Prescription Drug Abuse - Administrative Office of the Courts

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Prescription Drug Abuse - Administrative Office of the Courts

Prescription Drug Abuse


Misperception:

When we don’t see specific drugs

anymore the problem has gone away.


Current Users

ANY ILLICIT DRUG:

20.1 million

(8% of population)

MARIJUANA: 15.2 million

PSYCHOTHERAPEUTIC

DRUGS: 6.2 million

COCAINE: 1.9 million

METHAMPHETAMINE: 314,000

Source: 2007 NSDUH = Drug Use in the past month

Source: 2008 NSDUH

HEROIN: 213,000


Scope and Extent of Problem

2004 2007 2008

0.3 million

0.35 million

0.23 million

Sedatives

1.2 million

1.1 million

.9 million

Stimulants

1.6 million

1.8 million

1.8 million

Anti-Anxiety

Medication

4.4 million

5.2 million

4.7 million

Narcotic Pain

Relievers

Source: 2004, 2007, and 2008 National Survey on Drug Use and Health


Prescription Drug Abuse

More Americans abuse prescription drugs than the

number of:

Cocaine, Hallucinogen, Heroin, and Inhalant abusers

COMBINED!!!


Past Year Initiates for Specific Drugs

Persons Aged 12 or Older 2008

Numbers in the Thousands


Percent Increase in Forensic Cases

2001-2008

265%

235%

Source: NFLIS


Emergency Room Data 2004-2008

• Increase of 97%: ER visits attributable to pharmaceuticals alone

(i.e., with no other type of drug or alcohol) (336,987 – 664,654)

– No Significant Change: ER visits attributable to cocaine, heroin,

marijuana, or methamphetamine

Drugs most frequently implicated in non-medical use:

– Opiates/Opioids 112% increase 2004-2008 (419,762)

• Oxycodone/combinations 148% increase

• Hydrocodone/combinations 124% increase

– Benzodiazepines 94% increase 2004-2008 (330,235)

• Alprazolam 134% increase

• Clonazepam 85% increase

SOURCE: 2004-2008 DAWN (Drug Abuse Warning Network)


% Increase in Poisoning Deaths in the

U.S. Since 2000

Source: CDC


Teens and Their Attitudes

• 2 in 5 teens believe that Rx

meds are “much safer” than

illegal drugs

• 31% teens believe there’s

“nothing wrong” with using

Rx meds without a

prescription “once in a

while”

• Nearly 3 in 10 teens believe

Rx pain relievers are not

addictive

Source: Partnership for Drug Free America


Teens and Their Attitudes

• Every day 2,500 teens use

Rx drugs to get high for the

first time

• 60% of teens who have

abused Rx painkillers did so

before the age of 15

• 1 in 7 teens admit to abusing

Rx drugs to get high in the

past year

• 56% believe that Rx drugs

are easier to get than

illegal drugs

• 62% believe that teens get

Rx drugs from their own

family’s medicine cabinet

– for FREE

Source: Partnership for Drug Free America


Teens and Their Attitudes

A dramatic softening in teen attitudes and beliefs

• 2008-2009

• 11% increase in use of alcohol

• 67% increase in use of Ecstasy

• 19% increase in use of marijuana

• 51% of teen agree that “being high feels good”

• 75% of teens say that “friends usually get high at

parties”

Source: Partnership for Drug Free America March 2, 2010


Sources of Information and Risks

% Learned a

lot about risks

of drugs from…

1998 2004 2005 2007 2008 2009

School 41 42 38 37 44 39*

Parents 26 28 28 29 35 31

TV Commercials 17 36 26 31 31 26*

The Internet 11 23 22 25 29 29

Websites like

YouTube

NA NA NA NA 14 17*

* = Significant at the .05 level vs 2008

Source: Partnership for Drug Free America, March 2, 2010


Parents and Their Attitudes

• Parents are still not discussing the risks of abusing

prescription and over-the-counter medicines

– Increase in parent / teen discussions about the risks of

illegal drugs, but not prescription drugs

– Only 24% of teens report that their parents talked with

them about the dangers of prescription drugs or use of

medications outside of a doctor’s supervision

– Just 18% of teens say their parents discuss the risks of

abusing over-the-counter (OTC) cough medicine

SOURCE: 2008 Partnership Attitude and Tracking Study (PATS) Released FEB 2009


Top Five Prescription Drugs

Sold in the U.S. (2004-2008)

