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Epidemiology
Steven Shoptaw, Ph.D.
October 7, 2004
Important Concepts in Drug Abuse and Dependence
• Prevalence: The total number or percentage of cases of a disease in a population at a given time
• Incidence: The extent or rate of occurrence, especially the number of new cases of a disease in a population over a period of time.
Definitional Problems
• Drug abuse/dependence is a behaviorally defined “disease” or disorder– No pathogens or biological indicators of the
condition
Medical/Biological Understanding
“Addiction is brain disease.”
Alan Leshner, Ph.D.
Moral/Choice Model
“You can look at [scans of] brains all day. They can be lit up like Christmas trees. But unless a person behaves in a certain way, we wouldn't call them an addict.”
Sally Satel, M.D.
Normal Development
• Teens and early adolescence marked by regular sampling of mind-altering substances, run-ins with the law, problems with parents, financial problems, and intense conflicted relationships
• The vast majority, however, resolve this condition and become regular taxpayers
Differential
• No known medical condition
• No diagnosable psychiatric condition– Axis I OR Axis II
• Behaviors don’t remit despite pressure from powerful external forces (e.g., jail, spouse, employer)
Natural History of Opioid Abuse
0
5
10
15
20
25
30
10 20 30 40 50 60 70+
Decade of Life
Day
s U
sed
in 3
0
1st treatment episode
Apologies to Doug Anglin
Abuse Diagnosis
Dependence Diagnosis
Jail
Natural History of Stimulant Abuse
0
2
4
6
8
10
12
10 20 30 40 50 60 70+
Decade of Life
Day
s U
sed
in 3
0
1st treatment episode
Apologies to Doug Anglin
Abuse Diagnosis
Dependence Diagnosis
Jail
Natural History of Alcohol Abuse
0
2
4
6
8
10
12
14
16
10 20 25 30 35 40 45 50 60+
Decade of Life
Hea
vy D
rink
ing
Day
s in
30 1st treatment episode
Apologies to Doug Anglin
Abuse Diagnosis Dependence Diagnosis
$$$$
UCLA
Sentinels
• Monitoring the Future– 30 years of cross-sectional survey of 50,000 8th,
10th and 12th graders on drug use– Online database, with tables and figures of
highest relevance available at: www.monitoringthefuture.org
5+ Drinks, Last 2 Weeks
0
5
10
15
20
25
30
35
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
8th Grade 10th Grade 12th Grade
www.monitoringthefuture.org, 2004
Cigarettes, 10+ Per Day
0
2
4
6
8
10
12
14
16
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
8th Grade 10th Grade 12th Grade
www.monitoringthefuture.org, 2004
Annual Prevalence of Illicit Drug Use Index
www.monitoringthefuture.org, 2004
Methamphetamine Use, Past Year
www.monitoringthefuture.org, 2004
More Sentinels
• National Household Survey on Drug Abuse (NHSDA)
• Drug Abuse Warning Network (DAWN)• Drug and Alcohol Services Information
System (DASIS)• Community Epidemiology Work Group
(CEWG)• Clinical Literature
Prevalence - NHSDA, 2000 Prevalence - NHSDA, 2000 Illicit Drug UseIllicit Drug Use
0
5
10
15
20
25
30
35
40
45
Ever Used Past Year Past Month
MalesFemales
Any Illicit Drug Use by GenderAny Illicit Drug Use by Gender
Per
cent
Adm
itti
ngP
erce
nt A
dmit
ting
Illicit Drug Use, Past Month -Illicit Drug Use, Past Month -1999, 2000, 20011999, 2000, 2001
0
1
2
3
4
5
6
7
8
Any Drug M.J. Prescriptn Cocaine
199920002001
Per
cent
Adm
itti
ngP
erce
nt A
dmit
ting
Prevalence – NHSDA, 2000Prevalence – NHSDA, 2000Cigarette Use by GenderCigarette Use by Gender
0
10
20
30
40
50
60
70
80
Ever Used Past Year Past Month
MalesFemales
Per
cent
Adm
itti
ngP
erce
nt A
dmit
ting
Cigarettes
• While 45% of Americans smoked in 1960s, 23% of general population now smoke cigarettes (CDC, 2002; Giovino, 2002)
• ~430,000 Americans die of smoking-related causes (Giovino, 2002)
• Treatment-refractory group (George & O’Malley 2004)– Lower educational attainment, less interest in behavioral
treatments that assist cessation, and medical psychiatric and substance abuse comorbidities
– Increasing percentage of smokers are women
Natural History of Smoking
• Early smokers (started before age 15) are more likely to progress to daily smoking than those who started smoking later
