorado Department of Revenue, Medical Marijuana Enforcement Division 5. 4 The 2013 cannabis FARS data from CDOT is preliminary. 5 Details are available on the Colorado Dept. of Revenue webpage, Medical Marijuana laws and regulations. DEWG Spring

25 Exhibit 25 (Appendix) shows current MMCs in the Denver metro area compared to those outside the metro area. As shown, there are currently 495 MMCs conducting business in Colorado. This is a small decrease from the 520 MMCs described in the April 2014 medical marijuana epidemiology report. Of the current 495 licensed MMCs, 273 (or 55.2 percent) are in the nine county Denver metro area (also a small decrease from the 58.8 of MMCs in the metro area in the April report). Of the 273 MMCs in the Denver metro area: 218 (or 80.0 percent) have a Type 1 license (with 1 to 300 primary patients); 28 (or 10.2 percent) have a Type 2 license (with 301 to 500 primary patients); and 27 (or 9.9 percent) have at Type 3 license (with 501 and above primary patients). On November 6, 2012, Colorado voters approved the legalized sale and use of recreational marijuana. To allow for creation and promulgation of new business rules for legalized sale (and use), legal marijuana retail stores did not open across Colorado until January 1, Also, through October 1, 2014, only current medical marijuana centers were permitted to also sell legal recreational marijuana. There are currently 233 licensed recreational marijuana retail stores in Colorado. Of these, 122, (or 52.4 percent) are in the City and County of Denver, while another 42 (18.0 percent) are in the rest of the Denver metro area. In addition, 22 stores, or 9.4 percent of total, are in the Front Range outside the Denver metro area. Finally, there are 47 (20.2 percent) on the entire Western Slope of Colorado (Exhibit 25, Appendix). DEA Price and Purity Information All offices within the Denver Field Division (DFD) reported marijuana availability as high during this reporting period with the exception of the Salt Lake City DO and Cheyenne RO, which reported moderate availability. Marijuana is widely available throughout Colorado. There has been a notable increase in both the demand for and supply of high-potency, domestically produced marijuana. In Colorado, marijuana is widely grown indoors, due in large part to state law allowing the use of marijuana for medical purposes and legalizing recreational use. Prices, both in the legal and black markets, have remained stable and in some cases decreased, suggesting the Colorado market may be saturated. A substantial and increasing amount of Colorado-produced marijuana and marijuana products such as edibles and hash oil are trafficked to out-of-state markets where they command higher prices. Synthetic Cannabinoids In 2013, Denver Health reported approximately 100 cases in Denver emergency departments (possibly 250 across Colorado) of people who became ill after smoking synthetic marijuana popularly known by such street names as "Spice," K2, and Black Mamba. These recent events have been in conjunction with increasing concern among law enforcement, treatment, and street outreach personnel about the availability and use of synthetic cannabinoids. The Denver Crime Lab (DCL) analyzed no synthetic cannabinoid exhibits from 2000 through However, there were 4 analyzed in 2010, 9 in 2011, 84 in 2012 and 274 in 2013, and 153 in The DCL also reported rapidly changing synthetic cannabinoid chemical compounds within the 2012 to 2014 time period. DEWG Spring

