1 national estimates from the drug abuse warning network capt kathy poneleit united states public...
TRANSCRIPT
1
National Estimates from the
Drug Abuse Warning Network
CAPT Kathy PoneleitUnited States Public Health Service
Office of Applied StudiesSubstance Abuse & Mental Health Services
AdministrationNovember 13, 2008
http://DAWNinfo.samhsa.gov
2
SAMHSA/OAS
Today's Agenda
No conflicts of interest
Overview of DAWN Key findings from 2007
– Nonmedical use of opiates/opioids– 2004-2007 comparisons– Extended- vs. immediate-release oxycodone– Extended- vs. immediate-release morphine
3
SAMHSA/OAS
DAWN Survey Design
Stratified probability sample of hospitals– Short-term, general, non-Federal hospitals
with 24-hour emergency departments (EDs)
National estimates account for:– Sample design– Unit nonresponse– Partial nonresponse in responding hospital
4
SAMHSA/OAS
National EstimatesOversample areas (urban) +Remainder area (urban & rural)
5
SAMHSA/OAS
Source of DAWN Estimates, 2004-2007
2004 2005 2006 2007
Eligible hospitals 4,505 4,549 4,568 4,575
Sample of hospitals 556 562 544 542
Responding hospitals 220 224 205 207
Response rate 39.6 39.9 37.7 38.2
Drug-related ED visits 2,537,722 3,009,025 3,441,855 3,998,228
Drugs reports 4,047,135 4,624,455 5,384,817 6,247,718
6
SAMHSA/OAS
DAWN Data Collection: Retrospective Review of Medical Records
Source: DAWN, 2007 data, 11/11/2008
National estimates
Charts reviewed 10,038,897
Cases found 375,031Drug-related
ED visits reviewed
ED visits not reviewed
7
SAMHSA/OAS
Analysis Domains
Drug-relatedED visits
Medical use Nonmedical use
Pharmaceuticals
Illicit drugs
Alcohol
Pharmaceuticals
8
SAMHSA/OAS
Definition: Nonmedical Use of Pharmaceuticals
Based on retrospective chart review– Exceeded prescribed or recommended dose– Used drugs prescribed for another– Malicious poisoning– Substance abuse
– Excludes drug-related suicide attempts– Includes suicide ideation, plan, gesture
9
SAMHSA/OAS
Drug-Related ED Visit Rates, 2004-2007
0
200
400
600
800
1,000
1,200
1,400
To
tal
Su
icid
e a
tte
mp
t
Se
ek
ing
de
tox
Alc
oh
ol
Illic
its
Ac
cid
en
tal
ing
es
tio
ns
Me
dic
al
us
e
No
me
dic
al
us
e
Mis
us
e/
ab
us
e
ED visits per 100K pop
Source: National estimates from DAWN, 2004-2007
No significant change *Significant change, 2004 vs. 2007
2005 vs. 2007
2006 vs. 2007
10
SAMHSA/OAS
Oxycodone
Controlled and Immediate Release
Oxycodone
Controlled and Immediate Release
11
SAMHSA/OAS
Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2007
16
66
30
77
58
8
49
9
95
51
83
23
0
10
20
30
40
50
60
70
80
90
100
Fentanyl* Hydrocodone* Morphine* Oxycodone*
Visits (thousands)
Source: National estimates from DAWN, 2007
* Single- & multi-ingredient formulations
CI lower bound
Estimate
CI upper bound
12
SAMHSA/OAS
Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2007
53
7
54
38
3
40
70
11
66
0
10
20
30
40
50
60
70
80
90
100
Opiates/opioidsnot specified
Buprenorphine*
Methadone
Visits (thousands)
Source: National estimates from DAWN, 2007
* Single- & multi-ingredient formulations
CI lower bound
Estimate
CI upper bound
13
SAMHSA/OAS
Classification of Oxycodone Reports
Controlled release (CR)– OxyContin (99%)
Alternate terms:– Generic OxyContin– Teva OxyContin– Impax OxyContin– Oxycodone CR– Oxycodone ER– Oxycodone SR
Immediate release (IR)– acetaminophen-oxy
e.g., Percocet (92%)
– aspirin-oxye.g., Percodan
– ibuprofen-oxye.g., Combunox
– oxycodonee.g., Roxicodone
14
SAMHSA/OAS
Classification of Oxycodone Reports (cont'd)
Unknown release type (UK)– Oxycodone (95%)
alternate terms: – Free oxycodone– M-Oxy– Oxycodone hydrochloride– Oxycodone metabolites
15
SAMHSA/OAS
