Substance Abuse Trends: Old and New Drugs

1. Substance Abuse Trends:Old and New Drugs Jane Maxwell, Ph.D. Addiction Research Institute Center for Social Work Research The University of Texas at Austin

6. Cocaine 6% Cocaine 7% Heroin 16% Heroin 13% Meth 9% Meth 8% Meth 27% Meth 17% Heroin 11% Heroin 10% Meth 13% Meth 25% Cocaine 17% Heroin 34% Heroin 9% Heroin 25% Cocaine 29% Cocaine 32% Cocaine 3% Cocaine 13% Cocaine 42% Heroin 3% Primary Drug of Abuse at Admission to Treatment: 2009 Cocaine 8% Cocaine 14% Heroin 8% Meth 4% Meth 1% Meth 2% Meth 1% Heroin 1% SISVEA & TEDS

7. QUICK SNAPSHOT OF PROBLEMS TO BE ADDRESSED * Alcohol Use by Young Women * Drugged Driving

8. Percentage of Texas Secondary Students Who Reported They Normally Consumed Five or More Drinks at One Time, by Gender: 2000–2012 Liu, L. Texas School Survey of Substance Use Among Students in Grades 7-12, DSHS.

9. Hutton, H. et al., (2008). The Relationship Between Recent Alcohol Use and Sexual Behaviors: Gender Differences Among Sexually Transmitted Disease Clinic Patients, Alcoholism: Clinical and Experimental Research Females and Drinking • Rates of STD higher for Texas females than males until they reach age 45+ (DSHS). • Women who binge drink have higher rates of STDs and more partners. Interventions should address binge drinking and risky sexual behaviors (Hutton, 2008, ACER). • When women preparty or participate in drinking games, they consume fewer drinks than males but reach comparable BAC levels and experience same amount of consequences (Hummer et al., RSA, 2012).

10. Percentage of Texas Seniors Who Had Driven While Drunk or High from Drugs: 1990–2012 Of those who drove 1+ times after drinking and 1+ times high on drugs, 50% did both Source: DSHS

11. 2007 National Roadside Survey: Prevalence of Drugs with Oral Fluid

12. Items Identified by Toxicology Laboratories: NFLIS 2004-2012 Source: DEA NFLIS

13. Average Purity of Heroin Samples in the US: 2003-2011 DEA’s Heroin Domestic Monitor Program

14. Mexican Black Tar Heroin Mexican Brown Heroin Mexican White Heroin South American Heroin

15. Heroin • Almost all heroin in the U.S. is from Mexico or South America. • East of the Mississippi, white South American heroinand in West , Mexican heroin, but seeing Black Tar move eastward and into the South, while South American now seen in Chicago and St Louis. • Number of U.S. heroin treatment admissions under age 25 increased from 16,357 in 1992 to 57,060 in 2010. • Reports of increasing heroin use among suburban youth and young users in Austin and in the US. • Harm Reduction Kits and wound/abscess care

16. Average Age of Persons Dying with Mention of Heroin in Texas: 1992-2011 Source: DSHS

17. *Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org **no data available for FY 2000-2001 Heroin-Related Deaths, San Francisco: 1993-2010 Naloxone distribution begins, 2003

18. Other Opiates Shifting back and forth between Rx opiates and heroin. Which came first? More research needed. Cost difference? In Texas, heroin cap is $10-$20 vs. $1/mg for 72 mg OxyContin and impact of “abuse resistant” formulations. Some injection drug users report prescription opiate use predates heroin use and tolerance motivates them to try heroin. But other reports of those who became addicted to prescription opiates and when controls were tightened, then shifted to heroin. Pollini et. Al., Problematic use of prescription-type opioids prior to heroin use among young heroin injectors. Substance Abuse and Rehabilitation 2011: 2 173-180, Lankenau SE, et al. (2012). Initiation into prescription opioid misuse amongst young injection drug users. Int J Drug Policy. 2012 Jan;23(1):37-44. Epub 2011 Jun 20.