(By Number of Prescriptions Sold)

Source: Verispan

93,680,000 101,639,000 109,652,000 117,200,000 121,266,000

1. Pain reliever

2. Cholesterol

3. Antibiotic

4. Blood pressure

5. Diuretic

6. Cholesterol

7. Heart disease


Hydrocodone, APAP C-III

‣ Hydrocodone / Acetaminophen (toxicity)

‣ Similarities:

– Structurally related to codeine

– Equal to morphine in producing opiate-like effects

‣ Brand Names: Vicodin ® , Lortab ® , Lorcet ®

‣ “Cocktail” or “Holy Trinity”

‣ Hydrocodone

‣ Soma ® / carisoprodol

‣ Alprazolam / Xanax®

‣ Street prices: $2 to $10+ per tablet depending on

strength & region


Methods of Diversion

• Practitioners / Pharmacists

– Illegal distribution

– Self abuse

– Trading drugs for sex

• Employee pilferage

– Hospitals

– Practitioners’ offices

– Nursing homes

– Retail pharmacies

– Manufacturing / distribution

facilities

• Pharmacy / Other Theft

– Armed robbery

– Burglary (Night Break-ins)

– In Transit Loss (Hijacking)

– Smurfing

• Patients / Drug Seekers

Drug rings

– Doctor-shopping

– Forged / fraudulent / altered

prescriptions

• The medicine cabinet /

obituaries

• The Internet

• Pain Clinics


States with PDMPs

• The 34 states that have operational PDMPs (capacity to receive

and distribute PDMP information to authorized users)

– Alabama, Arizona, California, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana,

Iowa, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi,

Nevada, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma,

Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia,

West Virginia, and Wyoming

• The 7 states (plus Guam) have legislation in place but are not

yet operational

– Alaska, Florida, Kansas, Oregon, New Jersey, South Dakota, and Washington

• Another 5 states have introduced legislation

– Georgia, Wisconsin, Maryland, Delaware, and New Hampshire

As of May 2010


Ryan Haight Online Pharmacy

Consumer Protection Act

• New DEA registration requirements for all Internet pharmacies

• Defines “online pharmacy”

• Defines “valid prescription”

• Requires at least one in-person medical evaluation

• Monthly reporting requirements

– Number of prescriptions

– Dosage unit totals

• Disclosure requirement on home page

– Name, address, phone, & E-mail of all pharmacies

– Name & license # of Pharmacist in Charge

– Name, address, phone, degree of all physicians

• Effective date: April 13, 2009


New Felony Offense

Internet Trafficking

‣ 21 USC 841(h)(1): It shall be unlawful for any

person to knowingly or intentionally:

(A) deliver, distribute, or dispense a

controlled substance by means of the

Internet, except as authorized by this title; or

(B) aid or abet any violation in (A)

Reaction – Moved to Non-Controlled Drugs


Explosion of South Florida

Pain Clinics

As of May 14, 2010, Florida has received 1,002 applications and has approved 944

*As of May 14, 2010, Broward 131; Miami-Dade 83; Palm Beach 111


Identifying Rogue Clinics

• Legitimate clinics can sometimes be distinguished

from rogue clinics by business practices

Business

Practice

Payment

Accepted

Affiliations

Physician

Accreditation

Alternative

Therapies Offered

Legitimate

Pain Clinic

Cash, credit, check, insurance

Local hospitals and therapy

centers

American Board of Pain Medicine

American Society of Interventional

Pain Physicians

American Board of Anesthesiology

Physical therapy, muscle therapy,

exercise

DRUG ENFORCEMENT

ADMINISTRATION

Typical Rogue

Pain Clinic

Cash or Credit

Card Only

None

None

None


Drugs Prescribed

• A ‘cocktail’ of oxycodone and alprazolam (Xanax ® )

