Substance Abuse Trends:Old and New Drugs

Jane Maxwell, Ph.D.Addiction Research Institute

Center for Social Work ResearchThe University of Texas at Austin

3-6%

1-2%

11-14%

Percentage of Drug Items Identified as Heroin by Tox Labs: NFLIS 2010

7-10%

15-16%

<1%

30-44%

11-15%

16-19.%

5-9%

Percentage of Drug Items Identified as Cocaineby Tox Labs: NFLIS 2010

20-29%

<5%

5-8%

1-3%

17-24%

Percentage of Drug Items Identified as Methamphetamine by Tox Labs: NFLIS 2010

11-14%

25-34%

0%

Heroin34%

Heroin3%

Cocaine42%

Cocaine32%

Cocaine29%Cocaine

13%

Heroin9%

Cocaine6%

Cocaine3%

Heroin25%

Cocaine7%

Heroin10%

Meth8%

Cocaine17%

Heroin11%

Meth9%

Meth17%

Meth27%

Meth13%

Meth25%

Heroin16% Heroin

13%

Primary Drug of Abuse at Admission to Treatment: 2009

SISVEA & TEDS

Cocaine8%

Cocaine14% Meth

1%Meth2% Heroin

1%

Heroin8%

Meth4%

Meth1%

* ALCOHOL USE BY YOUNG WOMEN

* DRUGGED DRIVING

QUICK SNAPSHOT OF PROBLEMS TO BE ADDRESSED

Percentage of Texas Secondary Students Who Reported They Normally Consumed

Five or More Drinks at One Time, by Gender: 2000–2012

2000 2002 2004 2006 2008 2010 20120%

5%

10%

15%

20%

25%

30%

35%

22% 22%20%

18% 18% 17% 16%

32%30%

26%24% 23% 22%

20%

Girls Boys

Liu, L. Texas School Survey of Substance Use Among Students in Grades 7-12, DSHS.

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).

Percentage of Texas Seniors Who Had Driven While Drunk or High from

Drugs: 1990–2012

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

0%

5%

10%

15%

20%

25%

30%

35%29%

15%

11%

16%

Driving While Drunk Driving While High From Drugs

Source: DSHS

Of those who drove 1+ times after drinking and 1+ times high on drugs, 50% did both

2007 National Roadside Survey: Prevalence of Drugs with Oral Fluid

Illegal BAC (alcohol)

THC

Narcotic Analgesics

Sedatives

Stimulants

Overall Drug Positive

0 10 20

0

2

2

2

2

11

2

6

2

1

3

14Night Day

PercentNHTSA Traffic Safety Facts, July & December 2009, DOT HS 811 175 & 249

Items Identified by Toxicology Laboratories: NFLIS 2004-2012

2004 2005 2006 2007 2008 2009 2010 2011 20120

5

10

15

20

25

30

35

40

CannabisCocaineMethamphetamineHeroin

Source: DEA NFLIS

Average Purity of Heroin Samples in the US: 2003-2011

Southeast Asian Southwest Asian Mexican South American0%

10%

20%

30%

40%

50%

2003 2004 2005 2006 2007 2008 2009 2010 2011

DEA’s Heroin Domestic Monitor Program

Mexican Black Tar Heroin

Mexican Brown Heroin

Mexican White Heroin

South American Heroin

Heroin• Almost all heroin in the U.S. is from Mexico or South

America. • East of the Mississippi, white South American heroin

and 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

Average Age of Persons Dying with Mention of Heroin in Texas: 1992-2011

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

31

32

33

34

35

36

37

38

39

40

41

37

39 38 3838

40

3738

38

39 39 39 3940 39

37

40

3635

34

Age

(Yea

rs)

Source: DSHS

*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org **no data available for FY 2000-2001

1993-1994

1994-1995

1995-1996

1996-1997

1997-1998

1998-1999

1999-2000

2002-2003

2003-2004

2004-2005

2005-2006

2006-2007

2007-2008

2008-2009

2009-2010

0

20

40

60

80

100

120

140

160Naloxone distribution begins, 2003

Heroin-Related Deaths, San Francisco: 1993-2010

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.

Change in Rates of ED Visits for Misuse or Abuse: DAWN 2004-2011

Hydrocodone

Oxycodone

Methadone

Alprazolam

Zolpidem (Ambien, etc.)