19. Change in Rates of ED Visits for Misuse or Abuse: DAWN 2004-2011 *Increase in CNS Stimulants is among adults over 18 using ADHD stimulants

20. Texas Heroin and Other Opiate Admissions by Age Group: 2005-1/2 2012 Heroin Other Opiates Source: DSHS

21. Number of Drug Poisoning Deaths: United States, 1999--2010 NOTES: Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm

22. Drug poisoning death rates by age: United States, 1999-2010 6 5 4 3 2 1 CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm

23. Nonmedical Use of Pain Relievers: NSDUH 2011

24. “SYRUP” in Texas • Codeine cough syrup continues to be abused. • Cut with Karo syrup, jolly ranchers, and soft drink. • Rap music on syrup continues. • Prepackaged to introduce to youths or ready to add the syrup?

25. Pharmacologic Treatments for Alcohol and Opiates Naloxone/Narcan for opiate overdoses Opiates: Naltrexone (Revia)-1 pill per day Depo-Naltrexone (Vivitrol)-injected every 30 days. Methadone-daily oral dose Buprenorphine—daily pill or film • Duo (Suboxone-film buprenorphine + naloxone • Mono (was Sububex but now generic) Alcohol Naltrexone (Revia) 1 pill per day Depo-Naltrexone (Vivitrol)-injected every 30 days. Acamprosate (Campral)-1pill 3x/day Disulfiram (Antabuse)-1 pill/day. Drugs targeting cocaine and methamphetamine under development

26. Cocaine: What’s going on? • Poison control, treatment, deaths, & tox lab indicators down nationwide; price up. • Amount of coca under cultivation in South America is down 15% • Demand in Europe for cocaine. • Use of Levamisole as a filler with serious medical consequences. • Users in Austin report it is so weak “not worth paying for”. • Vitamin C vs. lemon juice & safe smoke kits

27. Global Cocaine Flows: 1998cocaine consumption in metric tons 267 63 267

28. Global Cocaine Flows: 2009cocaine consumption in metric tons 123 157

29. New Problems with Cocaine • Levamisole is cancer medication also used in de-worming animals. • Found in almost 100% of all cocaine now—added in South America. • Can result in agranulocytosis (discoloration of skin, beginning in ears—sign of skin cell death) • Results in neutropenia (bone marrow does not make enough white blood cells)

30. Marijuana Blunts--Impact of new way of using cannabis What will happen with medical marijuana and legalization?

31. % Texas Secondary Students Who Had Used Marijuana in the Past Month, by Ethnicity: 1990-2012 Source: DSHS

32. Monitoring the Future Survey: 1991-2012: Marijuana Use by 12th Graders

33. Consequences of Marijuana Abuse Acute (present during intoxication) • Impairs short-term memory • Impairs attention, judgment, and other cognitive functions • Impairs coordination and balance • Increases heart rate • Psychotic episodes Persistent (lasting longer than intoxication, but may not be permanent) • Impairs memory and learning skills • Sleep impairment

34. Long-Term Cumulative Effects of Chronic Abuse • Can lead to addiction • Increases risk of chronic cough, bronchitis • Increases risk of schizophrenia in vulnerable individuals • Age of onset of cannabis use directly associated with age at onset of psychosis and age of first hospitalization. • May increase risk of anxiety, depression, and amotivational syndrome • New finding suggesting neurotoxic effect of cannabis on the adolescent brain and cessation did not fully restore functioning. National Institute on Drug Abuse, Research Report Series, Marijuana Abuse, updated 9/2010. Galvez-Buccollini et al., Association between age at onset of psychosis and age at onset of cannabis use in non-affective psychosis. Schizophrenia Research, 139 (1), 157-160, 2012;Meier; Caspi, Ambler et al., Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences, published ahead of print, August 27, 2012.

35. www.nida.nih.gov/ResearchReports/Marijuana/default.htmlAnother Excellent ResourceNational Cannabis Prevention and Information Centrehttp://ncpic.org.au.

