Substance Abuse Trends: Old and New Drugs

Jane Maxwell, Ph.D.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%

1998 Miami DMP SamplesSouthwest Asian 2.1 % Pure

Southeast Asian 2.3 % Pure

South American 19.2 % Pure

Heroin

Heroin Sources and Supply Routes

Mexican Black Tar Heroin

Mexican Brown Heroin

South American Heroin

Heroin

• Almost all in Texas is Black Tar & Mexican brown; continuing occasional mentions of white heroin with no DEA footprint.

• Price range has narrowed with ounce dropping from $700-$5000 to $700-$4000.

• Houston DEA reports heroin is moderately available but more available than 6 months ago. Increased street level availability. Seizures up. Afghan heroin thru mail to Killeen-Fort Hood.

• El Paso DEA reports seizures have increased and more available.

• Dallas DEA reports supply is stable. Youths still using “cheese” (heroin powdered using Tylenol PM®).

• All CEWG members report increasing heroin use and increasing number of youth and young users.

Heroin Indicators in Texas:1998-2011

# PCC Calls % Treatment % Tox Items # Deaths Purity*1

10

100

1000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Log

Scal

e

*Dallas

Texas Heroin Admissions by Age Group: 2005-2011

2005 2006 2007 2008 2009 2010 20110%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

50+40s30s20sU20

Source: DSHS

Age and Race/Ethnicity of Persons Dying with Mention of Heroin: 1992-2010

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

32

33

34

35

36

37

38

39

40

BlackHispanicWhiteAge

Rac

e/E

thni

city

Age

(Yea

rs)

Source: DSHS

Other Opiates

OxyContin, Vicodin, hydrocodone, oxycodone, methadone, codeine, etc. •Favorites vary by region (oxycodone vs. hydrocodone)•Shifts back and forth between Rx opioids and heroin

Public Health Impact of Opioid Pain Reliever Use

For every opioid overdose death in 2009 there were

Past Year nonmedical users

People with abuse/dependence

ED visits for misuse or abuse

Abuse treatment admissions

0 100 200 300 400 500 600 700 800 900

795

118

30

9

15Source: Len Paulozzi at 2012 ASAM; data from TEDS, DAWN, NSDUH

Drug poisoning death rates by age: United States, 1999-2009

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 20090

5

10

15

20

25

30

15-24 years 25-34 years 35-44 years 45-54 years 55-64 years65 years and over

Dea

ths

per 1

00,0

00 p

opul

atio

n

16

1

2

3

4

5

6

Major “Other Opiates” in TexasHydrocodone 10X Higher

Hydrocodone/VicodinSchedule III

1998

2001

2003

2005

2007

2009

2011

0

500

1000

1500

2000

2500

3000

Poison Control DPS Labs

OxycodoneSchedule II

1998

2001

2003

2005

2007

2009

2011

0

50

100

150

200

250

300

Poison Control DPS Labs

“Holy Trinity”• “Houston Cocktail”• Hydrocodone, alprazolam, and

carisoprodol (Vicodin, Xanax, Soma)• 6 Houston “pain clinic” doctors each

wrote between 23,907 and 43,383 scripts in a 15-month period.

• Real-time on-line Texas prescription monitoring program underway.

19

Nonmedical Use of Tranquilizers: Numbers in Thousands, NSDUH

2010

Clonazepam Alprazolam Diazepam Benzodiazepines0

2000

4000

6000

8000

10000

12000

14000

16000

18000

12-1718-2526+

Source: SAMHSA

Benzodiazepines in Texas: 1998-2011

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

0

50

100

150

200

250

300

350

400

450

500

Alprazolam Diazepam Clonazepam Deaths

% It

ems

Exa

min

ed

# D

eath

s

Poisoning Deaths with Benzodiazepine and Opioid Analgesics Mentioned:

NCHS 1999-2008

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 -

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000 Opioid Analgesics Benzos

Benzos & Opioid Analgesics Heroin

Benzo and Heroin

Num

ber o

f poi

soni

ng d

eath

s

Source: NCHS, National Vital Statistics System

“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?

