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From Rx to Heroin:The Opiate Epidemic
Stephanie Siete
Director of Community Education
CommunityBridgesAZ.org
Rx Drug Use – An Epidemic
“Prescription drug abuse is the nation's fastest-growing drug problem”
White House Office on National Drug Policy
Today, at least half of all U.S. opioid overdose deaths involve a prescription opioid
CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov
In 2014, almost 2 million Americans abused or were dependent on prescription opioids
Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2014
US loves Rx
The United States has 5% of the world’s population &
consumes 75% of the world’s prescription drugs.
http://www.unodc.org/documents/data-and-analysis/WDR2011/World_Drug_Report_2011_ebook.pdf
(PDF, 10MB)
National Institute on Drug Abuse(NIDA) 2015
The number of prescriptions written for opioid pain relievers in the U.S. has risen from around 76 million a year in 1991 to nearly 207 million a year in 2013.
In August, 2015, the FDA granted approval to Purdue Pharma to prescribe the powerful and often abused opioid OxyContin for patients as young as 11.
Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health,
National Prescription Audit, years 1997-2013, Data Extracted 2014
Opioids are a class of drugs that include the illicit drug heroin as well as the licit prescription pain relievers oxycodone, hydrocodone, codeine, morphine, fentanyl and others
Opioids are chemically related and interact with opioid receptors on nerve cells in the brain and nervous system to produce pleasurable effects and relieve pain
Opioids
Opioids Act on Many Places in the Brain and Nervous System
• Opioids can depress breathing by changing neurochemical activity in the brain stem, where automatic body functions such as breathing and heart rate are controlled
• Opioids can increase feelings of pleasure by altering activity in the limbic system, which controls emotions
• Opioids can block pain messages transmitted through the spinal cord from the body
As many as 1 in 4 people who receive prescription opioids long term for non-cancer pain in primary care settings struggles with addiction
Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids
Rx by the #s
About 16 million people in the U.S. abuse prescription medications
52 million Americans over the age of 12 have used prescription drugs non-medically in their lifetime
Men abuse prescription medications more than women
However, 12 to 17 year old females abuse prescription medications more than males
An estimated 20% of high school students admit to taking an Rx drug without a doctor's prescription
Who Abuses Prescription Drugs?
American Society of Addiction Medicine (ASAM): "Definitions Related to the Use of Opioids for the Treatment of Pain: Consensus Statement of the American Academy of Pain
Medicine, the American Pain Society, and the American Society of Addiction Medicine."
Opioid side effects, even when taken as directed
Tolerance—you may need to take more of a medication for the same pain relief
Physical dependence—symptoms of withdrawal when the medication is stopped
Increased sensitivity to pain
Constipation
Nausea, vomiting, and dry mouth
Sleepiness and dizziness
Confusion
Depression
Low levels of testosterone that can result in lower sex drive, energy, and strength
Itching and sweating
Painkillers – 5.1 million
Tranquilizers/depressants – 2.2 million
Stimulants – 1.1 million
Most abused prescription drugs fall under 3 categories:
Source: National Institute on Drug Abuse
The most common drugs involved in prescription opioid overdose deaths include:
1. Methadone
2. Oxycodone (such as OxyContin®)
3. Hydrocodone (such as Vicodin®)
Most Commonly Overdosed Opioids
Ossiander EM. Using textual cause-of-death data to study drug poisoning Ossiander EM Am J Epidemiol. 2014 Apr 1;179(7):884-94. doi: 10.1093/aje/kwt333. Epub 2014 Feb 1112.)