36. SPICE SYNTHETIC CANNABIS

37. Cannabis vs. Cannabinoids: Clinical Cases Most symptoms are similar to cannabis intoxication • Tachycardia • Reddened eyes • Anxiousness • Mild sedation • Hallucinations, acute psychosis • Memory deficits Symptoms not typically seen after cannabis intoxication • Seizures • Hypokalemia (low potassium level) • Hypertension (high blood pressure) • Nausea/vomiting • Coma • Agitation, violent behavior • Acute kidney injury • Some batches may have longer half-lives leading to prolonged psychoactive effect. Schneir 2012 J Med Tox; Rosenbaum et al. 2012 J Med Chem; Forrester et al. 2011 J Add Dis; Hermanns-Clausen et al. 2012 Addiction; MMWR 62(06);93-98, 2/15/13.

38. Cannabinoids Identified in U. S. NFLIS Toxicology Labs 44 variations reported in 2011 19 variations reported in 2010 55 variations reported in 2012 SOURCE: National Forensic Laboratory Information System, 2010, 2011, 2012

39. Timeline • JWH-018/073 arrived early and have come and gone. • JWH-250 arrived a little later and has also cycled out. • JWH-081 was part of a second wave that has already completed its cycle. • JWH-122 was part of the same wave but has persisted in popularity and is part of the current scene. • AM-2201 was part of the same second wave and has gained in popularity, probably currently the most prevalent. • JWH-022 and JWH-210 are showing signs of increasing popularity. • Recent emergent drugs are the adamantoyl (AM-1248) and tetramethylcyclopropyl (XLR-11 and UR-144) indoles which are ahead of the latest attempts to schedule these drug classes. Source: B. K. Logan, Testing Strategies to Monitor Novel/Emerging/Designer Drug Use in At-Risk Populations, CPDD 2012

40. Texas Poison Control Exposures and Effect of Controls Synthetic Cannabis Synthetic Cathinones SOURCE: Forrester, M.B. (2013). Synthetic Cannabinoids (Marijuana Homologs) 2013 and Synthetic Cathinones (Bath Salts) Reported to the Texas Poison Control Network Update, March 1, 2013.

41. Amphetamine-Type Stimulants:MDMA, Khat, Meth, Amphet, Synthetic Cathinones An Emerging Liking for Speedy or Upper Drugs?

42. Comparison of Amphetamine and Methamphetamine Indicators in Texas 2011 Source: DSHS and NFLIS

43. Median Methamphetamine Purity in the Continental United States (1985-2005) Meth trends are cyclical Impact of US and Canadian precursor regulation on methamphetamine purity in the United States. (Cunningham JK, Liu L-M, Callaghan R. Addiction; 104, 441-453, 2009.

44. All Methamphetamine Purchases Domestic STRIDE DataJanuary 2007 –June 2012 From July 2007 through June 2012, the price per pure gram of Methamphetamine decreased 72%, from $288.69 to $81.29, while the purity increased 128%, from 41% to 93%.

45. Different Manufacturing Processes I. Ephedrine/Pseudoephedrine Based (d-form): A. “Nazi Method”-lithium, anhydrous ammonia B. Cold method-red phosphorus, iodine crystals C. “One Pot” and “Shake and Bake” cooking using dry ammonia nitrite and cough syrup rather than liquid anhydrous ammonia. II. P2P/Phenylacetone (Illegal in US-Schedule II, precursor legal in Mexico) (l and d,l-forms). If drug is 100% potent, it’s all d-form. If 0% potent, is all l-form. Mexican chemists are refining their process to produce more potent P2P meth.

46. DEA Methamphetamine Profiling Program: 2010-4th Q 2012 Source: DEA

48. Meth in Austin Now • Crystal is back and easy to get. • Injecting meth is more socially acceptable than in the past. • Seems more centered in a closed MSM population. • Users reporting better highs, more psychosis—IS METH PROBLEM GETTING WORSE?

49. Glimpses of MDMA Situation: 1999-1/31/13 • Australian EDRS reports drop in MDMA use from 52% in 2003 to 27% in 2011 and up to 32% in 2012. • Both Australia and UK reported MDMA “drought”. • Shift from PMK to safrole to make MDMA. • Predictions of return of high quality MDMA but from China, not BeneLux sources. *http://www.ecstasydata.org/stats_substance_by_year.php

50. Emerging Psychoactive Drugs in Texas Psychedelics Stimulants