1

National Estimates from the Drug Abuse Warning Network

Judy K. Ball, Ph.D., M.P.A.Office of Applied Studies

Substance Abuse and Mental Health Services Administration5 May 2008

http://DAWNinfo.samhsa.gov

2SAMHSA/OAS

Today's Agenda

No conflicts of interest

Overview of DAWN Key findings from 2006

– Nonmedical use of opiates/opioids– 2004-2005 comparisons– Extended- vs. immediate-release oxycodone

3SAMHSA/OAS

DAWN Methods

Stratified probability sample of hospitals– Short-term, general, nonFederal hospitals with

24-hour emergency departments (EDs)– Oversample areas– Remainder area

National estimates account for:– Sample design– Unit nonresponse– Partial nonresponse in responding hospital

Entire U.S.

4SAMHSA/OAS

National EstimatesOversample areas (urban) +Remainder area (urban & rural)

5SAMHSA/OAS

Source of DAWN Estimates, 2004-2006

2004 2005 2006

Eligible hospitals 4,505 4,549 4,568

Sample of hospitals 556 562 544

Responding hospitals 220 224 205

Response rate 39.6 39.9 37.7

Design weight response rate 26.7 25.8 24.9

Weighted response rate 23.9 28.9 26.1

Drug-related ED visits 168,841 268,128 269,339

Drug reports 275,829 420,420 419,438

6SAMHSA/OAS

DAWN Data Collection: Retrospective Review of Medical Records

Source: DAWN, 2006 data, 4/3/2008

National estimates

charts reviewed

9,837,481

cases found

346,946Drug-related

ED visits reviewed

ED visits not reviewed

7SAMHSA/OAS

Analysis Domains

Drug-relatedED visits

Medical use Nonmedical use

Pharmaceuticals

Illicit drugs

Alcohol

Pharmaceuticals

8SAMHSA/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

9SAMHSA/OAS

Drug-Related ED Visit Rates, 2004-2006

0

200

400

600

800

1,000

1,200

*Tot

al

*Sui

cide

atte

mpt

Seek

ing

deto

x

Alc

ohol

Illic

its

*Acc

iden

tal

inge

stio

n

**M

edic

alus

e

*Non

med

ical

use

Mis

use/

abus

e

ED visits per 100K pop

Source: National estimates from DAWN, 2004-2006

No significant change *Significant change, 2004 vs. 2006

2005 vs. 2006

10SAMHSA/OAS

Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2006

16

58

20

65

50

80

15

44

7

25 26

71

0102030405060708090

100

Fentanyl* Hydrocodone* Morphine* Oxycodone*

Visits (thousands)

Source: National estimates from DAWN, 2006

* Single- & multi-ingredient formulations

CI lower boundestimateCI upper bound

11SAMHSA/OAS

Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2006

51

4

45

36

0.8

38

6454

8

0102030405060708090

100

Opiates/opioidsnot specified

Buprenorphine*

Methadone

Visits (thousands)

Source: National estimates from DAWN, 2006

* Single- & multi-ingredient formulations

CI lower boundestimateCI upper bound

12SAMHSA/OAS

Classification of Oxycodone Reports

Extended release (ER)– OxyContin (99%)alternate terms:– Generic OxyContin– Teva OxyContin– Impax OxyContin– Oxycodone CR– Oxycodone ER– Oxycodone SR

Immediate release (IR)– acetaminophen-oxy

e.g., Percocet (91%)

– aspirin-oxye.g., Percodan

– ibuprofen-oxye.g., Combunox

– oxycodonee.g., Roxicodone

13SAMHSA/OAS

Classification of Oxycodone Reports (cont'd)

Unknown release type (UK)– Oxycodone (97%)alternate terms: – Free oxycodone– M-Oxy– Oxycodone hydrochloride– Oxycodone metabolites

14SAMHSA/OAS

Nonmedical Use of Pharmaceuticals, Oxycodone, by Release Type, 2004

22

18

5

1512

3

30

25

8

0

5

10

15

20

25

30

35

40

Extended Immediate Unknown

Visits (thousands)