Among those who died from prescription opioid overdose between 1999 and 2014:
Overdose rates were highest among people aged 25 to 54 years
Overdose rates were higher among non-Hispanic whites and American Indian or Alaskan Natives, compared to non-Hispanic blacks and Hispanics
Men were more likely to die from overdose, but the mortality gap between men and women is closing
Overdose Deaths
In 2014, 467,000 adolescents were nonmedical users of pain relievers
168,000 having an addiction to prescription pain relievers
In 2014, an estimated 28,000 adolescents used heroin in the past year
An estimated 16,000 were current heroin users
An estimated 18,000 adolescents had a heroin use disorder in 2014
People often share their unused pain relievers, unaware of the dangers of nonmedical opioid use. Most adolescents who misuse prescription pain relievers are given them for free by a friend or relative
The prescribing rates for prescription opioids among adolescents and young adults nearly doubled from 1994 to 2007
Impact on Special PopulationsAdolescents (12 to 17 years old)
Women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men. Women may become dependent on Rx pain relievers more quickly than men
48,000 women died of prescription pain reliever overdoses between 1999 and 2010
Prescription pain reliever overdose deaths among women increased more than 400% from 1999 to 2010, compared to 237% among men
Heroin overdose deaths among women have tripled in the last few years. From 2010 through 2013, female heroin overdoses increased from 0.4 to 1.2 per 100,000
Impact on Special Populations(women)
Opioid Addiction 2016 Facts & Figures
Who is using
Heroin?
Overdose deaths involving prescription opioids have quadrupled since 1999, and so have sales of these prescription drugs
From 1999 to 2014, more than 165,000 people have died in the U.S. from overdoses related to prescription opioids
In 2014, almost 19,000 people died from overdoses involving prescription opioids (52 per day)
Rx Opioid Overdose Data
http://www.cdc.gov/drugoverdose/data/overdose.html
Four in five new heroin users started out misusing prescription painkillers
Rate of heroin overdose deaths nearly quadrupled from 2000 to 2013
During this time, the rate of heroin overdose showed an average increase of 6% per year from 2000 to 2010, followed by a larger average increase of 37% per year from 2010 to 2013
94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”
National Opioid Overdose Epidemic
Accidental Rx Overdoses
Opioids drive continued increase in drug overdose deaths
Drug overdose deaths increase for 11th consecutive year
Drugs Deaths on the Rise in the US 6,100 in 1980 16,849 in 1999 (4,030 opioid analgesics) 36,500 in 2008 38,329 in 2010 (16,651 opioid analgesics) 43,982 in 2013 (16,235 opioid analgesics) 47,055 in 2014 (18, 893 opioid analgesics)
In 2012 the number-one cause of death in 17 US states was prescription drug abuse (Source: American Society of Interventional Pain Physicians)
Page last updated: February 20, 2013Content source: Centers for Disease Control and Prevention
Hydrocodone
Oxycodone
o OxyContin most recognized and abused form
o Prescribed to relieve pain
o Twice as strong as morphine
o Time released (8-12 hours)o Pills crushed and snorted or cooked down and injected to
break down time release component
o Strong, heroin-like, euphoric effects
o Expensiveo Dollars to milligrams: 10, 20, 40, 50 (ex)
o Other variations: Percocet and Percodan
Oxymorphone“Opana”
Powerful semi-synthetic opioid analgesic (painkiller)
$25-$30 a pill
Strategic goal of Endo Pharmaceuticals was to market Opanato become the #2 painkiller for treating severe and long term pain after OxyContin
Doctors begin prescribing it over OxyContin
Injecting Opana – according to FDA “abuse deterrent” coating makes it easier to inject
Increased HIV/AIDS cases as a result
Zohydro ERFDA approved
High dose hydrocodone narcotic painkiller
Zohydro contains as much as 50 mg of hydrocodone
Manufactured as a powder in a capsule, rather than a pill – easy to abuse
10 times more powerful than Vicodin
US presently consumes 99% of worlds hydrocodone
PDMPs are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients
Designed to monitor this information for suspected abuse or diversion (i.e., channeling drugs into illegal use)
Can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history
Info can help prescribers and pharmacists identify patients at high-risk who would benefit from early interventions
Be in the know Share what you know
Talk to your kids
Safeguard your medicine
Dispose of Rx drugs properly
Family time/dinner
Set healthy examples
Set boundaries and enforce them
http://www.drugfree.org/newsroom/pats-2012
www.medicineabuseproject.org
What can YOU do?
