Pharmaceutical Abuse Trends in Maine

Margaret Greenwald, MDMaine Chief Medical Examiner &Marcella H. Sorg, PhDMargaret Chase Smith Policy CenterUniversity of Maine

Rx Drug Summit 2011

Drug-Induced Mortality Patterns:Canary in the Coal Mine

Margaret Greenwald, MDMaine Chief Medical Examiner

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Perspective

• Over 10 years of drug related death analysis and data collection

• Increases began 1999-2000 reaching current levels around 2002 at time first published data

• Early identification of now well documented nationwide epidemic of prescription drug abuse

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SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Drug Death Investigation• Determination of cause of death is complicated, time consuming,

and a significant strain on the resources of the OCME• Victims often have combination of chronic diseases as well as

multiple opiate and other pain relievers, antidepressants, and benzodiazepines

• Police officers document scene, inventory all drugs (requires counting of all pills) and provide information about circumstances

• Autopsy findings, medical history, and toxicology drug levels are compared to PMP, Drug Inventory and investigative information – Access to PMP (Prescription Monitoring Program) though extremely

helpful is a recent tool

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Rx Drug Summit 2011

SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

(OPIOID)

(OPIOID)

(OPIOID)

(BENZODIAZEPINE)

Drug Patterns Change • Since 2002, drug deaths numbers have

remained relatively stable, but the involved drugs have changed.

• As prescribing patterns have been modified to try to minimize abuse, the drugs involved in the deaths have reflected the most widely available opiate/ opioid

• The following graph illustrates using the changing frequency of methadone and oxycodone involved in the deaths

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Rx Drug Summit 2011

SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Case Example Illustrates Complexity• A young woman in her late 20s with history of chronic

pain syndrome, PTSD, and ‘panic attacks’• Prescriptions: oxycodone, fentanyl patches, alprazolam

(Xanax), lexapro• Most recent prescriptions were 2 weeks prior to death

for 10 fentanyl patches, 180 oxycodone, 90 alprazolam• Lived with 3 children and boyfriend• History: Boyfriend admitted that on night of death they

supposedly smoked marijuana together, then she crushed and snorted her Xanax (prescribed) and some street methadone (diverted)

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Investigation• Autopsy: Two fentanyl patches present• Toxicology: alprazolam (prescribed), fentanyl (prescribed),

clonazepam (diverted), methadone (diverted), amphetamine (diverted), and citalopram/lexapro (prescribed)

• Scene Investigation: no oxycodone, empty container of alprazolam. Plate with crushed pills was accessible to children

• More investigation: Father of 11 year old came to pick up son and meds. Called PD and indicated something wrong with son’s medications (Adderall) –capsules empty

• PMP: early refills on alprazolam• Comment: A urine screen by prescriber might have shown

absence of oxycodone, presence of methadone and possibly presence of amphetamine

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Observations• Drug death investigations (one small component of

this epidemic) have strained resources at our office and for law enforcement

• Health care practitioners are also feeling stress as they try to figure out how to adequately diagnose and treat chronic pain without having to constantly police their patients to prevent abuse .

• Tools such as PMP, narcotic contracts, drug screening are all good to identify abuse, but do not prevent it.

• Practitioners need community support, skills and strategies to deal with those patients who cannot or will not comply

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Maine Pharmaceutical Abuse: Deaths, Treatment, & Crime

Marcella H. Sorg, PhD, D-ABFADirector, Rural Drug & Alcohol Research Program

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SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Accidents

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SOURCE: OFFICES OF CHIEF MEDICAL EXAMINER IN MAINE, NEW HAMPSHIRE AND VERMONTANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

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SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Opioids =72% of2010 deaths

Oxycodone Deaths 2010 (N=49)

• 7 (oxycodone alone)• 10 (plus 1 or 2 other opioids)• 11 (plus 1 or 2 benzodiazepines)• 9 (plus 1 or 2 opioids & 1 or 2 benzodiazepines)• 2 (plus 1 or 2 benzodiazepines & alcohol)• 3 (plus 1 or 2 opioids & alcohol)• 5 (plus alcohol)• 2 (plus some other drug)

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SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

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DATA SOURCE: Maine Health & Environmental Testing LabANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

DATA SOURCE: Maine Health & Environmental Testing LabANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

DATA SOURCE: Maine Health & Environmental Testing LabANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINERANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

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SOURCE: MAINE OFFICE OF SUBSTANCE ABUSE, PRESCRIPTION MONITORING PROGRAMANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

SOURCE: Maine Office of Chief Medical ExaminerANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine

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DATA SOURCE: Maine Office of Substance AbuseANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine

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DATA SOURCE: Maine Drug Enforcement AgencyANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

42% in 2011 through Sept.

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DATA SOURCE: Maine Drug Enforcement AgencyANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

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Ranked Law Enforcement Seizures Jan-May 2011

SOURCE: Health & Environmental Testing LabANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

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DATA SOURCE: Maine Office of Substance AbuseANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

DATA SOURCE: Maine Office of Substance AbuseANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE

Rx Drug Summit 2011

DATA SOURCE: Maine Office of Substance AbuseANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine

Overdoses Are Just the Tip of a Very Large Societal Iceberg of Substance Abuse

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Deaths

CrimeAddiction

Medical CostsLost Productivity

What We Know: Mortality• Pharmaceutical death numbers are staying high:

97% of drug deaths– Most have combination of drug types:

• Opiates/opioids (74%)• Benzodiazepines (34%)• Antidepressants (35%)• Muscle relaxants (9%)• Diphenhydramine (Benadryl) (7%)

– Alcohol is a co-intoxicant in 22% of drug deaths– Most opioid deaths involve oxycodone (29%),

methadone (30%) morphine (10%) hydrocodone (10%), tramadol (7%), fentanyl (6%)

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What We Know: Arrests

• Arrests for pharmaceuticals are increasing, 43% of 2010 MDEA drug arrests– Many involve a combination of drug types: (most

frequent: opioids (38% in 2010)– Heroin (5%) and cocaine (22%) involvement

decreased, but still important; traffickers have combination illicits & pharmaceuticals

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What We Know: Treatment

• Treatment admissions for pharmaceuticals; primary opioid admissions were 34% of admissions

• Admissions include problems at the secondary and tertiary levels involving other drugs

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What We Know: Supply

• The supply of scheduled drugs tracked by the PMP from legitimate prescriptions has increased every year since SFY2004

• Many pharmaceuticals are unused each year and remain unsecured in households.

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What we don’t know

• Magnitude of drug-related crimes (beyond trafficking and possession), e.g., pharmaceutical robberies, burglaries, gun trafficking

• Amount of surplus in our pharmaceutical dispensing systems

• Amount of illegal internet sales• Which state has the “worst” problem

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Summary• Maine pharmaceutical abuse is getting worse• Supplies of pharmaceuticals increasing from both

legitimate and illicit sources, including unused drugs many households

• Consequences are impacting public safety and public health: arrests, addiction treatment, ER visits, impaired driving, and deaths

• Policy solutions need to be multi-faceted, addressing addiction risks and treatment, prescribing, drug supply, drug trafficking, and the need to monitor trends across public health and public safety arenas

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Thank you

• This research was funded in part by: – US Dept. of Justice/Bureau of Justice

Assistance– US Dept. of Justice/Offices of the United

States Attorneys– National Institute on Drug Abuse/CEWG

Rx Drug Summit 2011