Nonmedical Use of Pharmaceuticals, Oxycodone, by Release Type, 2004-2007
21
25
141517
19
12
18
22
35
10
28
35
1922
24 26
18
2529
58
14
30
35
46
24
31 33
25
3337
8
11
19
0
5
10
15
20
25
30
35
40
45
50
2004 2005 2006 2007 2004 2005 2006 2007 2004 2005 2006 2007
Visits (thousands)
Source: National estimates from DAWN, 2004-2007
CI lower bound
Estimate
CI upper bound
ControlledControlled ImmediateImmediate
UnknownUnknown
16
SAMHSA/OAS
Oxycodone, CR vs. IR – All Visits
40 39
9
41
51
16
43
62
29
51
41
78
0
10
20
30
40
50
60
70
80
Controlled Immediate Unknown
Thousands
Source: DAWN estimates for the U.S., 2004-2007
*Significant change, 2004 vs. 2007
2005 vs. 2007
2006 vs. 20072006 vs. 2007
No significant changeNo significant change
2004
2004 20
0520
05 2006
2006 20
0720
07
17
SAMHSA/OAS
Oxycodone, CR vs. IR – Medical Use
3
13
26
19
56
23
99
16
31
0
10
20
30
40
50
60
70
Controlled Immediate Unknown
Thousands
Source: DAWN estimates for the U.S., 2004-2007
*Significant change, 2004 vs. 2007
2005 vs. 2007
2006 vs. 20072006 vs. 2007
No Significant changeNo Significant change
2004
2004
2005
2005
2006
2006
2007
2007
18
SAMHSA/OAS
Oxycodone, CR vs. IR – Nonmedical Use
2218
5
24 25
8
2629
14
28
19
35
0
10
20
30
40
50
60
70
Controlled Immediate Unknown
Thousands
Source: DAWN estimates for the U.S., 2004-2007
*Significant change, 2004 vs. 2007
2005 vs. 2007
No significant changeNo significant change
2006 vs. 20072006 vs. 2007
2004
2004
2005
2005
2006
2006
2007
2007
19
SAMHSA/OAS
Oxycodone, CR vs. IR
53%46% 40% 36%
16% 20% 18% 17%
44%48%
45%46%
72%66% 56%
15%22% 25%
13%30%
0%
66%
25%12% 17%
0%
20%
40%
60%
80%
100%
2004 2005 2006 2007 2004 2005 2006 2007
UK
CR
IR
Source: DAWN estimates for the U.S., 2004-2007
% of visits Nonmedical use Medical use
20
SAMHSA/OAS
Nonmedical Use: Hydrocodone and Oxycodone by Release Type, 2004-2007
22 24 26 28
1825
29355
8
14
19
0
10
20
30
40
50
60
70
80
90
2004 2005 2006 2007
Thousands
Source: DAWN estimates for the U.S., 2004-2006
Hydrocodone
UK
ERIR
Oxycodone:
21
SAMHSA/OAS
Nonmedical Use: All Opiates/Opioids, ED Visit Rates, 2007
0
25
50
75
100
125
150
175
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
22
SAMHSA/OAS
Nonmedical Use: All Hydrocodone, ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
23
SAMHSA/OAS
Nonmedical Use: All Oxycodone, ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
24
SAMHSA/OAS
Nonmedical Use: Oxycodone CR,ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
25
SAMHSA/OAS
Nonmedical Use: Oxycodone IR,ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
26
SAMHSA/OAS
Nonmedical Use: Oxycodone UK,ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
27
SAMHSA/OAS
Nonmedical Use: Disposition from ED,Oxycodone by Release Type, 2007
Source: DAWN estimates for the U.S., 2007
% of ED visits
Controlled UnknownImmediate
Some follow-up
No evidenceof follow-upcare
28
SAMHSA/OAS
Nonmedical Use: Number of Drugs,Oxycodone by Release Type, 2007
Source: DAWN estimates for the U.S., 2007
% of ED visits
Controlled UnknownImmediate
1 drug
Multipledrugs
29
SAMHSA/OAS
Nonmedical Use ED Visits: Conclusions
Opioid analgesics nearing 287,000 visits– ¼ Oxycodone ¼ Hydrocodone– in immediate and unknown release types
Highest visit rates in patients aged 21-54 Majority of patients treated and released Polydrug use was higher for immediate
versus controlled release
30
SAMHSA/OAS
MorphineControlled and Immediate Release
MorphineControlled and Immediate Release
31
SAMHSA/OAS
Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2007
16
66
30
77
58
8
49
9
95
51
83
23
0
10
20
30
40
50
60
70
80
90
100
Fentanyl* Hydrocodone* Morphine* Oxycodone*
Visits (thousands)
Source: National estimates from DAWN, 2007