Strategy 1: Reduce Illicit Acquisition and Diversion of Prescription Drugs
Proper storage and disposal options and public messaging (e.g., permanent drop boxes, take-back events)
Increased use of the Prescription Drug Monitoring Program(sign-up, use)
Strategy 2: Promote responsible prescribing and dispensing policies and practices
Develop and Implement a research-based "Best Practice" curriculum for prescribers and pharmacists
Recognition of responsible prescribers and dispensers
Initiative Strategieshttp://azcjc.gov/ACJC.Web/Rx/strategies.aspx
Strategy 3: Enhance Rx Drug Practice and Policies in Law Enforcement Education and training on Rx drug abuse and diversion crimes
Improve coding structure of data management systems for tracking Rx crimes
Strategy 4: Increase public awareness and patient education about Rx drug misuse Media dissemination to create a sense of urgency about the Rx
misuse and abuse problem in Arizona
Education (Rx 360 curriculum) for adults and youth about the risks of Rx drug misuse and abuse
Patient Education Module
Strategy 5: Enhance assessment and referral to substance abuse treatment
Initiative Strategieshttp://azcjc.gov/ACJC.Web/Rx/strategies.aspx
Safeguard your medicine and Rx drugs
Similar product, different brand
Medreturn.com MedReturn, LLC is committed to providing a
safe, secure and environmentally friendly way to help law enforcement agencies and communities collect unwanted or expired household medication, including prescriptions, over-the-counter drugs and unused pharmaceuticals
1-877-218-0990 AZ drop box locations
• Opened in 2012
• Medically Monitored Integrated Treatment
• Individual and Family
• Education, Counseling, & Psychosocial Support
• Board Certified Addictionologists & Medical Staff
Prescription Drug AddictionAn American Epidemic
No blaming, shaming, or guilting.You are not the problem.
Education and Support vs. “Intense Therapy”
Provides recommendations to primary care providers about appropriate prescribing of opioids to improve pain management and patient safety
Recommendations focus on the use of opioids in treating chronic pain (i.e., pain lasting longer than three months or past the time of normal tissue healing) in patients 18 years and older
Guidelines not intended for patients who are in active cancer treatment, palliative care, or end-of-life care
New CDC Guidelines for Opioids
Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective treatment while reducing the number of people who suffer from opioid use disorder or overdose from these drugs
CDC aims to save lives and prevent prescription opioid overdoses by equipping providers with the knowledge, tools, and guidance they need
Why New Guidelines?
Must improve safety of prescribing
Reduce harms such as opioid use disorder or overdose
Goals
The face of addiction has changed
It fixes us…. The doctor said so.
It’s not ugly. It’s tired.
It’s legal. It’s not questioned.
It’s in your home. It’s not a street drug.
A pill for every ill
Who truly knows the signs of addiction?
People are dying… does general public really know why?
Be in the Know! Educate. Communicate. Intervene.
Save a life.
Rx drug addictionNo one is immune
Why go from Rx to Heroin?
Cheaper
Same effects
Addiction drives behavior
Heroin
Pure heroin is a white powder with a bitter taste that predominantly originates in South America, Afghanistan and Southeast Asia South American heroin has become the most prevalent type
available in the US
Particularly in the Northeast, South and Midwest
“Black tar” heroin is sticky like roofing tar or hard like coal and is predominantly produced in Mexico and sold in U.S. areas west of the Mississippi River Dark color from crude processing methods leaving behind
impurities
Heroin
o Illegal, highly addictive drug processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants
o Most widely abused illicit narcotic in USo Physical tolerance build up is fasto Use to avoid pain of withdrawal “getting sick” seek to
“get well”
o Purity levels vary – too much pure heroin can result in respiratory arrest and deatho Overdose is a daily possibility
“Doda” or “Dode” –Poppy Husk / Pod Tea
Doda (aka Dode) is a powder made by crushing opium poppy husks
Typically prepared as an herbal tea or added to water or tea
Effects: euphoria, drowsiness, warming & flushing, pupillary constriction; higher doses can lead to nausea, itching, vomiting, respiratory arrest leading to death
Openly sold in foreign countries & on the Internet
"the poor man's heroin" because it's a narcotic derived from the same plant: the opium poppy
Heroin Purity
• In 1980s = 3.6% pure
• 1990 = 18% pure
• 1998 = 41% pure
• Today = 60-90% ???