Source: National estimates from DAWN, 2004

CI lower boundestimateCI upper bound

15SAMHSA/OAS

Nonmedical Use of Pharmaceuticals, Oxycodone, by Release Type, 2005

24 25

8

17 18

5

3133

11

0

5

10

15

20

25

30

35

40

Extended Immediate Unknown

Visits (thousands)

Source: National estimates from DAWN, 2005

CI lower boundestimateCI upper bound

16SAMHSA/OAS

Nonmedical Use of Pharmaceuticals, Oxycodone, by Release Type, 2006

2629

1419

22

10

33

37

19

0

5

10

15

20

25

30

35

40

Extended Immediate Unknown

Visits (thousands)

Source: National estimates from DAWN, 2006

CI lower boundestimateCI upper bound

17SAMHSA/OAS

Oxycodone, ER vs. IR – All Visits

40 39

9

41

51

16

43

62

29

0

10

20

30

40

50

60

70

Extended Immediate Unknown

Thousands

Source: DAWN estimates for the U.S., 2004-2006

No significant change *Significant change, 2004 vs. 2006

2005 vs. 2006

18SAMHSA/OAS

Oxycodone, ER vs. IR – Medical Use

3

13

26

19

56

23

9

0

10

20

30

40

50

60

70

Extended Immediate Unknown

Thousands

Source: DAWN estimates for the U.S., 2004-2006

No significant change *Significant change, 2004 vs. 2006

2005 vs. 2006

19SAMHSA/OAS

Oxycodone, ER vs. IR – Nonmedical Use

2218

5

24 25

8

2629

14

0

10

20

30

40

50

60

70

Extended Immediate Unknown

Thousands

Source: DAWN estimates for the U.S., 2004-2006

No significant change *Significant change, 2004 vs. 2006

2005 vs. 2006

20SAMHSA/OAS

Oxycodone, IR vs. ER

53% 46% 40%

16% 20% 18%

44%48%

45%72% 66%

66%

12% 15% 22% 13% 17% 25%

0%

20%

40%

60%

80%

100%

2004 2005 2006 . 2004 2005 2006

UK

ERIR

Source: DAWN estimates for the U.S., 2004-2006

% of visits Nonmedical use Medical use

21SAMHSA/OAS

Nonmedical Use: Hydrocodone and Oxycodone by Release Type, 2004-2006

22 24 26

1825

295

8

14

0

10

20

30

40

50

60

70

2004 2005 2006

Thousands

Source: DAWN estimates for the U.S., 2004-2006

Hydrocodone

UK

ERIR

Oxycodone:

22SAMHSA/OAS

Nonmedical Use: All Opiates/Opioids, ED Visit Rates, 2006

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., 2006

**

*

23SAMHSA/OAS

Nonmedical Use: All Hydrocodone, ED Visit Rates, 2006

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., 2006

**

24SAMHSA/OAS

Nonmedical Use: All Oxycodone, ED Visit Rates, 2006

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., 2006

*

*

**

25SAMHSA/OAS

Nonmedical Use: Oxycodone ER,ED Visit Rates, 2006

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., 2006

**

** *

26SAMHSA/OAS

Nonmedical Use: Oxycodone IR,ED Visit Rates, 2006

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., 2006

* **

27SAMHSA/OAS

Nonmedical Use: Oxycodone UK,ED Visit Rates, 2006

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., 2006

28SAMHSA/OAS

Nonmedical Use: Disposition from ED,Oxycodone by Release Type, 2006

Source: DAWN estimates for the U.S., 2006

% of ED visits

Extended UnknownImmediate

Some follow-up

No evidenceof follow-upcare

29SAMHSA/OAS

Nonmedical Use: Number of Drugs,Oxycodone by Release Type, 2006

Source: DAWN estimates for the U.S., 2006

% of ED visits

Extended UnknownImmediate

1 drug

Multipledrugs

30SAMHSA/OAS

Nonmedical-Use ED Visits: Conclusions

Opioid analgesics nearing 250,000 visits– ¼ Oxycodone ¼ Hydrocodone– in immediate and unknown release types– Polydrug use is typical

Highest visit rates in patients aged 21-54 Majority of patients treated and released

31SAMHSA/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 enable better surveillance– Generics– Proposed new OxyContin® formulation