National Drug Early Warning System (NDEWS) Annual Project Report 2016

Transcription

1 National Drug Early Warning System (NDEWS) Annual Project Report 2016 August 2016 NDEWS Coordinating Center NDEWS is funded under NIDA Cooperative Agreement DA awarded to the Center for Substance Abuse Research (CESAR) at the University of Maryland, College Park. Opinions expressed in this report may not represent those of NIH or NIDA.

2 1. Project Overview The National Drug Early Warning System (NDEWS) was launched in 2014 with the support of the National Institute on Drug Abuse (NIDA). NDEWS is an innovative public health surveillance system that identifies new drugs and drug trends as they emerge. During Year 1 (August 1, 2014-July 31, 2015), the project focused on new drugs, such as synthetic cannabinoids (e.g., Spice/K2) and designer stimulants (e.g., Molly), and on changes in the use of more traditional drugs such as heroin. During Year 2 (August 1, 2015-July 31, 2016), NDEWS investigated several additional illicit drugs, including synthetic opioids (e.g., fentanyl, the W series, and U-47700); the impact of naloxone legislation and availability; and the misuse of legal drugs such as loperamide. NDEWS components are designed to detect, monitor, and follow up on emerging drugs and drug trends to develop a more complete and accurate understanding of drug use and misuse in the United States. The key components of NDEWS (Figure 1) are the Scientific Advisory Group (SAG), 12 Sentinel Community Sites (SCSs), the NDEWS Network, the NDEWS Presents webinars, and ongoing information-gathering tasks, including news scans and social media scans. The Center for Substance Abuse Research (CESAR) at the University of Maryland, College Park (UMD), manages the NDEWS Coordinating Center and has recruited a team of nationally recognized experts to collaborate with to build NDEWS. During Year 2, the NDEWS Coordinating Center worked with these experts and the NIDA Project Scientist to address six NDEWS goals. These goals enhanced the field of substance use epidemiology by developing new methods of data collection and new collaborations between researchers and practitioners and by providing enhanced mechanisms for information sharing, collaboration, and communication. The NDEWS goals for Year 2 were as follows: 1) Convene SAG at least once as a virtual meeting. Virtual meetings will be held at least annually during years 3 through 5. 2) Maintain and expand an NDEWS Network of scientists, public health experts, law enforcement representatives, SCS representatives, and others as part of a virtual community for sharing information and assisting with local research. In Year 2, the Network was expanded to more than 1,200 members. 3) Conduct a national drug scan by using both traditional and innovative sources, such as social media scans, news scans, and an innovative collaboration with the American Association of Poison Control Centers. 4) Maintain a system of harmonized community indicators and methodologies for tracking emerging drugs nationally and in up to 12 SCSs. In Year 2, drug poisoning deaths, taken from the National Vital Statistics System (NVSS) mortality data queried from the CDC WONDER database, were added as a new national indicator. 5) Initiate two HotSpot studies during Year 2. HotSpot studies were planned and initiated in New Hampshire (NH) and Maryland (MD). During years 3 5, up to one HotSpot study will be conducted per year. To remain responsive to drug outbreaks, the Coordinating Center will work with NIDA to explore possibilities for additional on-site studies and alternatives to on-site studies using new technology. For instance, at NIDA s request, the Coordinating Center is currently conducting a HotSpot study of fentanyl overdoses in NH that will include a second phase in Year 3 with expanded data collection activities. National Drug Early Warning System (NDEWS) Annual Project Report

3 6) Disseminate NDEWS reports and other information through multiple mechanisms, including the virtual community and a NDEWS website. New dissemination methodologies implemented in Year 2 included the NDEWS Presents Monthly webinars and two new types of reports. The Special Report on Fentanyl was designed to monitor fentanyl trends across the United States and in NDEWS sites. The NDEWS Notes from the Field was designed to summarize Network discussions and highlight important information and resources about specific drugs. This report highlights the key accomplishments within each of these goals. It is organized around the NDEWS graphic in Figure 1 and is divided into six sections and three appendices, as follows: 1) Project Overview 2) The People of NDEWS 3) Detecting and Monitoring 4) Following Up 5) Information Exchange and Dissemination 6) Next Steps 7) Appendices Figure 1: NDEWS 2015: Detecting, Monitoring, and Following Up on Drug Trends NIDA Scientific Advisory Group (SAG) Detecting & Monitoring: National Sources for Detecting New Trends and Emerging Drugs NDEWS Network for Nationwide Discussions and Topical Inquiries Ongoing Monitoring in 12 Sentinel Community Sites NDEWS Coordinating Center (CESAR, UMD) Following Up: Targeted Surveys and Scans HotSpot Studies and Geo-Specific Scans NDEWS Information Exchange & Dissemination National Drug Early Warning System (NDEWS) Annual Project Report