26 Recent data from the Rocky Mountain Poison and Drug Center (RMPDC) also details the problem arising from synthetic cannabinoid use. In 2010, RMPDC received 44 human exposure calls related to synthetic cannabinoids, with 39 in 2011, 34 in 2012, 90 in 2013 and 21 in Symptoms reported by callers included tachycardia (abnormally rapid heart rate), confusion, agitation/irritability, dysphoria, hallucinations/delusions, nausea/vomiting, drowsiness/lethargy, tremors, mydriasis (pupil dialation), seizures, etc. Marijuana Meeting Recap There are three times as many retail and medical marijuana stores in Colorado than Starbucks coffee shops. This fact brought forth during the DEWG marijuana discussion surprised few and was considered central to the impact of legalization and how it impacts the reported marijuana trends previously described. Most feel the substantial increases in Colorado and Denver, for past month use (12 and over); hospital discharges; emergency department visits, and crime lab exhibits are in large measure related to legalization. Another possible implication of legalization is the decline in treatment admissions from The group pointed out that this was because it was no longer criminal behavior to engage in the use of marijuana. In 2007 it took on average 9 years to seek treatment between age of first use and age of first treatment. In 2014 that average jumped to 11 years; the group discussed this is most likely associated with the perception of risk of marijuana. Nevertheless, the group discussed that we may be seeing an increase in treatment over the next 8-10 years due to legalization. Trend Summary Methamphetamine Methamphetamine continues to be a substantial problem in Denver. However, data suggest that most of the methamphetamine indicators are on the rise. Methamphetamine Indicators Methamphetamine Treatment Admissions In the Denver metro area (Exhibit 13, Appendix), methamphetamine admissions (excluding alcohol) were third behind and marijuana and cocaine from 2006 to 2008, second behind only marijuana from 2009 through 2012, third behind marijuana and heroin in 2013, and second again behind marijuana in However, for treatment admissions in all of Colorado (excluding alcohol), methamphetamine was second only to marijuana from 2006 to 2013, and first, exceeding marijuana, in 2014 (Exhibit 14, Appendix). In the Denver metro area, methamphetamine treatment admissions decreased from 1,699 in 2006 to a low of 1,475 in 2011, but then increased to a high of 2,127 in In Colorado, methamphetamine treatment admissions also decreased from 5,071 in 2006 to a low of 4,365 in 2011, but then increased to a high of 6,184 in In the Denver metro area, methamphetamine treatment admissions as a percentage of total admissions (excluding alcohol) decreased from 21.5 percent in 2006 to 17.9 percent in 2011, but increased to 24.7 through Likewise, in Colorado, methamphetamine decreased as a percentage of total admissions (excluding alcohol) DEWG Spring

27 from 30.1 to 24.2 percent from 2006 to 2011, but then increased to 31.1 through Methamphetamine Demographic Data As reported, methamphetamine was the second most common drug in which clients sought treatment for in the Denver Metro area in 2014 (excluding alcohol). In 2014, 57.0 percent of those treated for methamphetamine were male, while 43.0 percent were female. Of these, 64.5% admitted to treatment for methamphetamine were White, 23.8 percent were Hispanic, and 9.4 percent were other (Exhibit 15, Appendix). The most common age for treatment admission in the Denver metro area for methamphetamine users was years of age (41.5 percent). The most common route of administration for methamphetamine in 2014 was smoking (58.8 percent) followed by injecting (31.8 percent), and inhaling (7.1 percent). The most common secondary substance reported after for methamphetamine for those with methamphetamine as a primary substance in 2014 was marijuana (29.8 percent), followed by those reporting none (29.3 percent), and alcohol (19.4 percent) (Exhibit 15, Appendix). Stimulant Related Hospital Discharges In the Denver metro area, stimulant hospital discharges were the fifth most common drug reported in substance abuse related hospital discharges from 2007 through Overall, from 2007 through 2013, the stimulant hospital discharge rate per 100,000 for the Denver metro area rose from 31.1 to 46.1 (Exhibit 16, Appendix). Stimulant Related Emergency Department Visits As shown in Exhibit 17 (Appendix), Denver metro stimulant ED visits (including alcohol) ranked fifth in 2011 and 2012, but were 4 th in The rate per 100,000 of stimulant ED visits in the Denver metro area nearly doubled from 52.6 to from 2011 to Methamphetamine Related Calls to the Rocky Mountain Poison and Drug Center (RMPDC) From 2006 to 2014, statewide methamphetamine related human exposure calls to the RMPDC increased more than four-fold from 29 to 131 (Exhibit 19, Appendix). Methamphetamine Related Crime Lab Exhibits Methamphetamine was the 2nd most common drug submitted for testing by local law enforcement in 2013 in the Denver metro area (i.e., Denver, Arapahoe and Jefferson Counties Exhibit 20, Appendix), but first in Colorado. As shown, methamphetamine accounted for 21.1 percent of the samples analyzed in the Denver metro area compared to 25.6 percent for all of Colorado, and 14.6 percent for the entire US (ranked #3). In 2014, the Denver Crime Lab (DCL) analyzed 1104 methamphetamine exhibits, up slightly from 998 analyzed in 2013, and up substantially from the 336 analyzed in DEA Price, Purity and Trafficking Information Methamphetamine transportation and distribution are controlled primarily by Mexican polydrug trafficking organizations. Methamphetamine loads are driven in private vehicles from Mexico, Arizona, Texas, Nevada, and California to Colorado. From Colorado, much of the DEWG Spring

