drug abuse in iowa · drug abuse in iowa evolving issues & emerging trends iowa office of drug...
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Drug Abuse in Iowa Evolving Issues & Emerging Trends
Iowa Office of Drug Control Policy
September 2016
1
Rapid Changes + Mixed Messages = ???s Evolving Risks involving Medicines, Synthetics, Marijuana, etc.
• What’s new (what is it, what’s in it, what’s it’s effect)?
• Does it heal or hurt (medicine or menace)?
• Is it legal or illegal?
• What do we tell children (or anyone else) about it?
• How is it different now, compared to what I experienced?
• What do we know about it & when will we know more?
• What’s next?
2
Youth Substance Use 40-Year Trends Current Use (past 30 days) Among U.S. 12th Graders
0%
10%
20%
30%
40%
50%
60%
70%
80%
3
Alcohol
Monitoring the Future, 1975-2015
Cigarettes
Marijuana
Drugs of Choice: All Iowans Primary Substance of Choice by Iowans in Treatment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Alcohol
Marijuana
Meth
Cocaine
Heroin
Other
6.3%
IDPH, 2014
4
50%
25.6%
14.8%
1.7% 1.6%
Iowa Youth Substance Abuse 6th, 8th and 11th Grade Users, Last 30-Days
0%
5%
10%
15%
20%
25%
2002 2005 2008 2010 2012 2014
Alcohol
Tobacco
Other Drug
Rx
OTC
Meth
3%
23%
12%
14%
9% 10%
6%
4%
3%
5
4%
Iowa Youth Survey, 2014
1% 1%
0
2
4
6
8
10
12
14
16
Marijuana Meth Rx Synthetic Opium Other
Iowa Drug-Related Traffic Fatalities Number Killed in 2014 Testing Positive for Illicit Drugs
6
Source: IDOT, 2014
Does not include alcohol-related fatalities.
Alcohol & poly-drug combinations were detected in some crashes.
15% of those killed in Iowa traffic fatalities
in 2014 tested positive for illicit drugs.
0
50
100
150
200
250
300
350
400
450
500
Iowa Drug-Impaired Driving 2015 Non-Alcohol Evaluation Findings by Drug Recognition Experts
7
IDPS, 2015
Iowa “Drug-Related” Prison Admissions Primary Drug Involved
0
200
400
600
800
1,000
1,200
8
Iowa Justice Data Warehouse, 2015
Rx Heroin
All
Drugs
Meth
Marijuana
Cocaine/Crack
Other
Iowa Drug-Related Child Abuse Confirmed/Founded Cases: Illegal Drugs in a Child’s Body
0
200
400
600
800
1000
1200
1400
1600
1800
633
IDHS, 2015
921
1,713
9
(Differential Response initiative began in 2014)
Alcohol & Tobacco/Nicotine
10
Iowa Annual Distilled Spirits Sales Millions of Gallons Sold to Adults
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
5.16 m
3.26 m
11
IABD, 2015
Excessive Drinking by Iowa Adults Percentage of Heavy or Binge Drinking by County
12
Robert Wood Johnston Foundation, 2013
Iowa Alcohol-Attributed Deaths & Hospitalizations
13
Iowa Substance Abuse Epidemiological Profile, 2012
Current Alcohol Use Last 30-Days
0%
10%
20%
30%
40%
50%
60%
70%
80%
12+ 12-17 18-25 26+
U.S.
Iowa
NSDUH, 2013/2014
14
Current Binge Drinking Last 30-Days
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
12+ 12-17 18-25 26+
U.S.
Iowa
NSDUH, 2013/2014
15
Iowa Tobacco-Associated Deaths & Hospitalizations
16
Iowa Substance Abuse Epidemiological Profile, 2012
Current Tobacco Use Last 30-Days
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
12+ 12-17 18-25 26+
U.S.