4 2. The People of NDEWS The people of NDEWS include six interconnected groups: The NIDA Project Scientist, the Coordinating Center staff, the Scientific Advisory Group (SAG), Sentinel Community Epidemiologists (SCEs), Community Epidemiologists (CEs), and the NDEWS Network. NIDA and Coordinating Center staff members are highlighted on the NDEWS website ( The other groups are made up of scientists, government officials, public health experts, law enforcement representatives, and others who use their diverse expertise to assist in the identification of new drugs and drug trends as they emerge. NDEWS Coordinating Center Staff The NDEWS Coordinating Center is housed at the Center for Substance Abuse Research (CESAR) at the University of Maryland, College Park, and consists of a unique, interdisciplinary team of scientists, analysts, and researchers, all from UMCP. Some current Coordinating Center staff members during Year 2 of this project include: Eric D. Wish, Ph.D. (PI), CESAR Erin Artigiani, M.A, CESAR Joseph Richardson, Ph.D., African-American Studies Jennifer Golbeck, Ph.D., College of Information Studies V.S. Subrahmanian, Ph.D., Computer Science Kathleen Stewart, Ph.D., Center for Geospatial Information Science (CGIS) Claudia Brugman, Ph.D., Center for Advanced Study of Language (CASL) Thomas Conners, Ph.D., Center for Advanced Study of Language (CASL) A full list of current Coordinating Center staff is available on the NDEWS website. Scientific Advisory Group (SAG) The SAG is a combination of 7 federal and 11 nonfederal representatives from across the country with expertise in a multitude of fields (Appendix 1). The SAG meetings and ongoing discussions provide a unique opportunity to create a new paradigm for identifying and understanding emerging drugs and drug trends. Coordinating Center staff, NIDA, and SAG members work together to build and shape each NDEWS component. The Coordinating Center held a virtual SAG meeting on October 2, 2015, to discuss important current/emerging drugs and drug issues, review Year 1, and discuss plans for Year 2. Coordinating Center staff also consulted with SAG members as needed for advice and guidance on issues such as DEA toxicology lab and National Forensic Laboratory Information System (NFLIS) data and the CDC WONDER death database. In addition, three SAG members presented as part of NDEWS Presents monthly webinars. Sentinel Community Epidemiologists (SCEs) and Community Epidemiologists (CEs) There are currently two types of local community epidemiologists: SCEs and CEs. The SCEs represent the 12 SCSs as the point of contact for their site and as members of the NDEWS Network. They work with Coordinating Center staff to prepare annual profiles on current drug use and abuse at their site and report on emerging drugs and drug trends. The CEs serve as the point of contact for an additional 7 sites (all former Community Epidemiology Workgroup sites) and as members of the NDEWS Network. (See National Drug Early Warning System (NDEWS) Annual Project Report

5 Appendix 2 for a complete list of SCEs and CEs.) Coordinating Center staff members continue to correspond regularly throughout the year with SCEs and CEs to respond to queries, share information and reports, and collect data and information on specific drug topics. In addition, the Coordinating Center conducts a 2-hour webinar with the SCEs and CEs (by Year 2, two had been held, one in September 2015 and the other in January 2016) to collect information about recent substance abuse developments in NDEWS communities, as well as to share information about upcoming events. The NDEWS Network is a virtual community of more than 1,200 researchers, practitioners, and concerned citizens across the country. This Network offers a forum to share and discuss information about emerging drugs and changing drug use trends, as well as to assist with local NDEWS research (see the Information Exchange and Dissemination section for more information). National Drug Early Warning System (NDEWS) Annual Project Report

6 3. Detecting and Monitoring Detecting and monitoring is the first step of the NDEWS process. The goal of the five activities highlighted in this section is to monitor, interpret, and synthesize timely data that can be used to identify emerging drugs and new patterns of use. The activities involve collaborating with experts in different fields to develop a set of innovative methodologies that will be used throughout the duration of NDEWS. Four activities involve the utilization of national sources, such as discussion lists maintained by the American Association of Poison Control Centers, social media sites such as Twitter, news scans of English language periodicals, and other traditional data sources. The fifth involves working with local epidemiological experts to monitor and report on trends in 12 SCSs across the country. National Sources Collaboration with the American Association of Poison Control Centers (AAPCC) Coordinating Center staff executed an annual contract with the AAPCC to support the regular sharing of information from members of three AAPCC discussion lists. As part of this collaboration, Coordinating Center staff sent queries directly to the medical directors of 55 poison centers across the country. In addition, AAPCC picked up queries posted to the NDEWS Network and shared them with the medical directors. During Year 2, the queries addressed clenbuterol, pregabalin, loperamide, gabapentin, marijuana concentrates, kratom, contaminated heroin, and a general query on changes in drug use and topics for NDEWS. Responses to loperamide were included in the inaugural NDEWS Notes from the Field report. As a result of ongoing information sharing through this collaboration and the NDEWS Network, Coordinating Center staff worked with AAPCC to provide an overview of their databases and the types of data available during the May 25th NDEWs Presents webinar. The slides and a complete recording of the webinar are available online at Social Media and Web Scans Twitter Collection and Special Searches The NDEWS Coordinating Center continued to work with Dr. Jen Golbeck and Dr. V.S. Subrahmanian during Year 2 to maintain the collection of geocoded tweets. Coordinating Center staff met regularly with Drs. Golbeck and Subrahmanian regarding Twitter scans and correlating tweets with other data sources. Dr. Golbeck and her staff continued to collect real-time, streaming, geolocation-tagged tweets in the United States throughout Year 2. A duplicate copy of the tweet database is being maintained through an Amazon Web Services cloud storage account owned by the NDEWS Coordinating Center. This data set is available to query for any new term at any time and is available for additional types of analysis (e.g., geocoding). Dr. Golbeck and her staff conducted several special request searches for the NDEWS Coordinating Center: 1) pulled two sets of tweets for a study to determine potential bias from focusing only on tweets with geocodes; 2) provided a set of fentanyl tweets for review and inclusion in the fentanyl special report; and 3) provided the results of a search for fentanyl tweets in NH and all tweets in NH in National Drug Early Warning System (NDEWS) Annual Project Report