28 Percent methamphetamine is distributed throughout the region and the Midwest. Much of the methamphetamine encountered in Denver during this reporting period came directly from Mexican supply sources in liquid form. Prices in Denver during this reporting period ranged from $ per ounce and $5,000-10,000 per pound. Methamphetamine Meeting Recap The majority of the DEWG discussion about methamphetamine pertained to the increases in methamphetamine indicators, especially since There has been a drastic increase in treatment admissions for methamphetamine since The DEWG discussed that this came during a time where the availability of cocaine was low. However, most felt that the main reason for the increase in methamphetamine use and related consequences was a large and consistent supply of highly pure methamphetamine coming from Mexico. Some in the DEWG pointed out that there are substantial differences in the demographic characteristics of methamphetamine and cocaine users. Trend Summary Prescription Opioids Prescription opioids continue to be a major drug of abuse in the Denver metro area. Past year use, treatment admissions and mortality for prescription opioids has slightly declined. However, hospital discharges, emergency department visits and crime lab exhibits all continue to rise at substantial rates. Prescription Opioid Prevalence Past Year Prescription Opioid Use from the National Surveys on Drug Use and Health (NSDUH) Exhibit 10 to 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 NSDUHs. For the Denver metro area, past year non-medical use of pain relievers increased from to from 5.71 to 6.57 percent (not significant), but declined from to to 5.69 (not significant). For Colorado, past year non-medical use of pain relievers increased from to from 5.47 to 6.31 percent (not significant), but declined from to to 5.55 (not significant). Both the Denver metro and Colorado respondents reported higher past year non-medical use of pain relievers than national respondents. Prescription (Rx) Opioid Indicators Exhibit 10: Non-Medical Use of Pain Relievers in the Past Year: Comparison of , & NSDUH: Denver Metro vs. Colorado vs. US Denver Metro Area Colorado US DEWG Spring

29 Opioid Treatment Admissions Rx Opioid was the fifth most common drug (excluding alcohol) reported by clients admitted to treatment in the Denver metro area from 2006 to 2013, except for 2014 when it moved to fourth. The number of Rx opioid treatment admissions in the Denver metro area has more than doubled from 433 in 2006 to a high of 930 in 2012, decreasing to 852 in 2013, followed by an increase to 890 in As to percent of total treatment admissions in the Denver metro area (excluding alcohol), Rx opioids nearly doubled from 5.5 percent to 10.3 percent from 2006 to 2014 (exhibit 13, Appendix). The statewide increase in Rx opioid treatment admissions was just as dramatic. Rx opioids was the fifth most common drug (excluding alcohol) reported by clients admitted to treatment from 2006 to 2011, but increased to fourth most common from 2012 to The number of Rx opioid treatment admissions in Colorado more than doubled from 915 in 2006 to a high of 2,367 in 2012, declining slightly to 2,299 in 2013 and to 2,112 in As to the percent of total treatment admissions in Colorado (excluding alcohol), Rx opioids more than doubled from 5.4 to 12.1 percent from 2006 to 2012, decreasing to 11.7 in 2013 and to 10.6 in 2014 (Exhibit 14, Appendix). Opioid Demographic Data As reported, prescription opioids were the fourth most common drug in which clients sought treatment for in the Denver metro area in 2014 (excluding alcohol). In 2014, 50.3 percent of those treated for prescription opioids were female, while 49.7 percent were male. Of these, 64.5% admitted to treatment for prescription opioids were White, 25.7 percent were Hispanic, and 6.2 percent reported other (Exhibit 15, Appendix). The most common age for treatment admission for opioid users in the Denver metro area was years of age (41.8 percent). The most common route of administration for prescription opioids in 2014 was oral/other (78.1 percent) followed by inhaling (10.1 percent) and smoking (6.3 percent). The most common secondary substance reported after for prescription opioids (for those with prescription opioids as a primary substance) in 2014 was none (34.4 percent), followed by those reporting alcohol (16.2 percent), and marijuana (15.3 percent) (Exhibit 15, Appendix). Rx Opioid Related Hospital Discharges As shown in Exhibit 16 (Appendix), Rx opioid related hospital discharges per 100,000 in the Denver metro area ranked third in 2007 and 2013, and second from 2008 through 2012, increasing from 85.7 to 135.9, or by 58.6 percent from 2007 to The number of Rx opioid hospital discharges increased from 2,301 to 4,030 during the same time period. Rx Opioid Related Emergency Department Visits As shown in Exhibit 17 (Appendix) Denver metro Rx opioid ED visits (including alcohol) ranked third from 2011 through The rate per 100,000 of Rx opioid related emergency department (ED) visits in the Denver metro area increased from to 135.6, or by 22.7 percent, from 2011 to DEWG Spring