Muscle Relaxants

Marijuana

Central Nervous System Stimulants*

0% 50% 100% 150% 200% 250% 300% 350%

96%

220%

74%

155%

152%

71%

86%

292%

*Increase in CNS Stimulants is among adults over 18 using ADHD stimulants

Texas Heroin and Other Opiate Admissions by Age Group: 2005-1/2 2012

Heroin

2005

2006

2007

2008

2009

2010

2011

2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

50+40s30s20sU20

Other Opiates

2005

2006

2007

2008

2009

2010

2011

2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

50+40s30s20sU20

Source: DSHS

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

2,000

4,000

6,000

8,000

10,000

12,000

Natural and semi-synthetic opioid analgesic Methadone

Cocaine Heroin

Synthetic opioid analgesic, excluding methadone

Num

ber o

f dea

ths

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

Drug poisoning death rates by age: United States, 1999-2010

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

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

30

15-24 years 25-34 years 35-44 years 45-54 years55-64 years 65 years and over

Dea

ths

per 1

00,0

00 p

opul

atio

n

BABY BOOMERS

1

2

3

4

5

6

Nonmedical Use of Pain Relievers: NSDUH 2011

All Ages 50-54 55-59 60-64 65 or Older

0

2

4

6

8

10

12

14

16

1314

12

6

34

3 21 1

2 1 1 1 0

LifetimePast YearPast MonthPe

rcen

t

“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?

Pharmacologic Treatments for Alcohol and Opiates

Naloxone/Narcan for opiate overdosesOpiates:

Naltrexone (Revia)-1 pill per dayDepo-Naltrexone (Vivitrol)-injected every 30 days. Methadone-daily oral doseBuprenorphine—daily pill or film

• Duo (Suboxone-film buprenorphine + naloxone• Mono (was Sububex but now generic)

Alcohol Naltrexone (Revia) 1 pill per dayDepo-Naltrexone (Vivitrol)-injected every 30 days. Acamprosate (Campral)-1 pill 3x/dayDisulfiram (Antabuse)-1 pill/day.

Drugs targeting cocaine and methamphetamine under development

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

Global Cocaine Flows: 1998cocaine consumption in metric tons

26763

267

Global Cocaine Flows: 2009cocaine consumption in metric tons

157123

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)

Marijuana

• Blunts--Impact of new way of using cannabis

• What will happen with medical marijuana and legalization?

% Texas Secondary Students Who Had Used Marijuana in the Past Month, by

Ethnicity: 1990-2012

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

0%

5%

10%

15%

20%

25%

Anglos

African Americans

Hispanics

Source: DSHS

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

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

0102030405060708090

100

% Used in Past Year% Great Risk in Using% Strongly Disapprove of Use% Easy or Very Easy to Get

Consequences of Marijuana AbuseAcute (present during intoxication)• Impairs short-term memory• Impairs attention, judgment, and other cognitive

functions• Impairs coordination and balance• Increases heart rate• Psychotic episodesPersistent (lasting longer than intoxication,

but may not be permanent)• Impairs memory and learning skills• Sleep impairment

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.

www.nida.nih.gov/ResearchReports/Marijuana/default.html

Another Excellent Resource

National Cannabis Prevention and Information Centre

http://ncpic.org.au.

SPICE

SYNTHETIC CANNABIS

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.

Cannabinoids Identified in U. S. NFLIS Toxicology Labs

JWH-018 64%JWH-073 ; 9%

JWH-081 ; 6%

JWH-250 ; 14%

19 variations reported in 2010

AM-2201 35%

JWH-01816%

JWH-081 6%

JWH-12213%

JWH-210 9%

SYNTHETIC CANNABINOID

7%

44 variations reported in 2011

AM-220141%

6%

SYNTHETIC CANNABINOID

MAM-2201 4%

UR-144 13%

XLR-1114%

55 variations reported in 2012

SOURCE: National Forensic Laboratory Information System, 2010, 2011, 2012

• 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

Timeline

Texas Poison Control Exposures and Effect of Controls

Synthetic Cannabis

0

20

40

60

80

100

Synthetic Cathinones

Jan 1

0Apr Ju

lOct

Jan 1

1Apr Ju

l Oct

Jan 1

2Apr

Ju

lyOct Ja

n0

20

40

60

80

100

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.

