2001 ANNUAL REPORT. January 1, 2001 to December 31, 2001 Joe Spillane, Pharm.D., ABAT Madeline Camejo, CPh., Pharm.D.

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1 2001 ANNUAL REPORT January 1, 2001 to December 31, 2001 Joe Spillane, Pharm.D., ABAT Madeline Camejo, CPh., Pharm.D. United Way of Broward County Commission On Substance Abuse Ft. Lauderdale Police Department Florida Department Of Law Enforcement Broward General Medical Center Nova Southeastern University 1

2 Broward County Commission on Substance Abuse Indicators of Substance Abuse in Broward County, Florida ANNUAL REPORT 2001 Joe Spillane, Pharm.D., ABAT Madeline Camejo, CPh., Pharm.D. There was a marked increase in cocaine induced fatalities in Broward County in This increase seems to be at least partly due to the mixing of cocaine and opioids (oxycodone, heroin, hydrocodone, methadone etc.). Cocaine is still the most common cause of illicit substance abuse emergency department visits at Broward General Medical Center, and still the most commonly detected illicit substance at the Broward Sheriffs Office Crime Lab. Heroin deaths continue to increase reaching a new high in This may be an indicator of the switch back from oxycodone of some opioid addicts. Oxycodone in 2001 was the cause of more fatalities than heroin, cocaine, or any other illicit substance and also reached a record high in Broward County. All indicators continue to point toward predominantly older (30 yrs or older) white males, abusing, seeking treatment, and visiting emergency departments because of heroin or oxycodone abuse. It also appears that oxycodone is continuing to be substituted for heroin and more recently - vice versa. There were no major changes regarding marijuana use in the first half of Interestingly, 51% of all illicit substance abuse cases among very young people (12-25yrs old) involved marijuana( only 31% involved cocaine), and 43% of all young (13-29yrs old) homicide victims in Broward in 2001 were positive for marijuana, while only one tested positive for cocaine. There were no new deaths to report from GHB or its precursors in Broward, and ED visits were roughly the same in 2001 as in There also were no new ecstasy caused fatalities. Prior to September 11, ecstasy trafficking, availability, and use appeared at an all time high. Since September 11 different methods of smuggling have surfaced. Additional trends since September 11 are discussed. Abuse of other amphetamines besides ecstasy appears to be increasing. Many different indicators point to a high level of alprazolam (Xanax) abuse. Introduction 1. Area Description Broward County is composed of 29 municipalities and an unincorporated area. The county covers 1,197 square miles including 25 miles of coastline. According to the 2000 census, the population was 1,623,018. The population is roughly divided into 63% white, 21% black, and 17% Hispanic. South Florida is responsible for 40% of the US trade with Central America, 37% of the Caribbean, and 17% of the South American trade. Broward County is the second most populated county in Florida, and it accounts for approximately 10% of Florida s population. Broward was the top growth county in Florida in the 1990 s adding 367,000 more people. It is situated just north of Florida s most populated county, Miami-Dade, and just south of Palm Beach County, the 3rd most populous county in Florida. This geography puts Broward in the middle of the most populated area of one of the most heavily populated states in this country. 2

3 2. Data Sources and Time Periods: Broward County Medical Examiner Department, 1999, 2000, and 2001 Drug Deaths (a review of all deaths in Broward County directly caused by or associated with drugs in 1999, 2000, and 2001). Florida Department of Law Enforcement Medical Examiners Commission, 2000 Annual Report -- Drug induced or related deaths in Florida Florida Department of Law Enforcement Medical Examiners Commission, 2001 Annual Report -- Drug induced or related deaths in Florida Broward General Emergency Department Drug Abuse Case Review--- a review of all drug abuse cases presenting to BGMC Emergency Department for the four time periods (1/1/00-6/30/00, 7/1/00-12/31/00, 1/1/01-6/30/01, and 7/1-12/31/01.). Spectrum Programs Inc. Broward County addiction treatment data (Jan 1 -Jun 30, 1999, July 1-Dec 31, 1999, Jan 1 -June 30, 2000, July 1- Dec 31, 2000, Jan-Jun 30, 2001 and Jul 1-Dec 31, 2001.). Broward Addiction Rehabilitation Center: Broward County addiction treatment data Jan 1- Jun 30, 2001 and Jul 1-Dec 31, Broward Sheriff s Office Crime Lab: reports of illicit substances analyzed 1999, 2000, Jan-Jun 30, 2001, and Jul-Dec 31, The Sun Sentinel: December 5, 2001, Measures aim at abuse of OxyContin. The Sun Sentinel: December 5, 2001, Feds search O.J. s house. Pg 3B The Miami Herald: October 15, 2001, Ritalin becoming recreational drug of choice for college kids. pg1a & 2a. USA Today: January 30, Jeb Bush s daughter arrested on prescription fraud charge. pg5a. USA Today: January 28, Date Rape drug GHB making inroads in nation s club scene. pg1a. Sun Sentinel: November 21, Palm Beach, Broward counties lead deaths from OxyContin abuse. Drug Use in Broward County: July-December Joe Spillane and Madeline Camejo, Broward County Commission on Substance Abuse. 3