Iowa
NSDUH, 2013/2014
17
U.S. Youth Cigarette vs. E-Cigarette Use Last 30-Days
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
8th 10th 12th
U.S. Cigs
U.S. E-Cigs
Monitoring the Future Survey 2015
18
Iowa Youth Cigarette vs. E-Cigarette Use Last 30-Days
0%
2%
4%
6%
8%
10%
12%
6th 8th 11th
Iowa Cigs
Iowa E-Cigs
Iowa Youth Survey 2014
19
20
Marijuana
Marijuana/Cannabis a.k.a.
Now
21
• Hash or Honey Oil
• Wax or Earwax
• Budder
• Crumble
• Shatter
• Black Glass
• Edibles
• Reggie
• Loud
• Weed
• Grass
• Pot
• Reefer
• Hash
• Hemp
• Joints
• Blunts
• Buds
Then
Distinction with a Difference
22
Cannabis-Based Medicine:
Cannabis derivatives that test safe & effective as research-based
medicines for use by health care professionals in treating patients
with valid medical needs, & regulated to reduce public safety
risks.
Medical Marijuana:
Differing forms of cannabis approved by legislative or popular vote
in some states for treating various health conditions, with fewer
controls & safeguards than FDA-approved medicines.
Iowa Law:
Permits regulated use of limited quantities of CBD oil to treat
qualified patients with intractable epilepsy.
Marijuana Laws & Use by Teens by State
“Medical” & “Recreational” Marijuana Laws (2016 Governing.com)
Past Month Use by 12-17 Year Olds (2013-2014 NSDUH)
23
• Olive = “Medical” marijuana (*25 & DC). [OH June 2016]
• Lime = “Medical” & “Recreational” marijuana (4).
• Not Shown: Low THC non-psychoactive “CBD” oils (18,
including Iowa, where the Pharmacy Board recommended
in 2015 the Legislature consider rescheduling CBD only).
Health Group Positions on Marijuana
24
• Major public health organizations (American Cancer
Society, American Glaucoma Foundation, American
Medical Association, American Psychiatric Association,
National Pain Foundation, National Multiple Sclerosis
Society, National Association of School Nurses, et al.) do
not support smoked marijuana.
• The American Academy of Pediatrics “opposes marijuana
use by children & adolescents…the use of ‘medical’
marijuana outside the regulatory process of the
FDA…&…legalization of marijuana.”
Marijuana: R&D of Derivatives
25
Marinol (Dronabinol) & Cesamet (Nabilone):
FDA-approved synthetic cannabinoids—containing
THC & CBD—legally available as prescription pills to treat
cancer chemotherapy nausea & appetite loss.
Sativex (mouth spray):
A product with 2 cannabinoids extracted from the
cannabis plant failed FDA-authorized tests for
cancer pain, but may be tested on spasticity problems.
Epidiolex (oral liquid):
Contains the non-psychoactive cannabis extract
Cannabidiol (CBD), & is an FDA orphan drug in
a fast-track study to treat severe seizures. If all
goes well, an Rx product could be available by end of 2017?
Marijuana
66.3%
Alcohol
21.9%
Other 6.5% Meth
4.1%
Cocaine 0.2%
Opiates/Synthetics 1.0%
Iowa Youth Drugs of Choice Primary Substance by Juvenile Clients Entering Treatment
IDPH, 2014
26
Source of Marijuana Seized in Iowa 2015 Iowa State Patrol Significant Highway Interdictions
27
California
53.3% Colorado
40%
Wyoming
6.7%
Iowa was the 4th most
frequent state destination
for Colorado marijuana
seized in highway
interdictions in 2015. 2016 El Paso Intelligence Center
Iowa Department of Public Safety, 2015
Iowa Marijuana ER Visits Cannabis Use as Causal or Contributing Factor
28
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2006 2007 2008 2009 2010 2011 2012 2013 2014
1,633
455
Iowa Department of Public Health, 2014
Marijuana impairs/worsens respiratory systems,
heart rate, coordination, judgment, memory,
problem-solving & mood. It contributes to auto
crashes & can cause severe anxiety & psychosis.