Amphetamine-Type Stimulants:MDMA, Khat, Meth, Amphet, Synthetic

Cathinones

An Emerging Liking for Speedy or Upper Drugs?

Comparison of Amphetamine and Methamphetamine Indicators in Texas

2011

NFLIS Methamphetamine

NFLIS Amphetamine

Treatment Methamphetamine

Treatment Amphetamine

020

0040

0060

0080

0010

000

1200

014

000

11967

657

2441

2117

Source: DSHS and NFLIS

Median Methamphetamine Purity in the Continental United States (1985-2005)

Months

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Med

ian

Pur

ity

0

20

40

60

80

100

US ephedrine single ingredient

product regulation

US pseudoephedrineproduct regulation

US ephedrine andpseudoephedrine bulk

powder regulation US ephedrine combinationproduct regulation

Canada precursor import/export

regulation

Canada precursor domestic distribution regulation

Canada essential chemical regulation

US pseudoephedrine retail sales regulation

Overall

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.

Meth trends are cyclical

All Methamphetamine Purchases Domestic STRIDE Data

January 2007 –June 2012

Jan-M

ar07

Apr-Ju

n07

Jul-S

ep07

Oct-Dec

07

Jan-M

ar08

Apr-Ju

n08

Jul-S

ep08

Oct-Dec

08

Jan-M

ar09

Apr-Ju

n09

Jul-S

ep09

Oct-Dec

09

Jan-M

ar10

Apr-Ju

n10

Jul-S

ep10

Oct-Dec

10

Jan-M

ar11

Apr-Ju

n11

Jul-S

ep11

Oct-Dec

11

Jan-M

ar12

Apr-Ju

n12

$0

$50

$100

$150

$200

$250

$300

$350

0.00

20.00

40.00

60.00

80.00

100.00

$159

$227

$289$306

$245

$244

$199

$179$189

$139$140

$128$126$112$104

$98$105$93 $94 $86 $90

$81

59

45

41

4248

55 56

65 6772 74

77 82

88 88 90 90 92 90 91 92 93

76 66

64

7477 76 76

7580 83

88

Pric

e Pe

r Pur

e G

ram

Purit

y in

Per

cent

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%.

Different Manufacturing ProcessesI. Ephedrine/Pseudoephedrine Based (d-form):

A. “Nazi Method”-lithium, anhydrous ammoniaB. Cold method-red phosphorus, iodine crystalsC. “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.

DEA Methamphetamine Profiling Program: 2010-4th Q 2012

3&4

2008

1Q-1

0

3Q-1

0

1Q-1

1

3Q-1

1

1Q-1

20%

20%

40%

60%

80%

100%

Purity and PotencyPurity PotencyMSM

3&4Q

-06 2008

1Q-10

3Q-10

1Q-11

3Q-11

1Q-12

3Q-12

0%

20%

40%

60%

80%

100%

Production RoutesP2PPhosphorus Iodine

Source: DEA

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?

Glimpses of MDMA Situation: 1999-1/31/13

1999

2001

2003

2005

2007

2009

2011

2013

0102030405060708090

Results of Pill Tests Containing MDMA*

Any MDMA MDMA Only

•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

Emerging Psychoactive Drugs in Texas

Psychedelics

Stimulants

Examples of Major Psychedelic Drugs

DRUG NAME DESCRIPTION2C-I Phenethylamine, via PiHKAL; stimulant and

hallucinogenSlow onset (1 hr); long duration of action (8-10 hr.)

2C-B Phenethylamine, via PiHKAL; visualsFaster onset (1 hr.); shorter duration than 2C-I

5-MeO-DMT Tryptamine; naturally occurring (toad, shamantic brews)Smoked: almost immediate, very intense, short effect (<30 min)

DMT Tryptamine; naturally occurringSmoked: almost immediate, very intense, short effect (<20 min)

SOURCE: Slide courtesy of R. Bruno et al., Emerging psychoactive substance use, DAD, 2011, with revisions by James Hall, 2012.

2C-Phenethylamine• A broad range of compounds

that share a common phenylethan-2-amine structure.

