Frontline Florida: Emerging Drug Trends The Opiate Epidemic

Transcription

1 # of Opioids Detected Among Decedents Number of Heroin Deaths Number of Rx Opioid Poisoning Patients Frontline Florida: Emerging Drug Trends The Opiate Epidemic James N. Hall, Epidemiologist Nova Southeastern University Center for Applied Research on Substance Use and Health Disparities Number of Heroin Deaths in Florida: 2 to 215* Heroin Cases 93 % Cause of Death 95 % w/other Drugs * X1H * Projected Increase based on 2 X 1 st Half of Source: Florida Medical Examiners Commission 215 Interim Report 7, 6, 5, 4, 3, 2, 1, Number of Nonmedical Rx Opioids Occurrences Detected among Decedents in Florida * 5,59 4,35 4,416 6,6 6,68 6,333 5,454 5,489 Opioids *215 projection based on 2 x 1H215 5,85 6,174* 5, Heroin Cases 47 % Cause of Death 89 % w/other Drugs Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 25 - June 215 Reports Number of Hospital Cases for Non-Fatal Rx Opioid Poisonings in Florida: Emergency Dept Inpatient 8,153 6, , ,571 9,524 8,443 8, ,95 Source: Analysis of data from the Florida Agency for Health Care Administration 214 Emergency Dept Inpatient Rx Opioid Poisoning Hospital Cases in Florida With and Without a Diagnosis of Opioid Abuse: 214 n= 11,95 With Without 93 % 11,3 7 % 875 Source: Analysis of data from the Florida Agency for Health Care Administration Number of Hospital Cases for Heroin Overdose Poisonings in Florida: 214 Hospital Heroin Poisonings Emergency Dept. Inpatient 1,925 1, Heroin With or Without Abuse Diagnosis 29% Without Abuse Diagnosis With Abuse Diagnosis 557 n = 1,925 1, % Source: Florida Agency for Health Care Administration Jim Hall upfrontin@aol.com 1

2 Number of Deaths Number of Heroin and Fentanyl Deaths in Florida: 2 to 215* Heroin Fentanyl * Projected Increase based on 2 X 1 st Half of 215 Source: Florida Medical Examiners Commission 215 Interim Report 794* * How Did We Get Here? History of Opiates Pain Management Pills Mills 21 st Century Heroin Non-Pharmaceutical Fentanyl Counterfeit Pills History of Opiates Opium the first drug from early agricultural civilizations Assyrians invented slicing the poppy pod Sumerians - The Joy Plant Egyptians first produced opium as a drug Thebaine Greeks Indian Subcontinent Medieval Trade spread the drug 184 German pharmacist first isolated Morphine Named after the Greek god of sleep and dreams, Morpheus History of Opiates in the U.S. 19 th Century 33 Wars forced production of Morphine Heavily used in US Civil War, leaving many addicted History of Opiates in the U.S. In 1874, Heroin was created in Germany and sold in the United States as a safe, non-addictive substitute for morphine. From the late 18 s to the 19 s, drug companies sold over-the-counter drug kits containing glass barreled hypodermic needles and vials of morphine or heroin. Heroin, morphine and other opiates were sold legally in the U.S. until controlled by Harrison Narcotic Tax Act in 1914 and made illegal in the 192 s In 1925, there were an estimated 2, heroin addicts in the U.S. History of Opiates in the U.S. 195 s Drug Advertising and Direct Marketing to Physicians antibiotic Terramycin 196 s Valium becomes first $1 million drug 198 s Purdue Pharma releases MS Conti WHO Ladder of Pain treatment Purdue Pharma releases OxyContin Nation s first Pill Mill South Shore, KY American Pain Society Pain as Vital Sign Jim Hall upfrontin@aol.com 2