7 preparation of an NDEWS HotSpot study (Coordinating Center staff members are in the process of reviewing the results of these NH searches). Modeling the Relationship of Tweets to Other Drug Use Indicators Dr. Subrahmanian prepared a methodology write-up for his analyses of modeling the relationship of tweets to other drug use indicators. Coordinating Center staff provided him with detailed information on several potential sources to assist with these tasks. In consultation with Coordinating Center staff, Dr. Subrahmanian began building a model to assess the relationship of tweets mentioning heroin or heroinrelated terms to heroin deaths across the 50 states. Data for this model are from the National Vital Statistics System (NVSS) mortality data queried from the CDC WONDER database. Dr. Golbeck presented on her and Dr. Subrahmanian s work to date at the NDEWS workshop at the College on Problems of Drug Dependence (CPDD) conference in Palm Springs, CA, on June 13, Identifying Novel Drug Terms in Tweets Based on Known Drug References The social media scans were expanded to include an advanced analysis of tweets by staff at UMD s Center for Advanced Study of Language (CASL). Drug vocabulary shifts widely and swiftly, with region, population (producers, consumers, enforcement), type of drug, and so on. Informal communication between drug suppliers and users may not make use of terminology or vocabulary items used by either the drug enforcement or public health communities. Social media present an opportunity to identify and track emerging trends in drug distribution and use, but only if the relevant terms can be identified, and their drug-related usages accurately discriminated from other usages. The study, Discovery of novel drug vocabulary in social-media text using supervised machine learning and human language analysis, by CASL began in June 2016 and aims to use Twitter to identify novel terms or novel uses of words referring to drugs and drug-related activities based on known drug-reference terms. Monitoring Drug Forums and Websites to Identify Emerging Drugs In May 2016, NDEWS initiated a collaboration with an expert in the field to monitor drug-related websites and user forums to identify and gather information about possible emerging drugs. This expert is conducting regular scans of some sites (e.g., blulight.org) and will be providing regular reports on possible emerging drugs. The first of these scans was recently submitted and is under review by Coordinating Center staff. News Scans The news scan methodology was used during Year 2 as part of three distinct tasks. First, news scans were conducted to develop a more focused methodology for the collection and use of news scan information as part of ongoing monitoring efforts by NDEWS. Select articles were posted to the NDEWS Network or website. News scans were also conducted to provide information for inclusion in two NDEWS Special Reports on fentanyl. A trend chart of the number of related newspaper articles was developed (see Figure 2), and individual articles were collected, reviewed, and coded for content. Finally, targeted news scans on emerging topics identified by NDEWS staff were conducted. Searches included such topics as flashblood, fentanyl in New Hampshire, synthetic cannabinoids and homelessness, heroin overdoses, heroin and fentanyl, and loperamide. These searches helped inform researchers analyses. National Drug Early Warning System (NDEWS) Annual Project Report

8 Figure 2: Number of Fentanyl-Related News Articles per Week Traditional Data Sources Although not without limitations, traditional data sources, such as treatment admissions and household surveys, provide history, context, and corroboration of more timely findings from other NDEWS components. In addition, selected comparable data from national and local data sources that are available for each of the 12 SCSs are used to provide cross-site comparisons in various NDEWS reports. Links to national sources of data on drug and alcohol use, the consequences of such use, and the availability of drugs across the United States, organized by indicator at the national and state levels, are posted on the Resources section of the NDEWS website. Drug Poisoning Deaths After extensive research, Coordinating Center staff chose to add drug poisoning deaths as a new NDEWS indicator. Staff members reviewed various publications that described and analyzed drug poisoning death data to assess the various ICD-10 codes used to define such deaths. Staff chose to use drug poisoning death statistics taken from the National Vital Statistics System (NVSS) mortality data queried from the CDC WONDER database, as well as to use definitions published in recent Morbidity and Mortality Weekly Reports (MMWR) by CDC staff. Coordinating Center staff also consulted with CDC staff and a SAG member on state-level variations in reporting of death data that would impact the description of drug poisoning deaths. Geospatial Analysis of Drug Poisoning Deaths In Year 2, Coordinating Center staff began working with staff at the UMD Department of Geographical Sciences, Center for Geospatial Information Science (CGIS), to conduct geospatial analysis of heroin and semisynthetic opioid deaths in the United States and in the SCSs from 1999 to This analysis will provide an enhanced spatial understanding of the patterns of drug-related deaths across these sites in the context of key sociodemographic parameters, such as age, race, and income. They will also analyze the relationships between the locations of the 12 NDEWS Sentinel sites and locations of current or emerging hotspots for drug deaths. Since April 2016, CGIS staff have conducted a literature search on spatial analysis and heroin, become familiar with and downloaded data from the CDC WONDER National Drug Early Warning System (NDEWS) Annual Project Report

9 database, and created sample maps of age-adjusted heroin deaths by county from 1999 to 2014 in the context of urbanization. Local Sources: Sentinel Community Sites (SCSs) The NIDA Project Scientist and NDEWS Coordinating Center staff work with SCEs in 12 SCSs to monitor indicators of drug use, consequences, and availability within and across the sites (see Figure 4). During Year 2, the 12 NDEWS SCSs were maintained and contracts were set up with the SCE in each site. The SCEs in all sites remained the same for most of Year 2. NDEWS Coordinating Center staff members are working with the city of Denver to identify and train a new SCE for Year 3. Figure 3: NDEWS Sentinel Community Sites Coordinating Center staff and the SCE for each SCS worked together to produce an annual SCS Drug Use Patterns and Trends report. In Year 2, Coordinating Center staff redesigned the profiles and developed guidelines for the SCEs to use to prepare a more focused profile. The 2016 report developed for each SCS includes three sections: National Drug Early Warning System (NDEWS) Annual Project Report