4 Indicators of Substance Abuse in Broward County: Annual Report Joe Spillane and Madeline Camejo, Broward County Commission on Substance Abuse. Indicators of Substance Abuse in Broward County: Annual Report Joe Spillane and Madeline Camejo, Broward County Commission on Substance Abuse. Indicators of Substance Abuse in Broward County. Jan 1 -Jun 30, Joe Spillane and Madeline Camejo, Broward County Commission on Substance Abuse. SAMHSA NIDA Drug Abuse Warning Network 2001 Update 3/01. Epidemiologic Trends in Drug Abuse Advance Report: December NIH Publication # Rockville, Md.: National Institute on Drug Abuse (2002). Johnston,LD., O Malley PM, & Bachman JG (2002). Monitoring the Future national results on adolescent drug use: Overview of key findings, (NIH Publication No. [yet to be assigned]) Bethesda MD: National Institute on Drug Abuse. Pulse Check: Trends in drug abuse Nov Office of National Drug Control Policy Publications. 4

5 Cocaine use remains at a very high level as indicated by emergency department visits, crime lab data, and drug abuse treatment admissions. Deaths are at a new high in Broward, with an increasing number of those involving cocaine and an opioid. It s still an older patient population seeking treatment for detoxification and seeking treatment in the emergency department. Cocaine Deaths During 2001, there were a total of 52 cocaine caused fatalities. There were 28 deaths where cocaine without heroin or oxycodone was considered the cause of death. There were 14 deaths where cocaine and heroin were considered causes of death, 9 deaths with cocaine and oxycodone as causes, and one other death where cocaine, oxycodone, and heroin were all considered causes. In all of 2000, there were a total of 40 cocaine-caused deaths, and in all of 2001 there were 52 such deaths, an increase of thirty percent. During 2001, four of the twenty-eight (14%) cocaine without heroin or oxycodone decedents were black, whereas only one of the twenty-four (4%) cocaine with heroin or oxycodone were black. It appears as though the recent increase in cocaine-deaths may be at least partly attributable to the opioid-cocaine combinations. The recently published FDLE 2001 Report of Drugs, cited 57 total cocaine caused deaths in Broward in The reasons for the disparity between this number and FDLE s # may be that many were pending toxicology results at the time the report was written. Throughout the entire state, there were 1105 cocaine related fatalities in This was the second all time high number Cocaine Emergency Department/Hospital Data For the year of 2001, a daily review of all emergency department charts at Broward General Medical Center (BGMC) was conducted to gauge illicit substance abuse related emergency department cases. 69, 892 charts were reviewed, and 3.5% or 2420 cases of drug abuse were found. This was an average of approximately 7 per day. Cocaine was clearly the most commonly involved illicit drug, accounting for 1290/2420 (53%) of the drug abuse cases in According to national Drug Abuse Warning Network(DAWN) data, cocaine was also the single most commonly involved drug in emergency department (ED) episodes throughout the country in 2000 (the most recent year for which there is data). There was no significant changes between 1999 and 2000, however, national cocaine ED episodes were up 27% since Most of the BGMC patients were male 947/1290(73%), 343/1290(27%) were female. Forty-nine percent, 634/1290, were white, 563/1290(44%) were black, 93/1290(7%) were Hispanic/other. Cocaine using patients seeking emergency department treatment at BGMC were 30yrs of age or older in 81% of these cases, which continues a trend towards older cocaine ED patients as last year 78% were 30yrs or older. The patient ages were as follows; 32/1290(2%) were less than 20yrs old, 216/1290(17%) were in their twenties, 568/1290(44%) were in their thirties, 395/1290(31%) in their forties, and 79/1290(6%) were fifty years old or older. 5

6 The most common reasons for coming to the ED were as follows; 1. Depression/suicidal- 427/1290(33%) 2. Dependence/seeking detox 102/1 290 (8%) 3. Chest pain/cardiac problems- 100/1 290 (8%) 4. Trauma/accidents 94/1290(7%) 5. Psychosis/ schizophrenia/ hallucinations- 98/1290(7%) 6. Gastrointestinal complaints 50/1290(4%). These six reasons accounted for 2/3 of all ED visits regarding cocaine and were very similar to the previous year. Crack cocaine was specifically mentioned in 407/1290(32%) of the cases in Cocaine was taken in combination with alcohol in 584/1290(45%) of the cases which was essentially the same rate as last year. This dangerous combination forms a cometabolite cocaethylene, which can dramatically increase toxicity. Another favorite combination during 2001 involved cocaine and marijuana. A total of 309 cases involved the combination cocaine and marijuana, which was 24% of all cocaine cases. Exhibit 1A 6

7 Exhibit 1B Emergency Dept/Hospital Data 2001 Percent of Illicit Drug Use Cases n=2420 Emergency Dept/Hospital Data 2001 Percent of cases involving patients less than 30yrs old 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Addiction treatment profiles for this report were compiled using data from two major treatment providers in Broward County, Broward Addiction Recovery Center (BARC) and Spectrum (Broward data only). A comparison to last year s data is impossible as we do not have BARC data from last year. (Exhibits 2A & 2B) 7

8 2001 Broward Cocaine Treatment Profile (any form) (Spectrum/BARC Data n=1610) Exhibit 2B 8