3 How Did Florida Get Here: The Nonmedical Rx Epidemic 2 to 21 Ft. Lauderdale Pill Mill.The doctor is in Top 5 October28 March in Florida 25 in Broward County 9,21,731 Dose Units ARCOS Sources of Oxycodone Dose Units Dispensed Annually in Florida ,, Pills 44,, Pills Dispensed by Practitioner Dispensed by Pharmacist or Hospital Source: Analysis of US Department of Justice 29 and 21 data by NSU Center for Study And Prevention of Substance Abuse 25% 2% 15% 1% 5% % Percent of Primary Addiction Treatment Admissions for Rx Opioids among all substances (including alcohol) in Florida: 1998 to % Rx Opioids as % of All 1.8% 7.3% 8.3% 2.1% 2.6% 3.4% 4.8% 4.8% 5.4% 5.4% 4.2% 16.1% Source: SAMHSA - Treatment Episode Data Sets Submitted by the Florida Dept. of Children and Families as of April 5, 212 Jim Hall upfrontin@aol.com 3

4 Number of Primary Addiction Treatment Admissions for Prescription Opioids Number of Primary Addiction Treatment Admissions for Prescription Opioids in Florida by Age: 1999 vs n= 2, % < 31 yrs. 21 n= 11, % < 31 yrs & over ,127 3,92 1, Florida Responds 29 to 214 SOURCE: US Dept. HHS-SAMHSA, CBHSQ: Treatment Episodes Data Set (TEDS) as reported by the Florida Department of Children and Families 4/5/212 29: FL Senate Bills 462 and 44 Florida joined thirty-four other states when it established a Prescription Drug Monitoring Program (PDMP) with the passage of Senate Bill 462 and companion Senate Bill 44 exemption of PDMP records from public records requirements. Yet, PDMP not funded or functional until the Fall of July 21 Senate Bill 2272 provided (1) legal authority for the Department of Health to shut down illicit pain management clinics, (2)includes improved standards of care that must occur at registered clinics and (3) limited practitioner dispensing of CS Schedule II to 3-day supply. August 21 New tamper-resistant reformulated OxyContin OP shipped by manufacturer. 211 February 211 Operation Pill Mill: South Florida March 211 Florida Law Enforcement Drug Strike Force created 211 July 1, House Bill 795 goes into effect. It Bans direct dispensing by medical practitioners, New permitting & inspection regulations for pharmacies, Shortening from 15 days to 7 days the PDMP dispensing reporting requirement, Codified new patient standard of care measures for physicians with enhanced penalties, $ 3 million for law enforcement Strike Force to close pill mills Jim Hall upfrontin@aol.com 4

5 # Cause of Death Occurrences 1H'8 2H'8 1H'9 2H'9 1H'1 2H'1 1H'11 2H'11 1H'12 2H'12 1H'13 2H'13 1H'14 2H'14 1H'15 Number Cause of Death Occurrences # of Opioids Detected Among Decedents Number of Unique Patients Identified By Threshold Levels Number of Prescribers and Number of Pharmacies by Quarter , 5 Prescribers & 2,864 5 Pharmacies 51-% Decrease Level 5 1,97 1,415 Level Source: Annual Report Florida s Prescription Drug Monitoring Program (PDMP) Levels 9, Level 7 Level , 6, 5, 4, 3, 2, 1, Number of Nonmedical Rx Opioids Occurrences Detected among Decedents in Florida * 5,59 4,35 4,416 6,6 6,68 6,333 5,454 5,489 Opioids CS-II Dispensing Limits and OxyContin Tamper Resistant *215 projection based on 2 x 1H215 Strike Force 5,85 House Bill 795 Takes effect Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 25 - June 215 Reports 6,174* 5,624 Number of Selected Lethal Rx Opioid Occurrences Among Deceased Persons in Florida 28 to 215 CS-II Dispensing Limits & OxyContin Tamper Resistant 9 Strike Force House Bill Takes effect Oxycodone Methadone Morphine Hydrocodone Fentanyl Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 28 - Jun 215 Reports Number of Selected Lethal Rx Opioid Occurrences Among Deceased Persons in Florida 212 to X X H'12 2H'12 1H'13 2H'13 1H'14 2H'14 1H'15 Oxycodone Methadone Morphine Hydrocodone Fentanyl Source: FDLE Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 28 - Jun 215 Reports Number of Neonatal Abstinence Syndrome Cases State of Florida: ,336 1,19 1,63 1,771 1,563 1,914 Source: Florida Agency for Health Care Administration Jim Hall upfrontin@aol.com 5