Iowans’ Current Marijuana Use
29
Most Iowans are not current marijuana users (past 30 days).
Use
5.17%
Do Not
Use
94.83%
Use
5.02
%
Do Not
Use
94.98%
Iowa Youth 12-17 years old
currently using marijuana.
Iowans 12 & older
currently using marijuana.
2013-2014 National Survey on Drug Use & Health
Youth Marijuana Attitudes Among Iowa 11th Graders
0%
5%
10%
15%
20%
25%
30%
30
Iowa Teens Perceiving
No Risk Smoking Marijuana
Once or More a Week
Iowa Youth Survey, 2014
12%
24%
Youth Marijuana Attitudes vs. Use Among U.S. 12th Graders
0%
10%
20%
30%
40%
50%
60%
31
Perceived Risk of
Occasional Marijuana Use
Past Year Marijuana Use
Monitoring the Future Survey, 2014
College students daily marijuana use surpassed
cigarette smoking for the 1st time in 2014.
Marijuana Matters
32
• About 9% of marijuana users become addicted. That
number increases to 1 in 6 among users who start in
adolescence, & to 25-50% among those who use daily. 2012 National Institute on Drug Abuse, NIH, Drug Facts
• Drug-related student suspensions & expulsions increased
40% in Colorado schools from 2008/2009-2013/2014. 2015 Colorado Department of Education
• Persistent marijuana use during adolescence can cause a
long-term 8-point drop in IQ, & harm attention span &
memory. 2012 National Academy of Sciences, Dunedin Study
• College student daily marijuana use surpassed cigarette
smoking for the 1st time, increasing to 5.9%, the highest
level since 1980. 2014 Monitoring the Future Survey/University of Michigan
Marijuana’s Increasing Potency U.S. Seizures, Concentration of THC by % of Weight
0.74% 3.75%
11.8%
*50+%
0%
10%
20%
30%
40%
50%
60%
1975 1995 2014 *Recent
Co
ncen
trate
s
Sources: University of Mississippi Marijuana Project, NIDA & DEA
*Concentrates contain THC levels of 50-90%. (Examples: Hash Oil, Marijuana Wax, Marijuana-Infused Edibles)
DEA
33
Concentrates Beyond the Plant…
34
Concentrates Beyond the Plant…
“Budder”
“Shatter”
“Ear Wax”
“Green Crack”
wax
Hash Oil Capsules
Butane Hash Oil
(BHO)
35
New Marijuana in Iowa
36
Approximately 9.5% of
all 2015 marijuana
samples submitted to the
Iowa crime lab involved
marijuana “preparations,”
or “concentrates” (e.g.,
hash oils, waxes &
marijuana-infused
edibles).
2015 Iowa Department of Public Safety, Division of Criminal Investigation
9.5%
“Concentrates”
90.5%
Plant Materials
Iowa Marijuana Policy
37
• Marijuana, or a substance with *any amount of THC, is
illegal as a Schedule I Controlled Substance in Iowa (similar
to federal law).
• The 2014 Iowa Medical Cannabidiol Act (SF 2360) permits
very limited use of CBD oils that are *low in THC (<3%) to
treat intractable epilepsy.
• 25 states & DC have voter approved or legislated “medical”
marijuana; 4 states have voter approved “recreational”
marijuana; & 18 states, including Iowa, have CBD laws.
• Congress is considering proposals, including a Marijuana
Effective Drug Studies (MEDS) Act to promote research on
the medical effectiveness & safety of marijuana components.
Meth
38
Iowa Meth Labs
0
200
400
600
800
1000
1200
1400
1600
(Gold = “One Pot” Labs)
Iowa Meth Labs Down 90% vs. Peak of 10 Years Ago. Source: IDPS, 2015
39
1,500
2
151
Iowa Meth Purity Crime Lab Fiscal Year Averages
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008 2009 2010 2011 2012 2013 2014
Source: IDPS, 2014
35%
40
93%
Iowa Meth Treatment Admissions
0
1000
2000
3000
4000
5000
6000
7000
8000
Source: IDPH, 2014
7,196
41
4,062
Rate of Meth Treatment *ALL 12+ Substance Abuse Treatment Admissions for Meth
0
20
40
60
80
100
120
140
160
180
U.S.