9 Cocaine Availability, Price & Purity Powder Cocaine and Crack are still described as widely available throughout Florida by Pulse Check: Trends in Drug Abuse-November Cocaine is still the most commonly analyzed substance by the Broward Sheriff s Office Crime Lab where it accounted for 78.7% of all items analyzed in the last half of 2001; In the first half of 2001, cocaine was 69.7% of all items. This compares with 77.6% of all substances analyzed from July-December, 2000 (down slightly from 78.4% in Jan-Jun 2000, and from 79.8% of all substances in Jul-Dec 1999). Crack cocaine sells for $5-$20 per 0.1gm amount roughly 80% pure in Miami. Powder cocaine sells for $40-60 per gram (approx 80% purity). The cocaine kilogram price range remained fairly stable at $ 18-22,000 as per law enforcement officials. The fact that South Florida s airports and seaports remain among the busiest in the nation for both cargo and international passenger traffic and the massive internal conspiracy problems in those ports of entry combine to keep this region as a major port of entry for illicit drugs. Cruise ship smuggling is mentioned as an important trend by law enforcement in South Florida. The BGMC ED has taken care of several cruise ship bodypackers in 2001, whereas prior to that, they were all from air travel. Cocaine Survey Data: Monitoring the Future Survey 12th Graders - Cocaine or Ecstasy Use within the last year The 1999 NIDA-funded Monitoring the Future Survey found 6.2% of 12 th graders nationally had used some form of cocaine in the past year. That figure was down to 5% in 2000 and down to 4.8% in 2001 (See Exhibit 3). In addition, crack use within the last year also declined from 2.7% in 1999 to 2.2% in 2000 to 2.1% in 2001 also among 12 th graders nationally. 9

10 BSO Crime Lab: Cocaine remains by far the most common drug worked by BSO Crime Lab. There were 2838 cocaine cases worked by the BSO Crime Lab in the last six months of This compares with 3848 cases in the first 6 months of There were 4105 cocaine cases in the first half of 2000, and 3301 in the second half of Beginning in 2001, the Crime Lab began working only those cases submitted by the State Attorney s Office, and of those cases only the items requested. This has resulted in about a 20% decrease in the number of items tested. 10

11 In the first half of 2001, we saw an increase in heroin deaths to roughly what they were prior to a drop off in That trend continued in the second half of So that heroin deaths are back at about the same levels as In addition, oxycodone deaths have remained high, so that Broward County experienced more opioid deaths than ever before in Oxycodone remains very popular and is being used in combination with and partially supplanting heroin in Broward and it s quite possible that heroin is starting to substitute for oxycodone which may be getting harder to obtain. Most emergency department visits for heroin or oxycodone are for withdrawal or because the patient is seeking detoxification. Most addiction treatment admissions and most deaths continue to be older white males. Miami led the nation in percent increase in DAWN ED mentions for heroin, increasing 2400% from 1990 to Heroin Deaths: In 2001, there were a total of 41 deaths in Broward where heroin was considered a cause of death. In 15 of these deaths, the combination of heroin and cocaine was determined to be the cause, at least 3 deaths were caused by oxycodone and heroin, and one death involved heroin, cocaine, and oxycodone. Heroin alone was involved in 9 deaths, while heroin combined with alcohol and benzodiazepines and methadone in various combinations accounted for the remaining heroin deaths. Thirty-eight of the 41 (93%) Broward heroin decedents during 2001 were white, which was very similar to 2000 (92% white), 1999 (95% white) and 1998 (97% white). The decedents continued to be predominantly male 33/41 (80%) which was also similar to the last several years. There were no teenage heroin decedents, 7/41 (17%) were in their twenties, 12/41 (29%) were in their thirties, 17/41 (41%) were in their forties, and 5/41 (12%) were in their fifties. All but one of these overdoses were considered accidental. There was a marked increase (71%) in heroin-caused fatalities in Broward County from 24 to 41 from 2000 to As per the FDLE report, Broward heroin deaths increased 200% from 17 in 2000 to 51 in The additional deaths listed in the FDLE report may represent cases pending when our report was written. It is unclear why the 2000 data reflect more heroin deaths in our report. Statewide, heroin caused fatalities hit an all time high of 271 in 2001(30% increase over 2000, and over 200% increase since 1995). In 2001, Broward ranked second only to Palm Beach County (57) in total number of heroin caused fatalities, and Broward had 50% more heroin deaths than Miami-Dade in Per the FDLE report the situation was the reverse in 2000, w/ Miami-Dade (61) having 260% more than Broward (17). 11

12 Exhibit 4 Heroin Emergency Department/Hospital Data: Based on a daily review of all emergency department charts at Broward General Medical Center for 2001, there were a total of 159 heroin cases(7% of all illicit substance abuse). The total for 2001 (159) was up 15% from 2000 when there were 138 cases for the entire year. The heroin cases in 2001 were predominantly older white males experiencing withdrawal and/or seeking detoxification. In 2001, there were 120/1 59 (75%) male and 112/159 (70%) were white. There were three teenagers, while 38/159 (24%) patients were in their twenties, 57/159/(36%) in their thirties, 49/159 (31%) in their forties, and 12/159 (7%) were fifty years old or older. The route of drug administration for 42/1 59 (26%) of the heroin cases was injecting. In 109/159 (69%) heroin cases the route of drug administration was unknown/not documented, in only six of the 159 (4%) of the heroin cases, the drug was documented as snorted. There were only two cases 2/159(1%) in which the documented route of abuse was smoking. Heroin was the sole drug of abuse (with or without alcohol) in 71/1 59 (45%) cases, cocaine was a co-exposure in 46/159(29%), heroin was used with a benzodiazepine in 32/159(24%) cases, and heroin was used with marijuana in 16/159(10%). Alcohol was involved in 57/159(31%). The 12

13 most common reason for the patient to visit the ED was withdrawal/seeking detox in 68/159 (43%) of the cases. Depression accounted for 38/159 (24%) of these cases, followed by altered mental status 23/1 59 (14%), and 14/159(9%) in the emergency department for medical clearance for jail or rehabilitation. Psychosis accounted for only 4/159 (2%) of cases. Exhibit 5 Heroin Addiction Treatment Profiles 13