Codeine Promethazine Cocktail

New “Relaxation” Drinks:Drank and Lean

Valerian Roots

Melatonin

Rose Hips

“Slow Your Roll”

“Slow Motion Potion”

SIZZURPCognac, Vodka, and Fruit Flavor

Cocaine: What’s going on?• Poison control, treatment, deaths, & tox

lab indicators down nationwide; price and purity up.

• Amount of coca under cultivation down• Demand in Europe for cocaine.• Use of Levamisole as a filler with

serious medical consequences.

Cocaine Indicators in Texas: 1998-2011

# PCC Calls % Treatment % Tox Items # Deaths10

100

1000

10000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

All Cocaine Purchases Domestic STRIDE Data

January 2007 – June 2011

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

ept10

Oct-Dec

10$0

$50

$100

$150

$200

$250

0

20

40

60

80

100

$98

$118$128

$115$123 $124

$181$197

$173 $174 $175

$192 $192 $195

$176 $17467

59 5761

57 57

46 4548 46 46 45 45 46 48 49

Price Per Gram Purity Mean

Pric

e Pe

r Pur

e G

ram

Purit

y in

Per

cent

From January 2007 through June 2011, the price per pure gram of cocaine increased 71%, from $98 to $167, while the purity decreased 27%, from 67% to 49%.

New Problems with Cocaine

• Levamisole is cancer medication also used in de-worming animals.

• 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)

Methamphetamine: It’s Back (It never went away)

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. (2009) Cunningham JK, Liu L-M, Callaghan R. Addiction; 104, 441-453.

All Methamphetamine Purchases Domestic STRIDE Data

January 2007 – June 2011

Jan-M

ar07

Apr-Jun07

Jul-S

ep07

Oct-Dec

07

Jan-M

ar08

Apr-Jun08

Jul-S

ep08

Oct-Dec

08

Jan-M

ar09

Apr-Jun09

Jul-S

ep09

Oct-Dec

09

Jan-M

ar10

Apr-Jun10

Jul-S

ep10

Oct-Dec

10

Jan-M

ar11

Apr-Jun11

$0

$50

$100

$150

$200

$250

$300

$350

0

20

40

60

80

100

$161

$230

$290 $308

$247

$248

$202

$182 $190

$140 $141

$129 $128$113 $106

$100 $109$90

56

42

39

4046

52 53

62 6469 70

73 78

83 84 85 8588PPG_mean Purity_mean

Pric

e Pe

r Pur

e G

ram

Purit

y in

Per

cent

From July 2007 through June 2011, the price per pure gram of methamphetamine decreased 69%, from $290 to $90 while the purity increased 127%, from 39% to 88%.

Methamphetamine & Amphetamine Indicators in Texas: 1997-2011

# PCC Calls % Tmt Admits # Deaths % of Tox Items1

10

100

1000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

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

Different Manufacturing ProcessesI. Methylsulfonylmethane (MSM) being used to

cut meth (or sold instead of meth).II. 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.

III. P2P/Phenylacetone (Illegal in US-Schedule II, precursors legal in Mexico) (l and d,l-forms).

DEA Methamphetamine Profiling Program: 2010-2012

3&4Q

-06 2008

1Q-10

3Q-10

1Q-11

3Q-11

1Q-12

0%10%20%30%40%50%60%70%80%90%

100%

Purity, Potency, and “Cut”Purity Potency MSM

3&4Q

-06 2008

1Q-10

3Q-10

1Q-11

3Q-11

1Q-12

0%

20%

40%

60%

80%

100%

Production RoutesP2PPhosphorus Iodine

Source: DEA

Source: DEA

Source: DEA

Biggest Risks of Meth Use:Mental

%Paranoia 37.9Depression 35.1Anxiety/panic 35.1Damage to brain function 27.6Psychosis 17.3Aggressive/violent behavior 15.9Memory impairment 12.2Cognitive impairment 4Long-term physical problems 9Lack of motivation 8

Source: Maxwell

Driving Behavior Reported by Sample of Meth Users in

Treatment

# times driven while under inflence of drugs in last 6 mos

% Driven under influence of drugs in last 6 mos

% Driven under influence of alcohol in last 6 mos

% Driven car in last 6 months

0 20 40 60 80 100

55

85

47

87

Source: Maxwell

Marijuana

Marijuana Indicators in Texas: 1997-2011

# PCC Calls % Treatment % Tox Itemss % Ever Used School Survey

10

100

1000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

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

Ethnicity: 1990-2010

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

0%

5%

10%

15%

20%

25%

AnglosAfrican AmericansHispanics

Source: DSHS

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• May increase risk of anxiety, depression,

and amotivational syndrome

National Institute on Drug Abuse, Research Report Series, Marijuana Abuse, updated 9/2010.