Iowa
Iowa Meth Use Treatment Rate 3rd Highest in US (& 8th Highest Number). Source: TEDS 2012
42
47 per 100,000
169 per 100,000
*Clients reporting
meth as primary
drug of choice
Opioid
& Rx
Abuse
43
Types of Medicines Abused
• Opioids (*Pain Relievers) – OxyContin®, Vicodin®, Percocet®
• Stimulants – Ritalin®, Adderall®, Sudafed®
• Anti-Anxieties – Xanax®, Valium®
• Anti-Depressants –Prozac®, Zoloft®
• Sedatives – Rohypnol®, Nembutal®, Seconal®
• Etc.
44
*Synthetic Opioid Examples: Oxycodone, Morphine, Methadone, Codeine, Fentanyl & Hydrocodone.
Hydrocodone combination products became Schedule II Controlled Substances in October 2014.
45
National Rx-Heroin Trends
NIH, 2015
Drug overdoses, led by opioids,
claim 78 U.S. lives daily. CDC 2016
About 3 out of 4 new heroin users
report previous Rx opioid abuse. CDC 2016
Opioid OD Death Rates: 2002-2014
46
NLC-CDC, 2014
2002 2014
Drug Poisoning Death Rate per 100,000
47
CDC , 2010-1014
Iowa state rate of drug poisoning deaths ranks 44th ( 8.8/100,000)
Pain Reliever Prescriptions: By State
CDC, 2014
48
Controlled Prescription Drug Seizures In Dosage Units by Iowa Division of Narcotics Enforcement Agents
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012 2013 2014
2,851 du
49
IDPS, 2015
Iowa Drug Treatment: Numbers Any Abuse of Non-Heroin Opiates & Synthetics Reported at Admission
0
500
1,000
1,500
2,000
2,500
3,000
2005 2006 2007 2008 2009 2010 2011 2012
2,506
764
TEDS, 2012
50
#1 “Exposure” call category:
Pain Medicines. Iowa Poison Control Center, 2016
Iowa Opioid-Related ER Visits Opioid Use (including Opiates & Others) as Causal or Contributing Factor
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2006 2007 2008 2009 2010 2011 2012 2013 2014
IDPH, 2014
1,555
51
519
Iowa Drug-Related OD Deaths: All Drugs
0
50
100
150
200
250227
46
Iowa Department of Public Health, Bureau of Health Statistics, 2016
52
118
*2015 Data is Preliminary
Iowa Opioid-Related OD Deaths: Rx & Heroin Rx = Pain Relievers (Rx Methadone, Other Opioids & Other Synthetic Narcotics)
0
10
20
30
40
50
60
70
80
90
77
5
Iowa Department of Public Health, Bureau of Health Statistics, 2016
53
43
1
15
20
Heroin
Rx Opioids
*2015 Data is Preliminary
Heroin
54
& Non-Medical
Synthetic Opioids (e.g., fentanyl analogs)
Hydrocodone
(Lorcet®)
= $5-$7/tab
Oxycodone Combinations (Percocet®) = $7-$10/tab
OxyContin®
= $80/tab
Heroin = $10/bag
Roxicodone®
Oxycodone IR
15mg, 30mg
= $30-$40/tab
Rx Pain Reliever-Heroin Connection
DEA, 2013
55
56
Rx-Heroin Trends
NSDUH, 2013
Heroin Seizures In Grams by Iowa Division of Narcotics Enforcement Agents
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012 2013 2014
2,919.81 g
57
Iowa Department of Public Safety, Division of Narcotics Enforcement, 2015
12.68 g
Often mixed with heroin, black market
synthetic opioids (fentanyl, fentanyl acetyl-
fentanyl, furanyl-fentanyl, W-18, U-47700,
etc.) can be more potent & lethal than heroin
…& may be legal.