• An average ‘patient’ receives prescriptions or

medications in combination

Schedule II Schedule III Schedule IV

Oxycodone 15mg, 30mg Vicodin (Hydrocodone) Xanax (Alprazolam)

Roxicodone 15mg, 30mg Lorcet Valium (Diazepam)

Percocet

Percodan

Demerol

Methadone

Lortab

Tylenol #3 (codeine)

Tylenol #4 (codeine)


Dosage Units Dispensed in Florida

• In 2008, the tri-county area pain clinics dispensed a

total of about 9 million dosage units of oxycodone

– Does not include prescriptions

• In 2009, Top 100 dispensing practitioners in U.S. for

oxycodone

– 97 practitioners were in Florida

• dispensed 20,715,907 dosage units of oxycodone

– 86 were in the tri-county area

• dispensed 18,760,745 dosage units of oxycodone

SOURCE: Broward County Florida Sheriff’s Office Pharmaceutical Drug Diversion Unit & ARCOS


Efforts to Avoid Law Enforcement

‣ Some clinics provide customers with

information on ways to get around law

enforcement if caught carrying prescription

drugs

‣ Staged burglaries

‣ Radio frequency detectors


What’s the Cost?

Deaths Associated with Rx Drugs in Florida

Reports of Rx Drugs

Detected in Deceased Persons

% Increase

2005-2008

Drug 2005 2006 2007 2008

Methadone 620 716 785 693

Oxycodone 340 496 705 941 176.8%

Hydrocodone 221 236 264 270

Benzodiazepines 574 553 743 929

Morphine 247 229 255 300

TOTAL 2,002 2,230 2,752 3,133 56.5%

SOURCE: Florida Medical Examiner’s Commission


Fentanyl

‣ Fentanyl Patches

Fentora®

Actiq ®

‣ Fentanyl Citrate dispensed in a

berry flavored lollipop-type

unit

‣ Fentanyl is 100 times more

potent than morphine

‣ Intended to be used for chronic

cancer pain & only for people

who are tolerant to prescription

opioid (narcotic) pain

medicines

Abused for its intense euphoric

effects


Other Controlled Substances

• Phentermine C-IV

• Phendimetrazine C-III

– Bontril®

• Benzodiazepines

– Alprazolam/Xanax ®

• Amphetamines

– Adderall C-II

– Methylphenidate C-II

• Ritalin®

• Concerta®


• Analgesic:

Non-Controlled Substances

– Tramadol (Ultram®, Ultracet®)

• Arkansas, and Kentucky

• Muscle Relaxant:

– Carisoprodol (Soma®)

• Alabama, Arkansas, Arizona, Connecticut, Florida, Georgia,

Hawaii, Indiana, Kentucky, Massachusetts, Minnesota, Nevada,

New Mexico, Oklahoma, Oregon, and West Virginia.

– Cyclobenzaprine (Flexeril®)

• Cough Suppressant:

– Dextromethorphan (DXM)

• Over-the-Counter (OTC) cold medication, such as: Coricidin HPB

Cough and Cold Tablets and Robitussin Cough Syrup


Designer Club Drugs

and

“Legal Highs”

…but legal doesn’t mean safe!!