14 Addiction treatment profiles for this report were compiled using data from two major treatment providers in Broward County, Broward Addiction Recovery Center (BARC) and Spectrum (Broward data only). A comparison to last years data is impossible as we do not have BARC data from last year. (Exhibits 6A& 6B) Exhibit 6A Broward Heroin Addiction Treatment (2001 Spectrum & BARC Data n=358) 70% 60% 62% 50% 40% 30% 4% All White Black Hispanic/Other 14

15 Broward Heroin Addiction Treatment Ages (2001 Spectrum & BARC data n=358) There were only 75 heroin cases worked by the BSO Crime Lab in the last six months of 2001, this compares with 74 heroin cases in the first half of There were 98 heroin cases during the first six months of 2000 and 90 in the last 6 months of This decline may be at least in part due to a change in operating procedure at the Crime Lab. Last year they did all non-cannabis cases submitted whereas this year they are only working those cases filed by the State Attorney s Office, and of those cases only the items that they request. This has resulted in a 20% decrease in the total number of items tested. Survey Data: NIDA s Monitoring the Future national survey of adolescent drug abuse revealed a statistically significant decrease in lifetime heroin use among 10 th and 12 th graders between 2000 and 2001, going from 2.2% to 1.7% among 10 th graders and from 2.4% to 1.8% among 12 th graders. Heroin Price and Purity Colombian Heroin is still described as widely available in South Florida, with ethnographers saying it has become more available and more pure from 2000 to As per the ONDCP s Pulse Check-Nov 2001, a 0.1gm bag of heroin (roughly 20% purity) sells for $10. 15

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17 Oxycodone is a semisynthetic opioid oral analgesic. It is a prescription pain medication and a schedule II controlled substance that has gotten a lot of media attention recently. Oxycodone (usually 5-10mgs) is found in a variety of brand and generic medications alone or in combination with acetaminophen or aspirin such as Tylox, Percocet, Percodan, Roxicet, Roxicodone, Endocet, Endocodone, Endodan etc. In addition, there is a sustained release product of oxycodone made by Purdue Pharma and approved by the FDA in 1995 with the brand name OxyContin. OxyContin is designed to deliver oxycodone in a controlled release manner over a twelve-hour period. However, if the OxyContin pill is crushed up and snorted or injected or chewed up and swallowed the full effect of the potentially lethal dose is immediate. OxyContin tablets 10,20,40, and 80mgs are selling on the street for anywhere from $0.25-$1 per milligram. There has been a flurry of activity associated with OxyContin lately. The drugs sales have skyrocketed from 300,000 in 1996 to 6 million prescriptions in There was a Florida Medical Examiners emergency report released in February of 2001 stating that there were 68 overdose deaths due to oxycodone or a related drug hydrocodone in the preceding 6 months, and this was even while excluding Miami-Dade and Broward Counties! In June of 2001, Purdue Pharma was sued for 5.2 billion dollars for some of its marketing practices associated with OxyContin. Also in June, Purdue took the 160mg tablet off the market, and Florida Medicaid took the unusual step of limiting the allowable # of OxyContin pills per month to 120. Special black box warnings were issued by the FDA and Purdue about OxyContin s abuse potential in July of 2001, and also in that month a physician in Palm Beach was charged with first degree murder for the inappropriate prescribing of OxyContin. In August the company announced plans to embed OxyContin with microscopic beads of naltrexone (an antagonist to opioids such as oxycodone), such that if the pill is crushed the naltrexone reversal agent would be released. This is projected to be ready in 3 years. In December of 2001, Gov. Jeb Bush unveiled legislation to establish a prescription drug database in Florida very much like 18 other states to combat prescription drug abuse. In November 2001, the Florida State s Attorney began investigating the marketing practices of Purdue Pharma to see if they were deceptive or misleading. Nationally, oxycodone emergency department drug mentions increased 239%, from 3190 in 1996 to 10,825 in 2000, and there was a 68% increase from 1999 to It should be noted that hydrocodone ED mentions increased as well and were and remain at higher levels than oxycodone from 10,473 in 1996 to 19, 221 in 2000, an 84% increase. Broward Oxycodone Deaths Oxycodone accounted for more deaths than heroin or cocaine or any other drug except alcohol and this is the largest number of deaths from oxycodone ever in Broward County. As per the FDLE Report, during 2001, there were 71 deaths in Broward County where oxycodone was detected and 59 cases where oxycodone was specifically mentioned as a cause of death There were 31 oxycodone caused deaths in 1999, 49 in 2000, and 59 in So that oxycodone deaths in Broward now lead the state and have doubled in 2 years. Upon our review of Broward Medical Examiners records only 55 oxycodone-caused fatalities were found (some may have been pending/unavailable at the time). In 2001, OxyContin was specifically mentioned in 20/55 (36%) and in most cases the route or method (crushing up or 17