6 Jim Hall 6

7 How the Epidemic of Drug Overdose Deaths Ripples Across America Drug Overdose Deaths per 1,: Jim Hall 7

8 Sunday May 1, 216 Drug overdoses killed 47,55 people in the US in 214, the latest year for which data are available. 15 All Drug Overdose Deaths 1 Opiate-Related 5 Non-Opiate Drug That s 129 deaths per day, on average. The majority of those deaths 28,647, or 78.5 per day involved an Opiate (synthetic opioid and/or Heroin) Payer for Hospital Overdose Poisonings Care for Rx Opioids and Heroin: State of Florida 214 VETERANTS ADM. TRICARE or OTHER FEDERAL GOVT SELF PAY/UNDER-INSURED OTHER STATE & LOCAL GOVT. OTHER NON-PAYMENT MEDICARE MANAGED CARE MEDICARE MEDICAID MANAGED CARE MEDICAID COMMERCIAL INSURANCE Inpatient Opioid and Poly-Opioid Poisonings Inpatient Heroin Poisonings N= 8, , 1,5 2, 2,5 Source: Analysis of Data from Florida Agency for Health Care Administration Payer for Hospital Overdose Poisonings Care for Rx Opioids and Heroin: State of Florida 214 Total Inpatient Opioid and Heroin Poisonings N= 8,278 VETERANTS ADM. TRICARE or OTHER FEDERAL GOVT SELF PAY/UNDER-INSURED OTHER STATE & LOCAL GOVT. OTHER NON-PAYMENT MEDICARE MANAGED CARE MEDICARE MEDICAID MANAGED CARE MEDICAID COMMERCIAL INSURANCE ,294 1,376 1,285 2, , 1,5 2, 2,5 Source: Analysis of Data from Florida Agency for Health Care Administration Jim Hall upfrontin@aol.com 8

9 Non-pharmaceutical Fentanyl: Canadian Fentanyl Trends Moving to the US Steven P. Kurtz, Ph.D., Director James N. Hall, Epidemiologist Nova Southeastern University Center for Applied Research on Substance Use and Health Disparities Acknowledgements 215 Drug Diversion Rates (per 1, pop) No change in Rx fentanyl diversion Research from Nova Southeastern University s Center for Applied Research on Substance Use and Health Disparities (ARSH) is supported by Denver Health and Hospital Authority - a public, not-for-profit agency based in Colorado. Mathew Young RADARS System Mosaic Approach Non-pharmaceutical fentanyl College Survey OTP Opioid Tx Program Early Experimenters Patients in Treatment Poison Center SKIP Survey of Key Informant Pts Acute Events Patients in Treatment Acetyl fentanyl and other analogues 5 to 1 times more potent than morphine Blood tests do not distinguish from pharmaceutical fentanyl Drug Diversion Criminal Justice/ Law Enforcement Legal status depends on the analogue Jim Hall upfrontin@aol.com 9

10 Reports of non-pharmaceutical fentanyl Non-pharmaceutical fentanyl (NPF) July September 214 Key Powder alone or combined with heroin Sold as prescription medications (pills) No reports of NPF Powder NPF alone or with heroin Alaska Hawaii Non-pharmaceutical fentanyl (NPF) October December 214 Non-pharmaceutical fentanyl (NPF) January March 215 Powder NPF alone or with heroin Powder NPF alone or with heroin Alaska Hawaii Alaska Hawaii Non-pharmaceutical fentanyl (NPF) April June 215 Non-pharmaceutical fentanyl (NPF) July September 215 Powder NPF alone or with heroin Powder NPF alone or with heroin Alaska Hawaii NPF Sold as Counterfeit pills Alaska Hawaii NPF Sold as Counterfeit pills Jim Hall 1