DEA, 2016
Drug-Related OD Incidents: Cedar Rapids
0
10
20
30
40
50
60
70
80
9080
CRPD, September 29, 2015
58
54
All Drugs
Heroin
Naloxone Use by Iowa EMS Providers # Times Administered
0
50
100
150
200
250
2010 2011 2012 2013 2014 2015
Iowa Department of Public Health, Emergency & Trauma Services, 2016
171 161
59
Almost 66% of 2015 Cases
Occurred in 30 Central & East
Central Iowa Counties
Ease of Access & Perceptions of Safety
60
Iowa PMP: Doses Dispensed Controlled Prescription Drugs, Schedule II-IV
0
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
350,000,000
2009 2010 2011 2012 2013 2014 2015
303M+
228M+
Iowa Department of Public Health, Board of Pharmacy, 2016
61
The U.S. makes up < 5% of the world’s population, but
consumes about 75% of its prescription drugs…
including 81% of its oxycodone & 99% of its hydrocodone. UN
Response to Reduce Rx Abuse: Iowa Plan
62
Education & Intervention
Secure Storage & Safe Disposal
Monitoring
Enforcement
**NEW…Iowa Laws to Reduce Opioid Abuse & Deaths:
-SF 2218 & HF 2460 expand use of opioid overdose rescue drug Naloxone.
-SF 2102 allows Prescription Monitoring Program & EHR integration.
Safe Medicine Disposal
National Take-Back Events: Special take-back events are a good way
to remove expired, unwanted, or unused medicines from the home.
Law Enforcement Collection: A growing number of law enforcement
agencies collect expired, unwanted, or unused pharmaceutical controlled
prescription drugs on an ongoing basis via secure drop-off boxes.
Disposal in Household Trash: You may carefully mix medicines with
substances such as kitty litter or used coffee grounds and place them in a
container such as a sealed plastic bag to throw in your household trash.
Disposal by Flushing: A few medicines have specific instructions to
flush them down the sink or toilet when they are no longer needed.
ODCP, 2015
63
Pharmacy Collection: Some pharmacies collect expired, unwanted, or
unused pharmaceutical controlled prescription drugs from patients.
U.S. “Take-Back” Initiative Amount (in Tons) of Rx Drugs Collected
0
50
100
150
200
250
300
350
400
450
500
DEA, 2016
11 Events, 5.5 Years = 6,463,026
Pounds ( < 3,232 Tons! )
64
122
447
Next National Prescription Drug Take Back Day:
October 22, 2016
Iowa “Take-Back” Initiative Amount (in Pounds) of Rx Drugs Collected
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
DEA, 2016
11 Events, 5.5 Years = 69,019 Pounds
( > 34 Tons! )
65
1,569
9,084
Next National Prescription Drug Take Back Day:
October 22, 2016
Iowa Permanent Rx “Take Back” Sites Controlled Prescription Drugs
66
ODCP, 2016
odcp.iowa.gov/rxtakebacks
Sites doubled to 93 vs. year ago & are on pace to double again by January 2017.