18 chewing up of tablets) of administration was not mentioned. Eighty-two percent (45/55) were considered accidents and 10(18%) suicides. There were 2 teenagers, twelve decedents were in their twenties (20%), twelve were in their thirties (20%), 23 decedents (39%) in their forties, and six decedents (10%) were fifty or older. Fifty-one of the fifty-five Broward oxycodone overdose decedents were white (93%), and 45/55 (82%) were male. As with most fatal overdoses, these deaths rarely involve one drug alone. In fact, only 1/55 oxycodone-caused deaths in 2001 involved oxycodone alone. Alprazolam (Xanax), and heroin often combined with oxycodone to cause fatalities as well as hydrocodone, cocaine, and alcohol. In addition, there were 12 additional non-oxycodone deaths where hydrocodone was considered a cause of death, and 15 non-oxycodone deaths where methadone was considered a cause. Exhibit 7 Emergency Department/Hospital Oxycodone Data: During 2001, there were 104 oxycodone overdose cases treated at BGMC. There were 74(71%) men and 30(29%) women, 88/104(85%) were white, and the ages of these patients ranged from years old. There were 3 teenagers(3%), 20/104 (19%) patients in their twenties, 22/104 (21%) in their thirties, 54/104 (52%) in their forties, and 5 (5%) were fifty years old or older. OxyContin was specifically mentioned in 74/104(71%) of these cases. The route of administration was unclear upon reviewing most charts. In 42/104(40%) of these cases the reason for visiting the ED was dependence/withdrawal. In 31/104 (30%) cases it was clearly for recreational use, in 15/104(14%) of cases the oxycodone 18

19 was being used for other psychic effects (such as excessive amounts for pain etc.), and in 15/104(14%) of cases the oxycodone was taken in a suicidal gesture. Twenty-seven, 27/104 (26%), patients presented with central nervous system depression, and there were 5/104 patients (5%) presenting because of convulsions. Fifteen (14%) patients received naloxone. Thirty (29%) patients required hospital admission, and the remaining patients were treated and released from the emergency department. Coingestants in these cases include benzodiazepines in 32/1 04 (3 1%) especially alprazolam 17 cases, marijuana in 19/104 (18%), cocaine in 17/104 (16%), other opioids such as heroin or methadone in 14/1 04 (13%), and hydrocodone 7/104 (7%). BSO Crime Lab: The BSO Crime Lab worked 95 oxycodone cases in the last 6 months of 2001, this compares to 80 such cases in the first 6 months, 71 in the last 6 months of 2000, and 69 in the first 6 months of There were also 69 hydrocodone cases in the last 6 months of 2001, 44 in the first 6 months of 2001, 58 in the last 6 months of 2000, and 69 in the first half of

20 Marijuana Emergency Department/Hospital Data: For the year of 2001, a daily review of all emergency department charts at Broward General Medical Center (BGMC) was conducted to gauge illicit substance abuse related emergency department cases. 69, 892 charts were reviewed, and 3.5% or 2420 cases of drug abuse were found. This was an average of approximately 7 per day. Of these, 832 (34%) involved marijuana, with 362/832 (44%) marijuana alone with or without alcohol. Seventy-five percent or 625/832 (75%) were male, 84/832 (10%) were teenagers, 243/832 (29%) were in their twenties, 252/832 (30%) were in their thirties, 183/832 (22%) were in their forties and 70/832 (8%) were fifty years old or older. The races of these patients were as follows; 469/832 (56%) white, 283/832 (34%) black, 79/832 (9%) Hispanic/ other/unknown. Marijuana ED/Hospital Data Age Groups Twenties 29% There were 309/832 (37%) cases of marijuana in combination with cocaine, which was discussed briefly in the cocaine section of this report. Marijuana was also found in combination with ecstasy/amphetamine in 31 additional cases. In 134/832 (16%) alcohol was the only documented coingestant with marijuana. The most common reasons for marijuana ED visits were as follows ; 1. Depression/suicidal 219/832 (26%) 2. Psychiatric related (hallucinations, anxiety, bizarre behavior, delusions etc.) 89/832 (11%) 3. Trauma 89/832 (11%) 20

21 4. Altered mental status 65/832 (8%) 5. Chest pain 48/832 (6%). Marijuana is still the most popular drug among young people visiting the emergency department. Roughly 51% (252/491) of all illicit substance abuse cases in the age group 12-25yrs old, involved marijuana. This compares to 151/491 (31%) with cocaine (only 39 with crack), 105/491 (21%) with benzodiazepines with 55 of these being alprazolam. There were 37/491 (8%) ecstasy cases, and 27/491 (5%) with heroin. This totals to more than 100% because some cases are combinations. Marijuana Treatment Profiles Addiction treatment profiles for this report were compiled using data from two major treatment providers in Broward County, Broward Addiction Recovery Center (BARC) and Spectrum (Broward data only). A comparison to last years data is impossible as we do not have BARC data from last year. Marijuana treatment data are summarized below (Exhibits 9A & 9B) Broward Marijuana Addiction Treatment (2001 Spectrum & BARC n=2257) 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Exhibit 9B 21

22 Broward Marijuana Treatment Ages (Spectrum & Barc Jan-Jun 2001 Data n=631) In 2001, at BARC and Broward Spectrum, a total of 2257 patients sought treatment and listed marijuana as the primary drug of abuse; this represents 25% of all Broward patients seeking addiction treatment for any drug during this time period. (Exhibit 9A) In contrast to cocaine and heroin, patients seeking treatment for marijuana tend to be younger. In fact, in 2001, a full 82% were 25 years old or younger. Survey Data: In 2001, 49% of 12 th graders nationally said they had tried marijuana at least once, this is up slightly from 48.8% in The is the fourth highest rate since 1987, only 97, 98, and 99 were higher. Also in the 2000 National Household Survey, among yr olds who said that their parents would strongly disapprove of even trying marijuana once, 7.1% had used some illicit drug within the last month. Among the same age group kids who said their parents would not strongly object, 31.2% had used some illicit drug within the last 30days. Youthful Homicides: In Broward County in 2001, there were 23 homicides with victims who were 13-29yrs old. Of these, 10/23 (43%) tested positive for marijuana. Only one tested positive for cocaine and this was a 22 yr old white male who also tested positive for methylated amphetamines. Marijuana Availability, Price, & Purity: Marijuana is still described as widely available throughout Florida with local commercial, sinsemilla, and hydroponic all available. A ¼ ounce of Sinsemilla (10-18% THC) sells for $