* Single- & multi-ingredient formulations
CI lower bound
Estimate
CI upper bound
32
SAMHSA/OAS
Classification of Morphine Reports
Controlled release (CR)– MS Contin (71%)
Alternate terms:– Avinza– Kadian– Morphine Sulfate SR– Oramorph SR– Morphine Extended
Release– Morphine Patches
Immediate release (IR)– Morphine Sulfate– Morphine Pill– Morphine IR– Morphine Rapi-Ject– Roxanol– Morphelan
33
SAMHSA/OAS
Nonmedical Use of Pharmaceuticals, Morphine, by Release Type, 2004-2007
5 56
9
1316
23
3
11
644323
3
44
2021
15
97
37
0
5
10
15
20
25
30
35
40
45
2004 2005 2006 2007 2004 2005 2006 2007
Visits (thousands)
Source: National estimates from DAWN, 2004-2007
CI lower bound
Estimate
CI upper bound
ControlledControlled ImmediateImmediate
34
SAMHSA/OAS
Morphine, CR vs. IR – All Visits
7
15
6
23
8
27
10
39
0
5
10
15
20
25
30
35
40
45
50
Controlled Immediate Unknown
Thousands
Source: DAWN estimates for the U.S., 2004-2007
*Significant change, 2004 vs. 2007
2005 vs. 2007
2006 vs. 20072006 vs. 2007
No significant changeNo significant change
2004
2004 20
0520
05 2006
2006 20
0720
07
35
SAMHSA/OAS
Morphine, CR vs. IR – Medical Use
1 436
27
3
10
0
10
20
30
40
50
60
70
Controlled Immediate Unknown
Thousands
Source: DAWN estimates for the U.S., 2004-2007
*Significant change, 2004 vs. 2007
2005 vs. 2007
2006 vs. 20072006 vs. 2007
No Significant changeNo Significant change
36
SAMHSA/OAS
Morphine, CR vs. IR – Nonmedical Use
59
3
13
5
16
6
23
0
10
20
30
40
50
60
70
Controlled Immediate Unknown
Thousands
Source: DAWN estimates for the U.S., 2004-2007
*Significant change, 2004 vs. 2007
2005 vs. 2007
No significant changeNo significant change
2006 vs. 20072006 vs. 2007
37
SAMHSA/OAS
Morphine, CR vs. IR
34%
16%23% 22%
30% 31%24% 22%
67%
83%77% 79%
71% 68%78% 79%
0%
20%
40%
60%
80%
100%
2004 2005 2006 2007 2004 2005 2006 2007
UK
CR
IR
Source: DAWN estimates for the U.S., 2004-2007
% of visits Nonmedical use Medical use
38
SAMHSA/OAS
Nonmedical Use: Hydrocodone and Morphine by Release Type, 2004-2007
5 3 5 69 13
1623
0
10
20
30
40
50
60
70
80
90
2004 2005 2006 2007
Thousands
Source: DAWN estimates for the U.S., 2004-2006
Hydrocodone
UK
CRIR
Morphine:
39
SAMHSA/OAS
Nonmedical Use: All Morphine, ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
40
SAMHSA/OAS
Nonmedical Use: Morphine CR,ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
41
SAMHSA/OAS
Nonmedical Use: Morphine IR,ED Visit Rates, 2007
0
10
20
30
40
50
60
Mal
e
Fem
ale .
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-4
4
45-5
4
55-6
4
65+
ED visits per 100K population
Age
Source: DAWN estimates for the U.S., 2007
42
SAMHSA/OAS
Nonmedical Use: Disposition from ED,Morphine by Release Type, 2007
Source: DAWN estimates for the U.S., 2007
% of ED visits
Controlled UnknownImmediate
Some follow-up
No evidenceof follow-upcare
43
SAMHSA/OAS
Nonmedical Use: Number of Drugs,Morphine by Release Type, 2007
Source: DAWN estimates for the U.S., 2007
% of ED visits
Controlled UnknownImmediate
1 drug
Multipledrugs
44
SAMHSA/OAS
Nonmedical Use ED Visits: Conclusions
Morphine related ED visits nearing 30,000– Immediate release – Controlled release is similar 2004-2007
Highest visit rates in patients aged 21-54 Majority of patients treated and released Polydrug use is typical
45
SAMHSA/OAS
Important Considerations:DAWN Depends on ED Medical Records
Link between ED visit and use of drug Dose levels and source of drug unavailable Nonspecific drug reports
– Opiates/opioids, unspecified (unnamed)– Unknown release-type
Unique names for immediate versus extended release enable better surveillance
46
SAMHSA/OAS
Acknowledgements
Rong Cai, Statistician