• No longer have to inject heroin to feel the effect. Purity so high effects felt by snorting or smoking
• 1996-1998 – 19 young people die of heroin overdoses in Plano, Texas• Purity levels ranged up to 75%
Heroin on the Rise in the US
From 2007 to 2012, the number of Americans using heroin nearly doubled, from 373,000 to 669,000
The number of people meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for dependence or abuse of heroin doubled from 214,000 in 2002 to 467,000 in 2012
National Survey on Drug Use and Health - 2012
Past Month and Past Year Heroin Use Among Persons Aged 12 or Older: 2002-2012
26% increase in heroin deathsbetween 2013 and 2014
Centers for Disease Control and Prevention – Dec. 8, 2015
10,574 people died of heroin-related deaths in 2014 (26% )
8,257 people died of heroin-related deaths in 2013
5,925 deaths in 2012
More than six out of 10 drug overdose deaths in 2014 involved opioids, including opioid pain relievers and heroin
Heroin use is increasing and so are heroin
related deaths
More than 10,500 people
died from heroin in 2014
Many States Don’t Have Accurate Heroin Overdose Figures
Heroin deaths underreported
Determining exactly how many people die of heroin overdoses is difficult to pinpoint because many states do not require reporting of specific details on drug overdoses
Information that is available is usually at least two years old
If everybody’s classified as multi-drug toxicity, you have no idea what’s killing people
Join Together – May 12, 2015
“On the nod”
Tired
“Doped out” “Dope sick”
Cold, clammy skin
Short, shallow breath
“pinpoint” pupils
Signs of Use
Withdrawal Symptoms Restlessness
Muscle and bone pain
Insomnia
Diarrhea and vomiting
Cold flashes with goose bumps (“cold turkey”) and kicking movements (“kicking the habit”)
Users also experience severe craving for the drug during withdrawal, which can precipitate continued abuse and/or relapse
America’s Heroin Epidemic: http://www.nbcnews.com/storyline/americas-heroin-epidemic
6 Celebrities who struggled with Heroin use
HeroinA Bad Batch?
Heroin laced fentanyl Fentanyl up to 100 times stronger than morphine
22 people died within a week in Pennsylvania (Feb. 2014)
28 more people in Philadelphia died after using heroin laced with the painkiller fentanyl between March 3 and April 20, the city announced May 12th, 2014 22 to 53 years of age
Sold as “Theraflu” or “Bud Ice”
The Dangers of Fentanyl-Laced Heroin - ABC News
Actor’s Overdose Death Sheds New Light On Fentanyl-Laced Heroin Issue « CBS Pittsburgh
Desmethyl Fentanyl derivative of the painkiller Fentanyl
• Dangerous new street drug 40 times stronger than heroin
• Police also seized 1,500 kilograms of ingredients that could produce at least 3 million more pills• “They were making one pill a second”
• The effects could be fatal
In AZ… Heroin mimics Oxy
Heroin in the Heartland – CBS News 60 Minutes
What is Fentanyl?
Narcotic
It can treat severe pain.