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24 GHB, gamma hydroxybutyrate is an anesthetic and commonly abused substance in South Florida. The drug is known by numerous street names including liquid X, G, scoop, Somatomax, Georgia Home Boy, etc., and there are several compounds, which are converted in the body to GHB. Two important precursors to GHB that are being abused as well gamma butyrolactone (GBL) and 1,4 Butanediol (BD). Gamma butyrolactone containing products may have ingredients listed as furanone, furanone dihydro, 4-butyrolactone, dihydro-2 (3H)- furanone dihydro, tetrahydro-2-furanone, and butryolactone gamma. Brand name examples of gamma butyrolactone include Blue Nitro, Renewtrient, GH Revitalizer, Gamma G, Remforce, Firewater, ReActive, Rest-eze, Beta-Tech, Thunder, Jolt, and Verve. Butanediol (BD) containing products may list active ingredients as tetramethylene glycol, sucol B, 1,4-butylene glycol, butane-1, 4diol, butylene glycol, and 1,4-tetramethylene glycol. Some brand names of BD containing products include, Zen, Serenity, Somatopro, InnerG, NRG3, Enliven, Growth Hormone Release Extract (GHRE), Thunder Nectar, Weight Belt Cleaner, Rest-Q, X-12, Dormir, and Amino Flex, Orange FX, Rush, Lemon fx Drop, Cherry fx, Bomb, Borametz, Pine Needle Extract, Promusol, and BVM. Artfully worded labels often say that this product does not contain GHB or 2(3) furanone dihydro. In addition, these labels may state that this product is a cleaner and that it is harmful if swallowed. However, it is sold in health food stores with dietary supplements, and a 32oz bottle typically sells for $40- $70. This is similar to what GBL and GHB containing products were selling for and far out of proportion with what most reasonable people would pay for a cleaner. These products have become popular at the rave scene and other parties, are commonly mixed with alcohol, have been implicated in drug rapes and other crimes, have a short duration of action, and are not easily detectable on routine hospital toxicology screens. Emergency Department Data: During 2001, the Broward General Medical Center Emergency Department treated 71 people with GHB or GHB precursor overdose. This compares with 77 in all of (Exhibit 10). Exhibit 10 24

25 In most of the GHB overdose cases during 2001, the reason for the ED visit was decreased responsiveness/coma, usually lasting less than three hours. The ages of the GHB toxicity patients ranged from 14-50yrs with an average of 27.5 yrs. There were seven teenagers (10%), 40 (56%) in their twenties, 19(27%) in their 30 s, four in their 40 s (6%), and one 50 year old. Forty-nine of these GHB overdose patients were men (69%) and 22(31%) women, and 60/71 (85%) were white non-hispanic, 7/71(10%) were black non-hispanic, 1/71 (1%) was white Hispanic, and the race/ethnicity was unknown in 3/71(4%) cases. A urine toxicology screen was amphetamine positive in 21/71(30%), cocaine positive in 12/71(17%), and marijuana positive in 9/71(13%). A urine toxicology screen was not obtained on every case. Alcohol was involved in 38/71 (53%) of the cases by history or because an alcohol level was obtained. The GHB cases where a blood alcohol level was obtained ranged from mgs/dl. The location of the incident requiring the ED visit was a local bar/nightclub or the beach in 28/71(39%) cases. Most, 42/71 (59%) presented to the ED between 11PM and 6 AM. Sixteen (23%) of the 71 patients were completely comatose (Glasgow Coma Scale of 3). Airway assistance (nasal trumpet, oxygen etc) was required on three patients. At least 6 (8%) of the 71 patients vomited. Most patients were treated and released in several hours from the ED. However, 6/71 (8%) required hospital admission, and 8 patients (11%) required endotracheal intubation. BSO Crime Lab 25

26 In 2001, there was 3 GHB, 13GBL, and 7 butanediol cases analyzed by the BSO Crime Lab. This compares with 15 GHB and 2 GBL cases analyzed in GHB Deaths: There were no deaths where GHB was considered a cause in the last six months of 2001, although some cases are still pending at this point. From 1996-December 31, 2000, in Broward County, there have been a total of 11 deaths that involved GHB in some way (two in 1996, two in 1997, three in 1998, one in 1999, and three in 2000). In nine of these cases, GHB was mentioned as one of the causes of death. In one other case, the patient was admitted to a hospital for GHB intoxication, appeared to have recovered from that and subsequently succumbed due to other reasons. In one other death, the patient was brought dead on arrival to the BGMC emergency department as a multiple drug overdose including GHB by history, however; the medical examiner found GHB to be non-contributory. Eight of the nine GHB caused fatalities involved coingestants including alcohol, cocaine, marijuana, benzodiazepines, opioids, carisoprodol (Soma), sertraline (Zoloft), and MDMA (ecstasy). Alcohol was detected in 7/9 cases from mgs/dl (legally drunk in Florida is 80mgs/dl). One recent fatality involved no coingestants and no alcohol. This case is important to point out because it refutes the commonly espoused misperception that GHB is only fatal when another CNS depressant is also taken with GHB. There were 28 GHB related deaths in all of Florida in 2001 which compares to 23 in 2000, however, during July-December 2001, there were only 8 GHB related deaths, down 60% from the Jan-Jun 01. National GHB DAWN Data: Across the country, there has been a tremendous increase in DAWN emergency department mentions from 56 in 1994 to 4969 in 2000(the last year where data is available). Although, ecstasy has probably received a lot more media attention and perhaps more use, there were more GHB ED visits than ecstasy in 2000 and every year prior to that as well. GHB Availability and Pricing: Ethnographers in Miami report a slight decline in GHB availability in South Florida and the drug sells for $5-$10 a swig or hit, with a 32oz bottle of GBL or 1,4 Butanediol for $