• Daily smokers more likely to be dependent than non-daily smokers
• Quit attempts more successful for smokers who begin after age 15
Kandel et al 2004
Smoking in Past Month by Smoking in Past Month by Ethnicity - NHSDA, 2000Ethnicity - NHSDA, 2000
0 10 20 30 40 50
CubanCentral/S.A.Puerto RicoMexicanVietnameseKoreanJapaneseFilipinoChineseAm Ind/AlaskaBlackWhite
Substance Use by Cigarette Substance Use by Cigarette Smoking, Past Month, 2000Smoking, Past Month, 2000
0
5
10
15
20
25
30
35
40
45
Any Illicit Binge Etoh Heavy Etoh
SmokersNonSmokers
Per
cent
Adm
itti
ngP
erce
nt A
dmit
ting
Phenomenology: Seriously Phenomenology: Seriously Mentally Ill Who SmokeMentally Ill Who Smoke
• Cigarette smoking associates with psychotic Cigarette smoking associates with psychotic symptoms in bipolar disorder (Corvin et al., symptoms in bipolar disorder (Corvin et al., 2001)2001)
• Schizophrenics often heavily dependent Schizophrenics often heavily dependent smokers with great difficulty in cessation smokers with great difficulty in cessation (Dalack et al., 1998)(Dalack et al., 1998)– Low motivation to quit; interaction between Low motivation to quit; interaction between
nicotine and negative affective symptoms nicotine and negative affective symptoms (Ziedonis et al., 1997)(Ziedonis et al., 1997)
Epidemiology: SMI and SmokingEpidemiology: SMI and Smoking
• 70-90% of chronic schizophrenics smoke 70-90% of chronic schizophrenics smoke cigarettes (Glassman, 1993; George, 1997)cigarettes (Glassman, 1993; George, 1997)
• In psychiatric outpatients, schizophrenics In psychiatric outpatients, schizophrenics have highest smoking rates (Hughes, 1992)have highest smoking rates (Hughes, 1992)
• Patients with bipolar disorder smoke at Patients with bipolar disorder smoke at higher rates than general population, but higher rates than general population, but lower than schizophrenics (Diwan et al., lower than schizophrenics (Diwan et al., 1998)1998)
Substance Use, Past Year Substance Use, Past Year by Serious Mental Illness: 2001by Serious Mental Illness: 2001
0
5
10
15
20
25
30
35
40
45
Illicit Drug Cigarettes Binge Etoh
SMINo SMI
Per
cent
Adm
itti
ngP
erce
nt A
dmit
ting
Past Year Substance Abuse or Past Year Substance Abuse or Dependence by SMI: 2001Dependence by SMI: 2001
0
5
10
15
20
25
Drugs/Etoh Drugs Only Etoh Only
SMINo SMI
Per
cent
Dia
gnos
edP
erce
nt D
iagn
osed
Heroin Prevalence
• Across years and across cultures, prevalence of heroin abuse is fairly stable at about 1.5% of the adult population.– Social upheaval linked to increases in heroin
abuse (Afghanistan, Iraq, Russia)
Cocaine EpiCocaine Epi
• Cocaine abuse: 1.7 million AmericansCocaine abuse: 1.7 million Americans– 400,000 crack cocaine abusers (SAMHSA, 400,000 crack cocaine abusers (SAMHSA,
2002)2002)– Concentrated in urban areas and in ethnic and Concentrated in urban areas and in ethnic and
racial groupsracial groups
• Primary reason for treatment admission in Primary reason for treatment admission in African Americans after alcohol in LA African Americans after alcohol in LA CountyCounty
Methamphetamine Epi
• Methamphetamine abuse: 600,000 AmericansMethamphetamine abuse: 600,000 Americans– Additional 500,000 abuse other amphetamine type Additional 500,000 abuse other amphetamine type
stimulants (SAMHSA, 2000)stimulants (SAMHSA, 2000)
• Fast growing problem with established use in West, Fast growing problem with established use in West, new problems in South and Midwest (Rawson et al., new problems in South and Midwest (Rawson et al., 2002)2002)
• 20% increase in treatment admissions (DASIS, 2003)20% increase in treatment admissions (DASIS, 2003)– Primary reason for admission in California after alcohol Primary reason for admission in California after alcohol
• International problem in Europe, S.E. Asia, Thailand, International problem in Europe, S.E. Asia, Thailand, New Zealand and AustraliaNew Zealand and Australia
Eureka Police Department
A classic example of what using methamphetamine for five years can do for your complexion.