10 1) The SCS Snapshot, prepared by Coordinating Center staff, attempt to harmonize data available for each of the 12 sites by presenting standardized graphics from local treatment admissions and four national data sources. The Snapshot provides site-specific graphics displaying data on drug use, substance use disorders and treatment, drug poisoning deaths, and drug seizures. The graphics are based on data from five data sources: 1) NSDUH for drug use behaviors among the household population; 2) YRBS for drug use behavior among students; 3) local treatment admissions data provided by the SCEs; 4) NVSS mortality data queried from the CDC WONDER database; and 5) NFLIS. See Figure 4 for a sample Snapshot. 2) The SCE Narrative, written by the SCE, provides their interpretation of important findings and trends based on available national data as well as sources specific to their area, such as data from local medical examiners or poison control centers. As a local expert, the SCE is able to provide context to the national and local data presented. The highlights prepared by the local SCE for their SCE Narrative are provided in Appendix 3. 3) The SCS Data Tables attempt to harmonize data available for each of the 12 sites by presenting standardized information from local treatment admissions and five national data sources. The Data Tables provide site-specific data on population characteristics, drug use, substance use disorders and treatment, drug poisoning deaths, and drug seizures available from several data sources. In addition to the five data sources used in the Year 1 tables, drug poisoning death data were added as a new indicator for Year 2. The data sources used for the SCS Data Tables report are as follows: 1) the American Community Survey (ACS); 2) the National Survey on Drug Use and Health (NSDUH); 3) The Youth Risk Behavior Survey (YRBS); 4) local treatment admissions data provided by the SCEs; 5) the National Vital Statistics System (NVSS) mortality data queried from the CDC WONDER database; and 6) the National Forensic Laboratory Information System (NFLIS). See Figure 5 for a sample data table. In addition to the annual SCS Drug Use Patterns and Trends reports, emerging substance use in the 12 SCSs are also monitored and reported on throughout the project in Sentinel Community Site Cross-Site Data Presentations. The SCS Cross-Site Data Presentations contain cross-site graphics displaying selected comparable data from national and local sources that are available for each of the 12 SCSs, comparing information on drug use, substance use disorders and treatment, drug poisoning deaths, and drug seizures available from four data sources: 1) YRBS; 2) local treatment admissions data provided by the SCEs; 3) NVSS mortality data queried from the CDC WONDER database; and 4) NFLIS. A sample Cross-Site Data graphic is provided in Figure 6. These reports necessarily rely on using a variety of data sources produced by governmental and local agencies so there may be variations within and across sites. For example, treatment admissions data for some sites was available for CY2015, whereas for others, only partial year data or FY2015 data were available. Some sources measure geographic areas that differ from the intended catchment area of a Sentinel site. For example, some surveys measure statewide patterns, whereas others provide countylevel estimates. Wherever appropriate, notes were provided specifying the time frames or areas covered by the findings presented. National Drug Early Warning System (NDEWS) Annual Project Report

11 Figure 4: Sample Sentinel Community Site Snapshot Graphic Substance Use Disorders and Treatment National Survey on Drug Use and Health (NSDUH): Survey of U.S. Population* Substance Use Disorders** in Past Year Among Persons 12+ Years, King County (Seattle Area)^, Estimated Percent, 95% Confidence Interval, and Estimated Number of Persons*** *U.S. Population: U.S. civilian non-institutionalized population. **Substance Use Disorders in Past Year: Persons are classified as having a substance use disorder in the past 12 months based on responses to questions that meet the criteria specified in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). ^King County: NSDUH Region 2 (King County). ***Estimated Number: Calculated by multiplying the prevalence rate and the population estimate of persons 12+ years (1,700,584) from Table C1 of the NSDUH Report. Source: Adapted by the NDEWS Coordinating Center from data provided by SAMHSA, NSDUH. Annual averages based on combined 2012 to 2014 NSDUH data. Treatment Admissions Data from Local Sources Trends in Treatment Admissions*, by Primary Substance of Abuse, King County (Seattle Area), (n = Number of Treatment Admissions) Demographic Characteristics of Treatment Admissions*, King County (Seattle Area), 2015 *Treatment Admissions: Includes admissions to all modalities of care in public-funded programs. **Rx Opioids: Includes oxycodone/hydrocodone, non-prescription methadone, and other opiates. Percentages may not sum to 100 due to rounding. See Sentinel Community Site (SCS) Data Tables and Overview & Limitations section for more information regarding the data. Source: Data provided to the King County (Seattle Area) NDEWS SCE by the Washington State Department of Social and Health Services (DSHS), Division Behavioral Health and Recovery, Treatment Report and Generation Tool (TARGET). National Drug Early Warning System (NDEWS) Annual Project Report

12 Figure 5: Sample Sentinel Community Site Data Table National Drug Early Warning System (NDEWS) Annual Project Report

13 Figure 6: Sample Sentinel Community Site Cross-Site Data Graphic National Drug Early Warning System (NDEWS) Annual Project Report