27 MDMA, (3,4 Methylenedioxymethamphetamine), also known as Ecstasy is an hallucinogenic amphetamine which has become popular as a club drug at raves. The psychoactive, synthetic, DEA Schedule I drug has gained the reputation as a hug drug which can promote empathy, relaxation, and sexuality. Many indicators such as crime lab statistics, drug confiscations in the area, and national survey data point to an increased abuse of this drug. For the first time, in 2000, more teens said they had abused ecstasy than cocaine. This trend has continued so that in 2001, almost twice as many 12 th graders nationwide (9.2%)say they ve used ecstasy in the last year than say they ve used cocaine (4.8%). Each pill generally contains mgs of MDMA. Wholesale prices in the United States are approximately $8/tab but they may retail in clubs and raves for $ As per local law enforcement sources, South Florida ecstasy prices may have started to drop in the first half of 2001, reflecting increased supply. In addition, giveaway deals are often brokered to establish future customers. The major source of the designer logo emblazoned pills seems to be clandestine labs in Western Europe especially the Netherlands and Belgium. Although, not verified, there are rumors of clandestine labs in South Florida beginning MDMA production. The practice of rolling has been reported in Orlando and Miami. This is when heroin is used to counteract the stimulant effect of the hallucinogenic amphetamine MDMA (Ecstasy). Ecstasy received both local and national attention when federal agents searched OJ Simpson s Kendall home in December 2001 in connection with an international ecstasy pipeline-no drugs were found and he was not arrested. BSO Crime Lab As of January 1, 2000, the BSO Crime Lab began to report out MDMA separately. During 2000, MDMA accounted for 244 cases. For comparison, during the same year of 2000, heroin only accounted for 188 cases, LSD accounted for 52 cases, methamphetamine accounted for 23 cases, ketamine accounted for 28 cases, and GHB/GBL accounted for 16 cases. So the BSO Crime lab worked more Ecstasy cases than heroin, LSD, GHB, or methamphetamine. In 2001, 253 ecstasy cases were worked which was more than heroin, LSD, GHB, GBL, butanediol, and methamphetamine combined. Hospital Cases Hospital cases involving ecstasy during 2001 can be divided into three major categories; 1. Those where ecstasy is specifically mentioned in the medical record and the patient tests positive for amphetamines (there were 18 of these cases), 2. Those where ecstasy is mentioned but the tox screen is either not obtained or negative for amphetamines (there were 43 of these cases), and 3. Those cases where ecstasy was not specifically mentioned but was suspected based on circumstances and the urine tox screen is positive for amphetamines (there were 18 of these cases). In the previous six month period, there were 13 cases where ecstasy was suspected/not mentioned and the tox screen was amphetamine positive. One recent change may be that many of the amphetamine positive tox screens represent methamphetamine or another amphetamine, so that we cant assume its ecstasy anymore. By totaling all three of these types of cases, there were a total of 79 cases where ecstasy was felt to be involved in This is up from 62 in It is suspected that with the increased airport security since September 11, ecstasy supply dropped off in the 2nd half of

28 Most of the above mentioned cases were young white non Hispanic kids, 70/79 (89%) were white not Hispanic, 15/79 (19%) were in their teens, 50/79(63%) were in their 20 s, 11/79 (14%) in their 30 s, 2 patients were in their forties, and one patient who said he was using ecstasy w/out tox screen verification was fifty-three. Many of the cases involved a combination of ecstasy and some other drug of abuse, including alcohol 35/79(44%), marijuana 28/79 (35%), GHB 23/79 (29%), cocaine 27/79(34%), and benzodiazepines 17/79 (22%) (especially alprazolam/xanax). The reason for the emergency department visit was altered mental status/ decreased responsiveness in 29/79(37%) 23 of these 29 patients had coingested GHB. Depression/suicidal ideation was the presenting complaint in 15/79(19%), and 12 of the 79 patients (15%) were in the ED due to anxiety, agitation, confusion, paranoia or bizarre behavior. All except two of these patients were treated and discharged from the emergency department without requiring hospital admission. Deaths MDMA (Ecstasy) was detected in 4 Broward decedents in 2001, all four of these individuals were in their twenties and two were homicidal gun shot wounds. MDMA (Ecstasy) was not considered causative in any of these deaths. Survey Data: According to the national Monitoring the Future Study, ecstasy was at an all-time high in popularity among 8 th, 10 th, and 12 th graders in 2001 again much more than cocaine among these age groups. In addition, there has been a sharp increase in the availability of ecstasy. In 1999, 40% of those teens surveyed said that ecstasy was fairly or very easy to get, by 2001, 62% claimed the drug was fairly or very easy to get. With this increased availability has come a decrease in price and giveaway deals which could result in new legions of users. Ecstasy is being used at private parties now as much as at raves. MDMA Trafficking: Based on the national System to Retrieve Information on Drug Evidence (STRIDE), the State of Florida is the highest MDMA trafficking area in the country, followed by New York and California. As per the US Customs Service, national MDMA tablet seizures have increased from 400,000 in 1997 to 750,000 in 1998, to 3,500,000 in 1999, to 9,300,000 in As per the DEA Source Determination Program, MDMA samples in 2000 showed that 12% of samples contained 28