Potent
Up to 50 times stronger than heroin and 100 times stronger than morphine
Controlled substance
High risk for addiction and dependence. Can cause respiratory distress and death when taken in high doses or when combined with other substances, especially alcohol
“Super Pill”March, 2016
“Super Pill” is designed to look like regular painkillers, but contains fentanyl
ORLANDO, Fla. —A deadly new drug that has the potential to kill someone in just minutes has made its way to Central Florida, law enforcement officials say
Fentanyl on the RiseApril, 2016
The federal Drug Enforcement Administration issued a public safety alert Friday warning that fentanyl-related overdoses are “occurring at an alarming rate” and urging the public to take only drugs prescribed by a physician and from a reputable pharmacy
Some people believe they are buying Norco, a less potent opiate, but it is fentanyl
12 deaths and 52 overdoses in a week in N. California
Remembering Prince
Died April 21, 2016
Age 57
Accidental opioid fentanyl overdose
The music icon suffered from hip pain throughout his career
PHOENIX - Arizona DEA agents work hundreds of drug cases a year. Agents often find pounds and pounds of marijuana and cocaine.
Some of the clandestine labs they bust are used for making meth or Spice. Rarely are agents surprised by what they find, but a recent bust uncovered something they’ve never seen before.
“It was like, 'oh wow,'” said DEA Special Agent Doug Coleman.
During a recent investigation, agents uncovered what is believed to be the nation’s first Spice lab using Fentanyl.
“We found many pounds of the Spice product and when you consider it is usually sold in gram quantities and Fentanyl itself is used in microgram quantities, you are talking about hundreds of thousands of doses could have gone out to street,” Coleman said.
The Spice was laced with Fentanyl -- the dealers used a cement mixer to combine the two drugs.
Arizona DEA agents bust nation's first-known Fentanyl-laced Spice lab
June 21, 2016 – Arizona Republic
W-18
First developed in a Canadian lab in 1984, promising and potent — intended to relieve pain in a less addictive way
Synthetic opioid was the most powerful in a series of about 30 compounds concocted at the University of Alberta
Chinese chemist found it, and in labs halfway around the world started developing the drug for consumers in search of a cheap and legal high — one experts say is 100 times more potent than fentanyl and 10,000 stronger than morphine
W-18
More than 2.5 pounds of W-18 was discovered in the home of a Florida man, who was sentenced to 10 years in federal prison after he pleaded guilty to smuggling fentanyl from China, reported the Sun Sentinel.
He faced no charges for possessing the W-18, however, because it’s not yet illegal in the U.S.
Currently no tests to detect the drug in a person’s blood or urine
makes it difficult for doctors to help someone who might be overdosing
The number of persons receiving drug treatment for prescription opioids rose from
360,000 in 2002 (10.3 percent of the total treatment population) to 772,000 (18.6 percent) in 2014
The number of persons receiving treatment for heroinincreased: 277,000 in 2002 to 618,000 in 2014
In addition, the number of heroin users in the US jumped from 404,000 in 2002 to 914,000 in 2014
Heroin "dependence or abuse" more than doubled from 2002 to 2014, increasing from about 214,000 to 586,000
Increase in Opioids = Increase in Treatment attributable to Rx opioids and heroin
Center for Behavioral Health Statistics and Quality (CBHSQ). Table 7.50A. 2014 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD; 2015
Number of persons 12 years or older who received last or current substance use treatment for heroin or pain relievers
Helpful Websites
communitybridgesaz.orgdrugfreeaz.org
http://www.drugfree.org/MJTalkKit/ drugfree.org/the-parent-toolkit/
getsmartaboutdrugs.comACPA.net
jointogether.orghttp://www.azcjc.gov/ACJC.Web/Rx/default.aspx
Resources
http://www.tascaz.org/
Banner Good Samaritan Poison and Drug Information Center24-hour phone: 1-800-222-1222
www.dea.gov
WTF: Why Teens Fail & What To Fix
whyteensfail.com
Amazon.com
Where can you find more information?
Call your local poison center at 1-800-222-1222. Poison centers are open 24 hours a day, seven days a week, every day of the year for poisoning emergencies and for informational calls, too.
www.aapcc.org
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Everything You Think You Know About Addiction Is Wrong | Johann Hari | TED Talks
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Stephanie Siete
Director of Community Education
Access to Care - 24/7
877.931.9142
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