14 4. Following Up HotSpots One unique capability built into NDEWS is the follow-up on potential emerging drug use problems with in-depth, on-site studies. NDEWS HotSpot studies send a team of epidemiologists to a locality to spend time on site to describe and understand an emerging drug problem. In preparation for these visits, the Coordinating Center uses NDEWS resources to gather real-time information about the problem, designates local liaisons to assist with planning site visits, identifies local experts to interview, and coordinates focus groups or other forms of local information gathering. Ideally, the HotSpot study results will enable public health officials and advocates to respond quickly to potential outbreaks in their local communities. Synthetic Cannabinoid Use by Urban Hospital Patients Prince George s County, Maryland, was selected as the first HotSpot site for a study on synthetic cannabinoids, Synthetic cannabinoids use by patients at an urban hospital in Maryland. Coordinating Center staff worked with Dr. Joe Richardson (UMD) and Dr. Brad Schwartz (Emergency Physician, Prince George s Hospital Center) to develop the protocol for a study of 20 patients seen at the Emergency Department of Prince George s Hospital Center (PGHED). An IRB application was submitted to and approved by the University of Maryland. An IRB application was submitted to the Prince George s Hospital Center and is pending review. Upon approval, Dr. Schwartz will work to identify patients meeting study requirements and Dr. Richardson will interview the patients about their drug use history and topics related to synthetic cannabinoids use. The Prince George s County HotSpot study will be completed in Fall Dr. Richardson presented on the plans for this study and results from similar studies at the June 2016 CPDD conference. Fentanyl Use in New Hampshire Based on discussions with NIDA staff and the information gathered from NDEWS sources, NDEWS staff concluded that a HotSpot study focusing on the emerging public health problem of fentanyl use in the state of New Hampshire was justified. In Phase 1 of the study, an NDEWS team made up of Coordinating Center staff and local substance abuse experts was assembled to 1) assess available data, 2) conduct a site visit to New Hampshire to interview local experts and collect information needed to plan the more extensive activities to be conducted in Phase 2, and 3) prepare the Phase 1 report. As part of the Phase 1 Study, Coordinating Center staff members worked closely with NDEWS members and NIDA grantees in New Hampshire. For example, the NDEWS Maine Sentinel Community Epidemiologist, Marcella Sorg, who has already worked closely with New Hampshire state government on heroin and fentanyl trends and has accessed overdose death data, is part of the NDEWS New Hampshire HotSpot team. Coordinating Center staff members implemented Phase 1 in June Phase 1 included convening the NH HotSpot Planning Committee, conducting the site visit, reviewing existing data, and preparing the Phase 1 report. The report, which will include special sections prepared by Dr. Marcella Sorg, University of Maine, on overdose death trends and by Dr. Lisa Marsch, Dartmouth College, on treatment admission trends, will be completed in early Fall. Phase 2 of the NH HotSpot study will be completed in Year 3 and is based on the recommendations in the Phase 1 report. The NDEWS Coordinating Center will set up sub-contracts with Dr. Marsch and Dr. Sorg. Planned activities include interviewing drug users and first responders, testing biological specimens, conducting an in-depth analysis of fentanyl-related overdose deaths, and conducting geospatial analyses of fentanyl-related overdose deaths. At NIDA s request, the NDEWS Coordinating Center National Drug Early Warning System (NDEWS) Annual Project Report

15 applied for an Administrative Supplement in July 2016 to cover the additional resources needed to conduct Phase 2 of the NH HotSpot study. National Drug Early Warning System (NDEWS) Annual Project Report

16 5. Information Exchange and Dissemination The primary modes for information exchange and dissemination are the NDEWS website, the NDEWS Network, NDEWS publications, and new this year, NDEWS Presents monthly webinars. Additional methods for exchanging and disseminating information that have been developed include preparing joint press releases with partner agencies (i.e., synthetic cannabinoids with AAPCC) and internal briefings for Coordinating Center and NIDA staff. NDEWS Website Coordinating Center staff launched the NDEWS website ( in June The website home page highlights information on emerging drugs and drug trends, including recent news alerts, reports, and publications; links to social media sites that regularly discuss information about emerging drug use; and videos and webinars. The five main sections of the site About Us, Research, Project Publications, Sentinel Sites, and Resources are designed to highlight specific components of NDEWS and provide visitors with access to current information on drug use and drug use trends, upcoming conferences and events, and recent news articles. The site also serves as a hub for SCEs, CEs, and other NDEWS members to share reports, journal articles, and other publications. During Year 2, the website was maintained, regularly updated, and expanded. New sections to the site were added, including drug-related social media links; links to other drug surveillance systems around the world; pages containing links to information on specific drugs (alpha-pvp, fentanyl, heroin, kratom, loperamide, marijuana concentrates, methamphetamine, naloxone, and synthetic cannabinoids); and AAPCC statistics. The NDEWS Annual Report, Cross-Site Graphics, Profile Reports, Special Reports, Reports from the Field, and NDEWS News were all added to the site in multiple places. In addition, the Cross-Site Graphics and Appendix Tables were individually added to the site grouped by drug, data source, and domain. There have been a total of 17,777 visits to the website in Year 2 (from August 1, 2015 to May 24, 2016) by 14,315 users. NDEWS Network The NDEWS Network is a virtual community of researchers, practitioners, and concerned citizens across the country. This Network offers a forum to share and discuss information about emerging drugs and changing drug use trends, as well as to assist with local NDEWS research. The Network was set up to allow for information exchange and collaboration even while the NDEWS infrastructure was being developed. It also provides links to other virtual communities, such as the LinkedIn Emerging Drugs discussion group. NDEWS Network Discussion List The Network was launched in 2015 by the Coordinating Center staff as an discussion list and now has more than 1,200 members from 12 countries who engage in ongoing discussions of emerging drugs and trends. The Network has enabled information sharing by its members who have posted queries, National Drug Early Warning System (NDEWS) Annual Project Report