30 2.0% 9.6% 9.5% 6.5% 8.9% 4.8% 9.3% 17.8% 32.7% 26.5% 32.7% 27.4% 32.1% 25.0% 29.8% 21.0% 22.8% 20.3% 20.2% 17.1% 19.6% 15.2% 10.1% 37.1% 30.6% 29.8% 43.8% 46.8% 44.0% 40.7% 31.4% 52.9% Rx Opioid Mortality Exhibit 18 (Appendix), shows Rx opioid mortality numbers and the rate per 100,000 population for the Denver metro area from 2007 through The number of Rx opioid deaths increased slightly from 506 in 2007 to 525 in 2009, but decreased to 479 through The Rx opioid mortality rate per 100,000 decreased slightly overall from 18.9 to 16.2 from 2007 to Rx Opioid Related Crime Lab Exhibits Oxycodone ranked seventh (n=215, 2.1 percent of total drugs samples analyzed) among the most common drugs submitted for testing by local law enforcement in 2013 in the Denver metro area (i.e., Denver, Arapahoe and Jefferson Counties Exhibit 20, Appendix), while hydrocodone ranked 9 th (n=95, 0.9 percent of total drugs samples analyzed). Rx Opioid Meeting Recap There was some discussion during the DEWG meeting that there is not a lot of organized prescription opioid trafficking. DEWG discussants reported that most users/abusers obtain prescription opioids from friends, family, and when a partially used prescription is carelessly left in the medicine cabinet. Prescription opioids remain very expensive with Oxycontin commanding.50 to $1 per milligram while other prescription opioids go for $3-5 per pill (see discussion on the relation of expensive opioids to increased heroin use). There has been a decline in hydrocodone prescriptions dispensed in Denver which is thought to be due in large measure to the rescheduling of this opioid from Schedule III to II in October 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.). EX HIBIT 11: DENVER CRIME LAB PERCENTA GE OF BENZODIAZEPINE S ANLAYZED, Treatment admission rates from in the Denver metro area were relatively low for benzodiazepines as a primary drug ranging from 43 in 2006 to 54 in Alprazolam Clonazepam Diazepam Lorazepam Denver Crime Lab data demonstrated that alprazolam (Xanax) continued to be the highest percentage of benzodiazepines analyzed from 2007 (32.7 percent) to 2014 (52.9 percent), followed by clonazepam from 2007 (26.5 percent) to 2014 (19.6 percent ) as shown in Exhibit 11 DEWG Spring

31 Number of Exhibits (above). Benzodiazepines contributed to 29 percent of deaths in Denver in 2013, often in combination with other substances. Prevalence Methylenedioxymethamphetamine (MDMA) The Healthy Kids Colorado Survey asks if high school students have used ecstasy in their lifetime. In 2011, 8.0 percent of high school students reported trying ecstasy in their lifetime and this slightly increased to 10.0 percent in MDMA, or ecstasy, morbidity and mortality remain relatively low in the Denver metro area, but some indicators increased from 2002 to 2011 and slightly decreased from 2011 to In 2002, there were only 3 MDMA treatment admissions which grew to 85 in 2011, 74 in 2012, 71 in 2013, but decreasing somewhat to 54 in 2014 (Exhibit 13, Appendix). Exhibit 12 to the right shows MDMA and MDMA substitute (e.g., MDMA and methamphetamine, MDMA and MDA, etc.) exhibits analyzed by the Denver Police Dept. crime lab from 2001 through In 2001, nearly all (110 or 98.2 percent) of the 112 MDMA/MDMA substitute exhibits were pure MDMA. The total MDMA/MDMA substitute exhibits increased to 192 and 173 in 2007 and 2008, respectively; however, Exhibit 12: Total MDMA/MDMA Substitute vs. Pure MDMA Exhibits Analyzed in Denver Crime Lab:2001 through MDMA and Substitutes MDMA 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; in 2011, 45 of 74 (or 61 percent) of MDMA/MDMA substitute exhibit were pure MDMA; in 2012 only 22 of 47 (or 46.8 percent) of MDMA/MDMA substitute exhibits were pure MDMA, in of 28 (78.6 percent), and in of 54 were pure MDMA (51.9 percent). Bath Salts A class of drugs appearing on the scene in the Denver metro area and in Colorado circa DEWG Spring