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

Dangerous, Imitation, Emerging Drugs

(DIED)

Imitation• Mimic Illegal Drugs• Imitate

– Fake– Impersonate– Rip Off

• Synthetic Cannabinoids “cannabimimetics”• Synthetic Cathinones - Khat- “Cathinimetics”

such as 4-MMC, MDPV, Mephedrone• Phenethylamines, Tryptamines, Piperazines• Beat the Drug Test

Drugs

• Not “spice,” “bath salts,” or “incense” • Psychoactive substances• Change the brain’s functions• Complex chemistry• Constantly changing to “stay legal”• Complicated neuropharmacology

Emerging Drugs Items Identified in Texas NFLIS Tox Labs: 2010 and 2011

Synthetic Cannabinoids 4-MMC, MDPV, Mephedrone

0200400600800

100012001400160018002000

79 158

1851

540

20102011

Texas Poison Control Exposures and Effect of Controls

Synthetic Cannabis Synthetic Cathinones

Feb May AugNov

Feb May Aug

Nov Feb May

0

20

40

60

80

100

Jan 10

AprJu

lOct

Jan 11

Apr Ju

l Oct

Jan 12

Apr 0

20

40

60

80

100

Source: DSHS

Synthetic Cannabinoid Varieties

July – December 2010

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

Synthetic Cannabinoid Varieties

Oct 2011 – Apr 2012

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

Synthetic cannabinoids: The compounds

NR2

O

R1

R3

a) Naphthoylindoles

JWH-018 JWH-073

JWH-398 JWH-200

JWH-081 JWH-015

JWH-122 JWH-210

JWH-019 JWH-007

5-Fluoropentyl-JWH-122

b) Cyclohexylphenoles

OH

OH R1R2

R3 R4

CP-47,497-C8

AM-2201 JWH-020

JWH-387 AM-1220

JWH-412 Auwarter et al, Synthetic Cannabinoid Receptor Agonists, Freiburg University, CPDD 2012

Chemicals - Summary

• 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

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 • Hypertension• Nausea/vomiting• Coma• Agitation, violent behavior

Schneir 2012 J Med ToxRosenbaum et al. 2012 J Med ChemForrester et al. 2011 J Add DisHermanns-Clausen et al. 2012 Addiction

Emerging Psychoactive Drugs in Texas: NFLIS Items ½ 2011

Psychedelics

Stimulants

Similar to cocaine and MDMA (‘ecstasy”)

Similar to cocaine and MDMA (‘ecstasy”)

Stimulant with Rapid Onset2-4 hour duration of action

Similar to Amphetamine 1/10 Potency of d-methamphetamine

Drugs

Slow Onset (1 hour); Long duration of action (8 to 1 0 Hours)

Faster Onset (1 hour); Shorter duration than 2C-I

Smoked: Almost Immediate, Very Intense, Short Effect (< 20 min)

drugs ?

Emerging Psychoactive Substances

Two classes: (1) Stimulants: mephedrone, MPDV, piperazines,

“bath salts”(2) Psychedelic: 2C-B, mescaline, DMT, etc.

Differences in users:1)Stimulant users similar to other ecstasy

users; (shifting to mephedrone and MPDV due to shortage of Ecstasy?)

2) Psychedelic users started ecstasy use earlier; more frequent users; used multiple substances; more legal, mental health & social problems.

Synthetic Cathinones:Bath Salts

• Could be MDPV, 4-MMC,mephedrone, or methylone.• Sold on-line with little info on ingredients, dosage, etc.•Advertised as Legal Highs, Legal Meth, Legal Cocaine, Legal Ecstasy.