29 amphetamine or methamphetamine but no MDMA, 5% contained no controlled substances, and 3% were determined to be other substances (caffeine, ephedrine, dextromethorphan, and diphenhydramine etc.)but sold as ecstasy. The average dose of MDMA containing tablets was 87mgs. In 2000, 63% of tablets were smuggled into the US by airline, 27% by express mail, and 10% by shipping. The most common departure points for MDMA smuggled into the country were the Netherlands 77%, Belgium 8%, Germany 3%, and Spain 3%. Exhibit 11 US Customs Service National Tablet Seizures 10,000,000 9,000,000 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 Ecstasy Bodypacker: The first report of internal bodypacking involving ecstasy comes out of Miami in the last part of An individual flew from Canada into Miami after having swallowed numerous packets containing MDMA. The objective, apparently, was to retrieve the pills from his feces for illicit distribution. This case is interesting, because it happened after September 1 st, and given the increased security measures, the high demand, and high profit potential, this may become an important smuggling method in the future. Amphetamine/Methamphetamine Methamphetamine has traditionally been a much larger issue in California, Texas, Nevada, and even in the Midwest than it has on the East coast. Even in the State of Florida, most amphetamine/methamphetamine cases were on the west coast in the Tampa area. There is 29

30 some preliminary indications that that may be changing. First, despite cutting back on their case load in 2001, there was an increase in the number of methamphetamine cases worked by BSO Crime Lab from 30 in 2000 to 39 in In addition, local law enforcement have noted a recent increase in crystal methamphetamine use particularly among gay men where it is referred to as Tina. Finally, assuming the increased airport and port security since September 11 will result in a decreased supply of ecstasy, more easily produced, domestic amphetamines and methamphetamines are likely to be substituted to capitalize on available profits. In fact, for the last six months of 2001, there were more BGMC ED cases where amphetamines of some type were either mentioned in the history or detected on tox screen, than there were ecstasy cases. There were a total of 29 such cases in the last six months of These were predominantly white males, 26/29 (90%) were white and 22/29 (76%) were male. There were 4 in their twenties, 13 in their thirties, nine in their forties, and 3 in their fifties. Most cases were amphetamine positive on tox screen 23/29 (79%), and in most cases the exact form of the amphetamine was not documented. However, crystal methamphetamine ( a smokable form of methamphetamine) was specifically documented in 3 cases. Cocaine was a cointoxicant in 8/29 (28%), marijuana in 6/29 (21%), GHB in 3/29 (10%), benzodiazepines in 6/29 (21%), and heroin or oxycodone in 3/29 (10%). Four patients came in for altered mental status, and 5 patients came in for GI problems, and five for depression. Other common chief complaints included chest pain 4/29, overdose 2/29, and other psychiatric problems. Methylphenidate (Ritalin) has also received local and national media attention as being abused by college students either orally or crushed up and snorted. University of Miami and University of Florida will include questions about its abuse in future substance abuse surveys on campus. Benzodiazepines (Alprazolam-Xanax) For a variety of reasons, it is much more difficult to track benzodiazepine abuse than other forms of substance abuse. However, there are certainly, some indicators that benzodiazepines in general and alprazolam(xanax) in particular is a substantial problem. First, BSO crime lab worked 258 alprazolam cases in the first six months of 2001 and 244 in the second six months of This is roughly twice as many as ecstasy, and more than twice as many as oxycodone. In fact, the BSO Crime Lab worked more alprazolam cases in 2001 than any other drug except cocaine. Alprazolam seems to be popular among opioid abusers it was involved in 21 of the 34 Broward oxycodone deaths in the second half of 2001 as well as many of the heroin deaths. Benzodiazepines were involved in 14/46 (30%) oxycodone hospital ED cases in the last 6 months of 2001, and the specific benzodiazepine, alprazolam was involved in 10/46 (22%) of the oxycodone cases. Alprazolam seems to be very popular among high school students as well. A fourteen year old and a thirteen year old girl became lethargic requiring the use of activated charcoal and supportive care after taking alprazolam together at the skating rink. Also, per discussions with Broward High School Substance Abuse Counselors, the most common drugs of abuse among high school kids is alcohol, marijuana, and Xanax. Students refer to them as Xany Bars or just bars. Nationally, DAWN data reveal that alprazolam is the 5th most commonly mentioned drug in ED visits across the country. This ranks behind cocaine, alcohol in combination, marijuana, and heroin. 30

31 Bodypacking A bodypacker is an individual who ingests packets of illicit drugs in an effort to smuggle those drugs into this country, and often bodypackers apprehended from Hollywood/Ft. Lauderdale International Airport are brought to BGMC for treatment. During 2001, there were 38 bodypackers treated at BGMC, and 34/38(89%) had ingested latex covered packets of cocaine There were 26/38(68%) men and 12/38(32%) women, and they claimed to have ingested anywhere from of these packets, with an average of 73 in those cases where a history of the amount was available. The races/ethnicity of these bodypackers were; 20/38 (53%) were black, 10/38(26%) were white, 3/38 (8%) were Hispanic, and 5/38 (13%) was unknown. In each of the cocaine bodypacking cases, where the country of origin was documented, it was Jamaica. One symptomatic heroin bodypacker from Venezuela flew to Miami, took a shuttle to Ft. Lauderdale and then became symptomatic. He was treated at Broward General. 31