The results of injecting illegal drugs into the muscle of an arm.
1990 1995
How to recognize a drug lab Many people may be unaware that they're living near a meth lab. Here are some things to look for:
•Late night secretive activity in a rural/farm area. •Unusual, strong odors (like cat urine, ether, ammonia, acetone or other chemicals). •Residences or buildings with windows blacked out. •Renters who pay their landlords in cash. (Most drug dealers trade exclusively in cash). •Lots of traffic - people coming and going at unusual times. There may be little traffic during the day, but at night the activity increases dramatically. •Excessive trash including large amounts of items such as: antifreeze containers, lantern fuel cans, red chemically stained coffee filters, drain cleaner and cold medicine. •Unusual amounts of clear glass containers being brought into the home. •The mixing of unusual chemicals in a house, garage or barn by persons not involved in the chemical industry. •Possession of unusual chemicals, such as large quantities of MEK, Coleman Fuel, Toluene, Acetone or cold/allergy medications.
www.henrycty.com/sheriff/meth.html
Infectious Diseases Associated Infectious Diseases Associated with Substance Abusewith Substance Abuse
• Infective EndocarditisInfective Endocarditis
• Gonorrhea/Syphilis/Chlamydia/other STDsGonorrhea/Syphilis/Chlamydia/other STDs
• PneumoniaPneumonia
• TuberculosisTuberculosis
• Viral Hepatitis and Liver DiseaseViral Hepatitis and Liver Disease
• HIVHIV
Infectious Diseases Associated Infectious Diseases Associated with Substance Abusewith Substance Abuse
• Infective Endocarditis (i.e., staphylococcus Infective Endocarditis (i.e., staphylococcus aurcus)aurcus)– Frequent among IDUsFrequent among IDUs– 8-16% of hospital admissions for IDUs8-16% of hospital admissions for IDUs– Organism colonizes skin, also includes drug, Organism colonizes skin, also includes drug,
adulterants, packaging, fluidsadulterants, packaging, fluids– Occurs mostly to right side of heartOccurs mostly to right side of heart– Most common symptom is chest pain, cough, fever, Most common symptom is chest pain, cough, fever,
chills, arthralgiachills, arthralgia– Antibiotic treatment or surgeryAntibiotic treatment or surgery
Infectious Diseases Associated Infectious Diseases Associated with Substance Abusewith Substance Abuse
• Gonorrhea/ChlamydiaGonorrhea/Chlamydia
• SyphilisSyphilis– Associates with MSM and non-injection drug Associates with MSM and non-injection drug
use in Los Angeles Countyuse in Los Angeles County
HIV Serostatus of LA County MSM Early Syphilis Cases Early Syphilis Cases
2002 (Provisional), n=4062002 (Provisional), n=406
HIV-30%
Unknown14%
HIV+56%
Kerndt, 2003
Infectious Diseases Associated Infectious Diseases Associated with Substance Abusewith Substance Abuse
• PneumoniaPneumonia– Most common reason for hospitalization for Most common reason for hospitalization for
IDUs (38%)IDUs (38%)– Depression of gag reflex causes aspirationDepression of gag reflex causes aspiration– Cigarette and other types of smoking damage Cigarette and other types of smoking damage
lung functionlung function– Malnutrition hampers healingMalnutrition hampers healing– HIV complicationsHIV complications
Infectious Diseases Associated Infectious Diseases Associated with Substance Abusewith Substance Abuse
• Pneumonia (Cont’d)Pneumonia (Cont’d)– Fever, cough, chest pain, and breathing Fever, cough, chest pain, and breathing
problems for several weeksproblems for several weeks– Pneumococcal pneumonia most common in Pneumococcal pneumonia most common in
substance abuserssubstance abusers– Chest X-Rays, sputum sample, blood cultures, Chest X-Rays, sputum sample, blood cultures,
arterial blood gasesarterial blood gases– IV antibiotics treatmentIV antibiotics treatment
Infectious Disease Associated Infectious Disease Associated with Substance Abusewith Substance Abuse
• Tuberculosis – about 1,000 active cases in Tuberculosis – about 1,000 active cases in LAC, 2003LAC, 2003– Mycobacterium tuberculosisMycobacterium tuberculosis– Airborne transmissionAirborne transmission– 10% of infected individuals develop active TB10% of infected individuals develop active TB– More common among debilitated and More common among debilitated and