11 Non-pharmaceutical fentanyl (NPF) October December 215 Non-pharmaceutical fentanyl (NPF) January April 216 Powder NPF alone or with heroin NPF alone or with heroin Alaska Hawaii NPF Sold as Counterfeit pills Alaska Hawaii NPF Sold as Counterfeit pills Canada: Non-Pharmaceutical Fentanyl Market High volume Chinese trade through Vancouver No searches of parcels under 3 grams Distant from Mexican heroin sources Non-Pharmaceutical Fentanyl (NPF) 212: New NPF Trafficking Fentanyl OD Deaths in British Columbia 212 CHINA 214 Jim Hall upfrontin@aol.com 11

12 NPF Pill press businesses Pill press equipment and NPF supplied by Chinese Internet ordering and Canadian in-country pill pressing Found in British Columbia, Alberta, Ontario and Quebec in Canada In the US so far: Los Angeles, New York, Ohio, Seattle Pill press plus 1K NPF = $1, Street value = $2,, Source: RCMP Real Fake Pinellas County Florida Fake Oxycodone with Fentanyl Pinellas County Florida Counterfeit Xanax with Fentanyl Authentic Oxycodone A 215 Real Xanax on grey background. Counterfeit Xanax on red background. Photo: San Francisco Department of Health Jim Hall upfrontin@aol.com 12

13 Non Pharmaceutical Fentanyl acetylfentanyl, butyrfentanyl, 3-methylfentanyl furanylfentanyl Other Novel Psychoactive Opiate-Like Substances W-18 AH U-477 MT-45 Expired patents W-18 Developed at the University of Alberta 198s Part of a class of 32 compounds, referred to as W-1 to W-32 or the W-series. Never pursued as potential pharmaceutical analgesics. Therefore there is little information available about W-18 and the other compounds in the series. Lack of pharmacological data means that assessments about potency and toxicity of W- 18 are also speculative. W-18 No receptor binding studies done with this compound W-18 is suspected to be highly toxic and thus should be considered a potentially very dangerous opioid until the appropriate pharmacologically has been conducted. Police in Edmonton, Alberta, rushed to warn the public and emergency departments about W-18 after they seized four kilograms of the drug in powder form. DEA agents in South Florida intercepted an international priority mail package with more than 1, blue fentanyl pills and other drug packages, including W-18, that were shipped from an inmate in a prison near Montreal. AH-7921 Synthetic opioid developed as a possible analgesic drug by the British pharmaceutical company Allen & Hanbury in AH-7921 is a μ-opioid receptor agonist No studies that have assessed its pharmacology and toxicology in humans 16 deaths have been associated with AH-7921 in Sweden, the United Kingdom, Norway, and the USA, and 2 deaths in Canada. U-477 Pharmaceutical analgesic that was never brought to market Synthetic µ-opioid agonist that was developed in the 197s by the Upjohn. Analogue of AH-7921 Potency is estimated to be 7-8 times that of morphine. No published studies assessing the effects of U-477 in humans Jim Hall upfrontin@aol.com 13

14 MT-45 A synthetic opioid patented in 1975 by a Japanese pharmaceutical company No human studies conducted to assess its pharmacological or behavioral effects Potency is estimated to be comparable to morphine Associated with hearing loss among users At least 28 deaths in Sweden between 213 and 214 and two in the USA Expired Patents Canadian Law Enforcement reports Chinese labs are acquiring expired patents to reproduce new synthetic substance for sales to the international market. Naloxone Auto-Injector Rise Up: Response to Heroin Epidemic Reduce inappropriate prescribing and use of opioids, Improve access to and insurance coverage for treatment, including medication-assisted treatment for opioid disorders Strength prescription drug monitoring programs Expand overdose recognition and response training and access to naloxone to treat opioid pain reliever and heroin overdoses Unite at the community level to address opiate addiction Promote only the appropriate use of medications Jim Hall upfrontin@aol.com 14

15 Branch of Community Organization Resources Available Activities Contact Branches of Community Law Enforcement First Responders Medical Community Non-Profits Addiction Treatment Judicial Faith-Based Education County Government Media Business Sector Youth/Parents Federal Agencies Jim Hall 15