•Taken orally or by inhaling.•Serious side-effects to self or others with prolonged or use of large amounts.

•Trendy names and slick packaging

Source: IRP, NIDA, NIH

Synthetic cathinones are b-keto (‘bk’) analogs of amphetamine

N CH3

HO

CH3

Methcathinone

N CH3

HO

CH3

4-Methylmethcathinone(Mephedrone)

H3C

N CH3

H

CH3

Methamphetamine

NO

O

O

3,4-Methylenedioxypyrovalerone(MDPV)

NO

CH3

O

O

3,4-Methylenedioxmethcathinone(Methylone)

CH3

H

Designer Stimulants

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

Chromatography - Screens

• Challenges with Chromatography Screening• Unavailability of the reference standard for new drugs

• Variable quality of reference standards

• Isotopic purity of labeled internal standards.

• Chemical similarity of new drugs within a class requires great care with identification.

• Sensitivity

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

Glimpses of MDMA Situation

1999

2001

2003

2005

2007

2009

2011

0102030405060708090

Results of Pill Tests Containing MDMA*

MDMA MDMA Only

•Australian EDRS reports drop in MDMA use from 52% in 2003 to 27% in 2011.•Both Australia and UK report MDMA “drought”.•Shift from PMK to safrole to make MDMA.•Winstock predicts return of high quality MDMA but from China, not BeneLux sources.

*http://www.ecstasydata.org/stats_substance_by_year.php

Ecstasy Indicators in Texas: 1998-2011

PCC Calls Treatment Tox Lab Items1

10

100

1000

10000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20092010

Texas Treatment Admissions with a Primary, Secondary or Tertiary

Problem with Ecstasy: 1998-2010

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

0%20%40%60%80%

100%

White Hispanic Black

DSHS data; analysis by JC Maxwell

Piperazines• Frenzy, Bliss, Charge, Herbal ecstasy, A2, Legal Z, Legal E.• Mainly available over internet and sold as ecstasy pills that

are “safe”.• Two classes: (1) benzylpiperazines (BZP) and (2)

phenylpiperazines (TFMPP).• Mimics effects of ecstasy (MDMA); dangerous with seizure

disorders, psychiatric illness, or coronary disease. • Adverse events included hypertension, reduced

consciousness, psychotic episode, hallucinations, tachycardia, hyperthermia, coma. Could be toxic if combined with MDMA or amphetamines.

• One death due to BZP and MDMA.

Arbo, Bastos, Carmo, Piperazine compounds as drugs of abuse, Drug and Alcohol Dependence 122 (2012)

Phencyclidine

• PCP, Angel Dust, Killer Weed• Dissolved in embalming fluid (“Fry,”

“Amp,” “Water, Water”).• Swallowed, sniffed, smoked on joints

dipped in “Fry”.• Out-of-body strength.

PCP Indicators in Texas: 1998-2011

# PCC Calls # Treatment # Tox Items # Deaths1

10

100

1000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

                                                                      

What is DxM? Dextromethorphan is a psychoactive drug found in common over the counter cough medicines.

Source: www.http:third-plateau.lycaeum.org/beginner/index.html

Dextromethorphan in Texas• At high doses, may produce dissociative

hallucinations.• Can produce tachycardia, hypertension,

agitation, ataxia, and psychosis at high doses.

• Abuse/misuse calls for Coricidin HBP to Texas Poison Control Centers were 7 in 1998 and 59 in 2011; average age 18.8 years.

• Abuse/misuse calls for DXM were 99 in 1998 and 530 in 2011; average age 21.

Past Month Use of Coricidin: Texas Secondary School Survey 2004-2010

7 8 9 10 11 120%

1%

2%

3%

200420062008

Source: DSHS

Data Sources

• Death data (DSHS) - 2009• Poison Control Center cases (DSHS) - 2011• Treatment admission records (DSHS) – 2011• Surveys (DSHS) 2010 • Forensic laboratory tests (NFLIS) – 2011• DEA Dallas, El Paso, and Houston Field

Division Intelligence Reports – 2011• AIDS cases (DSHS) -2011• NIDA, R21 DA025029