immunocompromised – substance abusers immunocompromised – substance abusers
Homeless HealthCare, LA 2004
Infectious Disease Associated Infectious Disease Associated with Substance Abusewith Substance Abuse
• HepatitisHepatitis– Hep A, B, C, D…Hep A, B, C, D…
– 41-48% of IDUs have history of acute hepatitis41-48% of IDUs have history of acute hepatitis
– 2/3 have abnormal liver transaminase (AST, ALT, 2/3 have abnormal liver transaminase (AST, ALT, GGTP)GGTP)
– Hep A transmitted fecal-oralHep A transmitted fecal-oral
– Hep B transmitted through body fluidsHep B transmitted through body fluids
– Non A/Non B (Hep C) transmitted through injection Non A/Non B (Hep C) transmitted through injection and via sexand via sex
Infectious Diseases Associated Infectious Diseases Associated with Substance Abusewith Substance Abuse
• Liver DiseaseLiver Disease– 2/3 have abnormal liver transaminase (AST, ALT,GTP)2/3 have abnormal liver transaminase (AST, ALT,GTP)– Alcohol directly hepatotoxic, other drugs contributeAlcohol directly hepatotoxic, other drugs contribute– Methadone is NOT hepatotoxic - Naltrexone is at very Methadone is NOT hepatotoxic - Naltrexone is at very
high doseshigh doses– Cocaine is hepatotoxic in animals and in humans at Cocaine is hepatotoxic in animals and in humans at
high doseshigh doses– Cocaine hepatotoxic associated with hypotension and Cocaine hepatotoxic associated with hypotension and
renal failurerenal failure– Ethanol + Cocaine = Cocaethylene, extremely Ethanol + Cocaine = Cocaethylene, extremely
euphoragenic and toxiceuphoragenic and toxic
Infectious Diseases Associated Infectious Diseases Associated with Substance Abusewith Substance Abuse
• HIVHIV– IDU and sexual behavior risksIDU and sexual behavior risks– IDU rate high in East (esp. among AA and LA)IDU rate high in East (esp. among AA and LA)– IDU rate low in WestIDU rate low in West– Value of testing and counseling in counselingValue of testing and counseling in counseling
Epi Can Strongly Inform HIV-Relevant Research
• Causality: Drug risks vary. While injection risk behaviors are directly tied to drug use, sexual risk behaviors are only associated with drug use
• HIV Prevalence: Prevalence factors strongly inform the value of specific HIV-research programs– IDU-specialized HIV prevention research may have more
value in East, Midwest, and South– Drug-related sexual risk reduction focus may have more
value in West
• Drug by Risk Interaction: Local differences in prevalence rates for specific drugs can direct the work
0102030405060708090
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
MSM
MSM+IDU
IDU
Hetero
Other
0102030405060708090
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
MSM
MSM+IDU
IDU
Hetero
Other
U.S. Adult Male AIDS Cases by Risk Behavior by Year
L.A. County Adult Male AIDS Cases by Risk Behavior by Year
CDC, 2004
L.A. County HIV Epi Pgm, 2004
0
10
20
30
40
50
60
70
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
IDUHeteroOther
0
10
20
30
40
50
60
70
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
IDUHeteroOther
U.S. Adult Female AIDS Cases by Risk Behavior by Year
L.A. County Adult Female AIDS Cases by Risk Behavior by Year
CDC, 2004
L.A. County HIV Epi Pgm, 2004
Local Prevalence Data Sharpens Understanding of HIV Epidemic
In Los Angeles County, heroin injectors at low risk; gay male meth users at extreme risk
010203040506070
MMT-LAC Her-LAC Meth-HWD Meth-RC
LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)
Methamphetamine and HIV in MSM: Methamphetamine and HIV in MSM: A time-to-response association? A time-to-response association?
0
20
40
60
80
100
Per
cent
HIV
+
ProbabilitySample1
StreetOutreach2
RecreationalUser3
OutpatientDrug free4
Residential5
1Deren et al., 1998, Molitor et al., 1998; 2Reback et al., in review; 3Reback, 1997; 4Shoptaw et al., 2002; 5VNRH, unpublished data
The End
• Open Every Talk with Local Epi
• Use Social Math to Drive Home the Point– Make comparisons that are easy to understand
and that use charts – not tables