17 local news stories, reports, journal articles, and other information. During Year 2 there were 529 posts to the NDEWS Network list (see Figure 7). Coordinating Center staff monitored and contributed to discussions and prepared more than 70 posts to request information or share information and articles about timely topics, data and report releases from other agencies (e.g., CDC WONDER overdose death data, Monitoring the Future, NSDUH, UNODC, and CCENDU), and funding announcements. Coordinating Center staff also posted about the release of NDEWS publications and invitations to the monthly NDEWS Presents webinars. Network members initiated posts on various topics, including specific drugs, local health advisories, marijuana use disorders, local standing orders/laws, drug testing, and counterfeit pills. Figure 7: Sample Topics from NDEWS Network Discussion Fentanyl Overdoses Online Drug Markets Synthetic Cannabinoids E-cigarettes Loperamide Quinidine Synthetic Opioids Naloxone Flakka Synthetic Opioids Desomorphine/Krokodil NDEWS Network Online In Year 2 of the project, a SharePoint-based NDEWS Network Community site was developed to allow more extensive information sharing and discussions by Network members. Structure and content for both the public and private SCE/CE pages were created, and a beta-version of the site was opened to the SCEs in May. The site will be launched to the full Network early in Year 3 and will 1) serve as a webbased NDEWS Network discussion list to facilitate communication and collaboration among Network members (both publicly and privately for certain subgroups) about emerging drug issues and 2) allow internal private project communication and document sharing among the various subgroups of the project. The current site consists of one main NDEWS Network page that will be open to Network members and two private pages that will be open only to SCEs/CEs and SAG members. The site will be expanded to enable private discussions by other subgroups as necessary. NDEWS Publications In addition to the annual SCS reports, NDEWS also publishes shorter, topic-specific reports. The NDEWS News is a one-page publication highlighting current NDEWS-related findings that provides rapid dissemination of crucial information. NDEWS Special Reports focus on specific drugs, synthesizing information from the various NDEWS components, including real-time data from SCEs, CEs, and SAG members (obtained via phone calls/ s), Twitter, news scans, and Web searches. Our newest publication, NDEWS Reports from the Field, summarizes information about a specific drug or drug use trend received in response to queries sent to NDEWS experts, such as the NDEWS Network and the listserv of the AAPCC poison center medical directors. National Drug Early Warning System (NDEWS) Annual Project Report

18 The NDEWS Special Report: Fentanyl and Fentanyl Analogs was published in December This inaugural issue of the NDEWS Special Report provided a more comprehensive understanding of current fentanyl trends, using findings from four key NDEWS components: 1) national indicators of availability and consequences, 2) NDEWS community sites, 3) Twitter scans, and 4) news scans. The NDEWS Reports from the Field: Loperamide was written and released in May This report summarized observations received in response to a query sent to the NDEWS Network and the AAPCC listserv in April One issue of the NDEWS News was written and released during Year 2 and highlighted findings from the Year 1 SCS Profile Reports. NDEWS Presents Webinars In February 2016, the NDEWS Coordinating Center launched NDEWS Presents, monthly webinars on timely substance use topics. The Coordinating Center held five NDEWS Presents webinars during Year 2. Recordings of the webinars, as well as links to the presentations and questions and answers, are posted on the NDEWS Website: Synthetic Drug Threats in the United States, Jill Head, Senior Forensic Chemist at the U.S. Drug Enforcement Administration s Special Testing and Research Laboratory (February 24, 2016) Understanding the Relationship Between Prescription Opioid Misuse and Heroin Abuse, Dr. Wilson Compton, Deputy Director of NIDA, NIH and Dr. Daniel Ciccarone, Professor of Family and Community Medicine, University of California, San Francisco (March 28, 2016) Designer Drugs of Abuse: The Science Behind the Headlines, Dr. Michael Baumann, Chief of the Designer Drug Research Unit of the Intramural Research Program at NIDA (April 27, 2016) An Overview of the National Poison Data System and Drug-Related Human Exposure Cases, Ashlea Zimmerman, Director of the National Data Services at the American Association of Poison Control Centers (May 25, 2016) Synthetic Opioids in Counterfeit Pharmaceuticals and Other Illicit Street Drugs: The Situation in Canada, Dr. Matthew Young, Senior Research & Policy Analyst at the Canadian Centre on Substance Abuse at the Carleton University and Lead Researcher with CCENDU; Jane A. Buxton, Professor and Director MPH Practicum, University of British Columbia, School of Population and Public Health and Physician Epidemiologist, Harm Reduction Lead, British Columbia Centre for Disease Control; and Michelle Craig, Acting Executive Director, Addiction and Mental Health, Alberta Health, Government of Alberta (July 20, 2016) National Drug Early Warning System (NDEWS) Annual Project Report

19 6. Next Steps Coordinating Center staff members have identified the following seven preliminary next steps to pursue in the coming year. They will be reviewed with the NIDA Project Scientist, SCEs, and SAG members: 1. Complete beta test and launch the NDEWS Network Portal to host the interactive virtual community. 2. Complete HotSpot studies in New Hampshire (fentanyl) and Maryland (synthetic cannabinoids), and conduct a new HotSpot study as appropriate. 3. Prepare summary report of key findings from the SCS Profiles. 4. Prepare special reports, including NDEWS News, NDEWS Special Reports, and Notes from the Field as needed to explore and describe emerging drug trends. 5. Continue to work with CASL staff to identify novel terms or novel uses of words referring to drugs and drug-related activities based on known drug-reference terms. 6. Continue to monitor drug forums and websites to identify and obtain information about emerging drugs. 7. Continue to develop and complete article on geospatial analyses of heroin and other opioids deaths with CGIS staff. 8. Continue to discuss the best way to assess, present, and use the cross-site data. 9. Continue to focus and refine the collection and use the information from news scans. National Drug Early Warning System (NDEWS) Annual Project Report

20 7. Appendices Appendix 1: NDEWS Scientific Advisory Group (SAG) Appendix 2: SCEs and CEs Appendix 3: SCS Profile Highlights National Drug Early Warning System (NDEWS) Annual Project Report