• Some are naturally occurring neurotransmitters (Dopamine and Epinephrine), while others are psychoactive stimulants (amphetamine), entactogens (MDMA), or hallucinogens (the 2C-X series of compounds).

• 2 C-X can be snorted or dissolved into a liquid and placed on blotter paper under the tongue.

• May last 6-10 hours; onset takes 15-120 minutes.

• Reports of seizures and renal failure.

Source: Michigan Department of Community Health, Weekly Imminent Danger Notification Update Briefing-August 23, 2012

52

Examples of Major Stimulant Drugs/Synthetic Cathinones

DRUG NAME DESCRIPTIONMephedrone 4-methyl-methcathinone; “Miaow”

Similar to cocaine and MDMA (ecstasy)Methylone β-MDMA: 3,4-methylenedioxy-methcathinone;

“Explosion”Similar to cocaine and MDMA (ecstasy)

MDPV 3,4-methylenedioxyprovalerone; MDPV; “NRG-1” (Brandt, 2010); “Ivory Wave”Stimulant with rapid onset; 2-4 hour duration of action

BZP 1-benzyl-piperazoneSimilar to amphetamine1/10 potency of d-methamphetamine

SOURCE: Slide courtesy of R. Bruno et al., Emerging psychoactive substance use, DAD, 2011, with revisions by James Hall, 2012.

• Cathinone mimics the effects of the Khat Plant.• Could be 4-MMC, mephedrone, orover 37 other varieties.• Sold on-line with little info on ingredients, dosage, etc.• Advertised as Legal Highs, Legal Meth, Cocaine, or Ecstasy.• Taken orally or by inhaling.• Serious side-effects include tachycardia, hypertension,

confusion or psychosis, nausea, convulsions.*• Labeled “not for human consumption” to get around laws

prohibiting sales or possession.• Austin outreach workers report bath salt use declined

quickly among injecting drug users*Wood & Dargan, Novel Psychoactive Substances: How to Understand the Acute Toxicity Associated with the use of these substances, Therapeutic Drug Monitoring, 34: 363-367, 2012.

Synthetic Cathinones:Bath Salts

Clinical effects of bath salts in patients admitted to ED (N=236)

Agitation 82%Combative/Violent behavior 57%Tachycardia/Racing heart 56%Hallucinations 40%Paranoia 36%Confusion 34%Myoclonus/Movement disorders 19%Hypertension 17%Chest pain 17%CPK elevations 9%

Source: Spiller et al., 2011

Synthetic Cathinones Identified in U. S. NFLIS Toxicology Labs

4-MEC

4-MEC

BUTYLONE

ETHYLCATHINONE

FLUO-ROMETH-

CATHINONE

METH-CATHINONE

NAPHYRONE

SOURCE: National Forensic Laboratory Information System, 2010, 2011, 2012 .

8 varieties identified in 2010

4-MEC

BUTYLONE

FLUORO METH-

CATHINONE

PENTEDRONE

SUBSTITUTED CATHINONE

25 varieties identified in 2011

4-MEC

ALPHA-PVP

BUTYLONE

PENTEDRONE

37 varieties identified in 2011

Chromatography - Screens• Challenges with Identification

• Do not give colored reaction with Marquis field test• Variable quality and availability of reference standards• Immunoassay field tests for methamphetamine give

false positive reactions for some cathinone derivatives.

• Some items may contain ketamine, cocaine, or piperazine derivatives.

• We know little about thedetailed pharmacology andthey are constantly changing.

Source; B. K. Logan, Testing Strategies to Monitor Novel/Emerging/Designer Drug Use in At-Risk Populations, CPDD 2012

http://www.uclaisap.org/slides/synthetic-drug-training-package.html

Other Club Drugs (that won’t go away)

• PCP, ketamine, dextromethorphan (dissociative drugs & specific dosing)

• GHB is still around and still some mentions of sexual assault with it. Immediate need for rape kit.

• LSD and other hallucinogens still around but in lower doses so not as obvious.

• Rohypnol is still present along the Texas-Mexico border.• Kratom-opioid-like effects from plant in SE Asia• Salvia divinorum-hallucinogenic herb with intense effects;

unpleasant & won’t use again.• BZP & TFMPP are combined to be an alternative to MDMA.• Will they ever go away or just cycle back again?

www.utattc.net