Synthetic
Drugs
67
Synthetic Cannabinoids & Cathinones Hallucinogens & Stimulants by State
2010 2012
DEA, 2013
68
Phenylalkylamines
Benzodiazepines
Piperazines
Arylcyclohexamines
Tryptamines
Synthetic Cannabinoids
Ecgonine Derivatives
Anabolic agents
Designer Drugs
phenazepam
Benzyl-
piperazines
BZP
MDBP
4-Bromo-2,5-
diMeO-BZP
MBZP
MDBZP
Phenyl-
piperazin
es:
mCPP
TFMPP
MeOPP
pFPP
Steroids:
THG
Many
examples
SARMs:
Andarine
LGD-2226
Mk-2866
2C Series –
2,5-dimethoxy-
ethanamine:
2C-B
2C-C
2C-D
2C-E
2C-H
2C-I
2C-N
2C-P
2C-T-2
2C-T-4
2C-T-7
2C-T-21
25I-NBOMe
D-Series-2,5-
dimethoxy-
phenyl-
propanamines:
2,5-DMA
3,4-DMA
DOB
DOC
DOET
DOF
DOI
DOM
DON
DOPR
MDOB
Dimethoxy derivatives:
Monomethoxy
derivatives
PMA
PMMA
N-ethyl-PMA
Trimethoxy
derivatives:
3,4,5-TMA
TMA-2
TMA-3
TMA-4
TMA-5
TMA-6
4-MTA
homologs
4-MTA
4-MTMA
4-MTEA
4-MTPA
4-MTBA
4-MTDMA
b-Keto-
phenethylamines
Mephedrone
MDPV
Methylone
Ethylone
Butylone
Flephedrone
Methcathinone
Ethcathinone
bk-MDDMA
Naphyrone
4-MEC
4-EMC
a-PVP
4-MePPP
a-PBP
buphedrone
Difurnanyl
compounds
Bromo-
dragonfly
2C-B-fly
Fluoro-
containing
compounds
4-FA
3-FA
2-FA
N-Methyl-4-FA
N-Ethyl-4-FA
3-F-4-MeO-A
Others
MDDMA
Ethyl-
amphetamine
N-OH-MDMA
MDDM
N,N-Dimethyl-1-
phenyl-2-
ethanamine
1-phenyl-2-
butylamine
MDA
AMT
DMT
DET
DPT
DBT
DiPT
MiPT
4-OH-DiPT
4-OH-MiPT
4-OH-MET
5-MeO-AMT
5-MeO-DMT
5-MeO-DiPT
5-MeO-MiPT
5-MeO-EiPT
5-AcO-DiPT
5-MeO-DPT
5-MeO-DALT
Classic
cannabinoi
ds
HU-210
IP-751
Parahexyl
and many
others
Cyclohexyl-
phenols
CP-47,497
CP-47,497-
C8
CP-55,950
Indoles/Pyrr
oles
JWH-018
AM2201
JWH-200
JWH-081
JWH-250
AM694
RCS-4
SR-18
UR-144
XLR11
Eicosanoids:
Anandamide
Oleamide
Others
AKB48
URB597
CB-13
4-Fluorotropa-
cocaine
b-CFT
p-FBT
Red = Controlled substance
Yellow = Positional isomer, controlled by definition
Green = Determined to be controlled substance analogue
PCPR
PCMPA
PCMEA
PCEEA
PCEPA
5-MeO-
PCP
MXE
4-Me-
PCP
3-MeO-
PCE
69 Modified from Wohlfarth and Weinmann, Bioanalysis, 2010
69
The Chemistry
Synthetic Opioid Alert
Dangers of Fentanyl & Fentanyl Analogues/Compounds
Fentanyl is commonly laced in heroin, causing significant
problems across the country, particularly as heroin abuse
has increased.
Drug incidents & overdoses related to fentanyl are occurring
at an alarming rate throughout the U.S. & represent a
significant threat to public health & safety.
Often laced in heroin, fentanyl & fentanyl analogues
produced in illicit clandestine labs are up to 100 times more
powerful than morphine & 30-50 times more powerful than
heroin.
70
Drug Trends in Iowa: Summary
• Alcohol remains Iowa’s most abused addictive substance.
• Iowans’ appetite for meth remains strong, fed by cartels.
• Marijuana is Iowa’s most used illicit substance, & is
morphing into new more potent forms.
• Medicine/Opioid abuse is Iowa’s fastest growing form of
substance abuse…leading to more heroin use too.
• Synthetic drugs are a fast-changing threat to Iowa youth.
• With exceptions, Iowans generally abuse drugs at rates
below many other states…& Iowa youth substance abuse
is declining. Challenges remain, now & in the future.
71
SHARE THE NEWS & STAY SAFE!
Iowa Governor’s Office of Drug Control Policy
Visit Our New Website: https://odcp.iowa.gov
72