N-benzylpiperazine / BZP Sch I

• AKA: “Frenzy”, “Nemesis”, “A2”

• Stimulant sold as an alternative to MDMA

– 6-8 hours

Abused by teens and young adults as a club

drug

• Risks

– Uncertainty of dosages

– Uncertainty of other ingredients: TFMPP / DXM

• Side Effects

– Anxiety, blurred vision, increased blood

pressure, insomnia, irregular heartbeat,

hallucinations, and paranoia


5-MeO-DIPT Sch I

• AKA “Foxy”, “Foxy methoxy”

• Hallucinogenic effects

– 3-6 hours

Abused by teens and young adults

• Tryptamine

– Psilocybin

• Dilated pupils, nausea, diarrhea, diminished

inhibitions


• 4-methylmethcathinone

• “Meow Meow” or “drone”

• Similar to MDMA

Mephedrone

• Not controlled federally, but an analogue of methcathinone

(sch I)

• However, it is sold as “plant food” with “discreet delivery”

• Linked to several deaths in the UK

• Side effects:

– Tachycardia

– Insomnia

– Bruxism

– Hypertension


Ivory Wave / Vanilla Sky

• Sold on Internet and in headshops as “bath salts”

• Chemical(s): MDPV & CFT

– MDPV similar to MDMA

• Methylenedioxypyrovalerone AKA “Sonic”

• 4x more potent then methylphenidate

• Dopamine reuptake inhibitor

– CFT Sch II - substitute for cocaine

• ß-CFT (WIN-35,428; 2-Carbomeythoxy-3-(4 fluorophenyl) tropane)

• Reported to be 3-10x more potent than cocaine if snorted

• Side effects:

– tachycardia, hypertension,

– dopamine depletion,

– dilated pupils, convulsions


THC-like Substances “Spice” / K2

• An herbal mixture called

“Spice” and K2 is sold in

European countries and in the

U.S. via the Internet, head

shops, tobacco shops and other

retail venues.

• “Spice” and K2 are found to

contain substances with

marijuana-like psychoactive

effects (e.g., HU-210, HU-211,

JWH-018, JWH-073 and CP

47,947 & homologues) and it

is abused by smoking.


Manufactures & Acquisition

• China, Cameroon, Pakistan, Russia

• Internet web sites

– Independent sites

– Commercial sites

• TradeKey.com

• Alibaba.com

• Tradevv.com


Problems with Designer Drugs & Chemicals

‣ Marketed to teens and young adults

‣ Easily attainable via the Internet

‣ Unknown ingredient(s)

‣ No consistency in manufacturing process

‣ Not tested or approved for human consumption

‣ No known dosage

‣ Synergistic effects likely when mixed with other drugs or alcohol

‣ Do not show up on drug screening tests

‣ Short-term effects are bad - Long-term effects unknown


Black Mamba

• Damiana a shrub native to:

– Mexico, Central America, South America and the

Caribbean

– Can have psychoactive effects on the central

nervous system


Salvia Divinorum

• A perennial herb in the mint family

(Labiatae or Lamiaceae).

• Indigenous to the state of Oaxaca,

Mexico.

• Internet sites advertise Salvia as a legal

alternative to other controlled

hallucinogens

• “Maria Pastora”, “Sage of the Seers”,

“Diviner’s Sage”, “Salvia”, “Sally-D”,

“Magic Mint”

• Sold as fresh and dried leaves, whole

plants, cuttings & extracts


Salvia Divinorum and Salvinorin A

Control Status as of April 2010

• Controlled as Schedule I in 14 States

• Delaware, Florida, Hawaii, Illinois, Kansas, Kentucky, Mississippi, Missouri,

Nebraska, North Dakota, Ohio, Oklahoma, South Dakota, and Virginia

• Only legal when Not intended for human consumption

• Louisiana, North Carolina, and Tennessee

• Illegal when provided to underage persons

• California (minors can possess), Maine (illegal to possess if under 18,

Maryland (pending)

• Illegal to manufacture, deliver, or sell, but legal to possess

• Wisconsin

• DEA is in the process of conducting a scheduling recommendation.

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