21 Appendix 1: NDEWS Scientific Advisory Group (SAG) ( ) The NDEWS SAG is a combination of 7 federal and 11 nonfederal representatives from across the country with expertise in a multitude of fields. The SAG meetings and ongoing discussions provide a unique opportunity to create a new paradigm for identifying and understanding emerging drugs and drug trends. Coordinating Center staff, NIDA, and SAG members work together to build and shape each NDEWS component. The SAG meet virtually once a year to discuss important current and emerging drugs and drug issues and Coordinating Center staff consult with SAG members as needed for advice and guidance on various issues. Caleb Banta-Green, PhD, MSW, MPH Alcohol and Drug Abuse Institute University of Washington calebbg@u.washington.edu Michael Baumann, PhD NIDA Intramural Research Program Designer Drug Research Unit mbaumann@mail.nih.gov CDR Tom Bosy, PhD Office of the Assist Secretary of the Navy Substance Abuse Office thomas.bosy@navy.mil Edward Boyer, MD, PhD Brigham and Women s Hospital edward.boyer@childrens.harvard.edu Fe Caces, PhD Office of National Drug Control Policy maria_fe_caces@ondcp.eop.gov Robert Carlson, PhD Center for Interventions, Treatment, and Addictions Research Wright State University robert.carlson@wright.edu Tom Carr Washington/Baltimore High Intensity Drug Trafficking Area thcarr@umd.edu Daniel Ciccarone, MD, MPH University of California San Francisco daniel.ciccarone@ucsf.edu Linda Cottler, PhD, MPH University of Florida Department of Epidemiology lbcottler@ufl.edu Robert DuPont, MD Institute for Behavior and Health bobdupont@aol.com Matt Gladden CDC ONDIEH/NCIPC Div of Unintentional Injury Prevention mgladden@cdc.gov Jim Hall Ctr for Applied Research on Substance Use and Health Disparities Nova Southeastern University upfrontin@aol.com Jennifer Havens, PhD, MPH Center on Drug and Alcohol Research Univ of Kentucky College of Medicine jhave2@uky.edu Jill Head DEA Emerging Trends Program/Reference Materials Program Special Testing & Research Laboratory jill.m.head@usdoj.gov Brian Kelly, PhD Purdue University bckelly@purdue.edu Rob Lyerla, PhD Substance Abuse and Mental Health Services Administration rob.lyerla@samhsa.gov Jane Maxwell, PhD University of Texas, Austin jcmaxwell@austin.utexas.edu Liqun Wong DEA (NFLIS) liqun.l.wong@usdoj.gov National Drug Early Warning System (NDEWS) Annual Project Report

22 Appendix 2: SCEs and CEs ( ) The NDEWS Coordinating Center has organized two types of local experts: Sentinel Community Epidemiologists (SCEs) and Community Epidemiologists (CEs). The SCEs are the point of contact for the 12 NDEWS Sentinel Community Sites, communities across the United States that are experiencing significant substance use and/or misuse problems. These sites were selected from former Community Epidemiology Workgroup (CEWG) sites to maintain collaborations with local experts with ready access to local data and information. The CEs are the point of contact for an additional 7 sites across the United States, all also former CEWG sites. Sentinel Community Epidemiologists (SCEs) Atlanta Metro Brian J. Dew, PhD Dept of Counseling and Psychological Services Georgia State University Phone: bdew@gsu.edu Chicago Metro Lawrence J. Ouellet, PhD School of Public Health University of Illinois at Chicago Phone: ljo@uic.edu Denver Metro Cindy Laub, PhD Office of Behavioral Health Strategies City and County of Denver Phone: cindy.laub@denvergov.org Wayne County (Detroit Area) Cynthia L. Arfken, PhD Dept of Psychiatry and Behavioral Neurosciences Wayne State University Phone: cynthia.arfken@wayne.edu Los Angeles County Mary-Lynn Brecht, PhD Integrated Substance Abuse Programs University of California at Los Angeles Phone: lbrecht@ucla.edu Maine Marcella H. Sorg, PhD, RN Rural Drug and Alcohol Research Program University of Maine Phone: mhsorg@maine.edu Southeastern Florida (Miami Area) James N. Hall, BA Center for Applied Research on Substance Use and Health Disparities Nova Southeastern University Phone: upfrontin@aol.com New York City Denise Paone, EdD Bureau of Alcohol and Drug Use Prevention, Care and Treatment New York City Dept of Health & Mental Hygiene Phone: dpaone@health.nyc.gov Philadelphia Suet T. Lim, PhD City of Philadelphia Dept of Behavioral Health and Intellectual disability Services Community Behavioral Health Phone: suet.lim@phila.gov San Francisco Phillip O. Coffin, MD, MIA San Francisco Dept of Public Health Phone: phillip.coffin@sfdph.org King County (Seattle Area) Caleb Banta-Green, PhD, MSW, MPH Alcohol and Drug Abuse Institute University of Washington Phone: calebbg@u.washington.edu Texas Jane C. Maxwell, PhD School of Social Work The University of Texas at Austin Phone: jcmaxwell@austin.utexas.edu Community Epidemiologists (CEs) Boston, MA Daniel P. Dooley Phone: ddooley@bphc.org Maryland/Washington, DC Eleanor Erin Artigiani, MA Phone: eartigia@umd.edu Phoenix, AZ James K. Cunningham, PhD Phone: jkcunnin@ .arizona.edu San Diego, CA Richard S. Garfein, PhD, MPH Phone: rgarfein@ucsd.edu Cincinnati, OH Jan Scaglione, RPh, PharmD Phone: jan.scaglione@cchmc.org Minneapolis, MN Carol L. Falkowski, BA Phone: carol.falkowski@gmail.com St. Louis, MO Heidi Israel, PhD Phone: israelha@slu.edu National Drug Early Warning System (NDEWS) Annual Project Report

23 Appendix 3: SCS Profile Highlights 1. Atlanta Metro, by Brian J. Dew, Ph.D., and Ned Golubovic, M.S. 2. Chicago Metro, by Lawrence J. Ouellet, Ph.D. 3. Denver Metro, by Cindy Laub, Ph.D., and Bruce Mendelson, M.P.A. 4. Wayne County (Detroit Area), by Cynthia L. Arfken, Ph.D. 5. Los Angeles County, by Mary-Lynn Brecht, Ph.D. 6. Maine, by Marcella Sorg, Ph.D. 7. New York City, by Denise Paone, Ed.D. 8. Philadelphia, by Suet Lim, Ph.D. 9. San Francisco City and County, by Phillip Coffin, M.D., M.I.A. 10. King County (Seattle Area), by Caleb Banta-Green, Ph.D. 11. Southeastern Florida, by James N. Hall, B.A. 12. Texas, by Jane C. Maxwell, Ph.D. National Drug Early Warning System (NDEWS) Annual Project Report

24 National Drug Early Warning System (NDEWS) Atlanta Metro Sentinel Community Site (SCS) Drug Use Patterns and Trends, 2016: SCE Narrative Brian J. Dew, Ph.D., and Ned Golubovic, M.S. Georgia State University Highlights Numerous indicators suggest that alprazolam is the primary benzodiazepine abused in metropolitan Atlanta and throughout Georgia. It is the benzodiazepine most frequently detected in Georgia Poison Control calls, Georgia Medical Examiner results, Fulton County Medical Examiner results, and ethnographic reports with users. Conversations with local users indicate an increase in the supply of, and demand for, liquid alprazolam. Although super pills have caused deaths in Florida and have been confiscated in Kentucky and Tennessee in 2016, this combination of alprazolam and fentanyl has not been reported in the Atlanta metropolitan statistical area (MSA). Compared with the previous two years, the availability of, and purity and pricing for, cocaine hydrochloride and crack/cocaine in Atlanta remained stable in The majority of cocaine in Atlanta continues to be Colombian, and the City remains a primary hub for distribution along the East Coast. Although the supply of and demand for cocaine remains stable, deaths related to the drug s use increased more than 33% both in Atlanta and throughout Georgia in 2015 versus deaths in Local ethnographic reports suggest an increased demand for higher quality marijuana and tetrahydrocannabinol (THC)-based liquids, with the latter being increasingly smoked in vapor pens and e-cigarettes. Multiple data sources indicate increased supply of methamphetamine in Atlanta with elevated average purity levels of between 85% and 90%. Increased purity levels of methamphetamine have led to more deaths both in Atlanta and throughout Georgia. Two large seizures of methamphetamine totaling more than $18 million in street value were made in the Atlanta suburbs in Law enforcement officials confiscated more than 65 gallons of liquid methamphetamine at these two conversion labs. The types and amounts of synthetic cathinones available in Atlanta continue to change with the influx of ethylone in In South Georgia, law enforcement and public health officials indicate an increasing amount of alpha-pvp (Flakka) entering the State via Florida. Heroin use in Atlanta continues to increase. Calls into Georgia Poison Control have doubled in the past three years, and multiple death-related data (drug poisoning, Georgia Medical Examiner, and Fulton County Medical Examiner) suggest over a 100% surge in heroin-related fatalities in 2015 compared with From conversations with local HIDTA and law enforcement officials, Atlanta is increasingly being considered a primary distribution center for heroin. National Drug Early Warning System (NDEWS) Annual Project Report

25 National Drug Early Warning System (NDEWS) Chicago Metro Sentinel Community Site (SCS) Drug Use Patterns and Trends, 2016: SCE Narrative Lawrence J. Ouellet, Ph.D. School of Public Health University of Illinois at Chicago Highlights Heroin continued to be the primary opioid abused in the Chicago region, and heroin use indicators maintained levels that had been elevated since the mid-1990s. Hydrocodone was the most commonly used prescription opioid in the Chicago MSA. Among new and notable drugs, synthetic cannabinoids remained common in NFLIS reports with 17 varieties documented. Both piperazine and tryptamine reports in NFLIS experienced substantial declines. Alprazolam was the most frequent benzodiazepine found in drug items seized by law enforcement. The number of items positive for alprazolam increased 152% from 2011 to Cocaine indicators suggested a continuing decline in availability and usage. In 2012, cocaine fell to third in the number of NFLIS drug reports among items seized and analyzed, behind marijuana and heroin, and the decline continued in 2014 and leveled in the first half of Cocaine also fell to third among reasons for entering publicly funded treatment programs in FY2009 and then fell to fourth from FY2012 to FY2015. Among detainees at the Cook County Jail who participated in the Arrestee Drug Abuse Monitoring Program (ADAM) II in 2012, urinalyses and self-reports indicated declines in cocaine use. Marijuana remained the drug most often found in NFLIS reports and was plentiful across the Chicago MSA. Cannabis in a soft waxy form was increasingly available, according to the Chicago Police Department. PCP reports continued to increase among NFLIS reports for the Chicago MSA. Between 2007 and 2014, PCP reports increased from 115 to 563. The number of reports in the first half of 2015 (n = 325) suggested a continued increase in the presence of PCP in the Chicago MSA. Methamphetamine remained uncommon in Chicago among groups other than men who have sex with men. National Drug Early Warning System (NDEWS) Annual Project Report