Epidemiology of Drug Addiction · Epidemiology of Drug Addiction Jane C. Maxwell, Ph.D. Center for Excellence in Drug Epidemiology ... J. Copeland & J. Maxwell, under review, 2006

Current Trends in Drug Abuse--2006

Jane Maxwell, UT CSWR, 512 232-0610

Epidemiology of Drug Addiction

Jane C. Maxwell, Ph.D.Center for Excellence in Drug Epidemiology

Gulf Coast Addiction Technology Transfer Centerwww.gcattc.net

There is no conflict of interest

Data Sources• Community Epidemiology Work Group (NIDA)• Treatment admission records (TEDS-DSHS)• Emergency room data (DAWN)• Price, purity, supply, trafficking data (DEA)• Surveys (National & DSHS)• Forensic laboratory tests by DEA and DPS• Maxwell, J. C et al. (2006). Drug use and

risk of HIV/AIDS on the Mexico-U.S. Border: A comparison of treatment admissions in both countries. Drug and Alcohol Dependence.

• Maxwell, J. C. Substance Abuse Trends in Texas: June 2006. at www.gcattc.net.



U.s. Treatment Admissions by Primary Substance of Abuse: 1992-2005

0

10

20

30

40

50

60

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

AlcoholHeroinOther opiatesMarijuanaCocaineStimulantsOther drugs

Source: SAMHSA

California Treatment Admissions by Primary Substance of Abuse:

1992-2005

0

10

20

30

40

50

92 93 94 95 96 97 98 99 00 01 02 03 04 05

Alcohol Crack Powder Cocaine Marijuana Heroin Stimulants

Source: SAMHSA

# Exhibits Identified by Toxicology Labs in U.S: 2000-2005

0%

10%

20%

30%

40%

50%

2000 2001 2002 2003 2004 2005

Cocaine

Marijuana

Methamphet &Amphet

Heroin

Source: NFLIS



Drugs Identified by NFLIS Laboratories by Region: 2005

0

10

20

30

40

50

Perc

ent

West Midwest Northeast South

Marijuana Cocaine Methamphetamine Heroin

Substances Identified by California Labs: 2005

0%

20%

40%

60%

80%

100%

San Diego Los Angeles SanFrancisco

Statewide

Cannabis Methamphetamine Cocaine Heroin

Source: SAMHSA

1998 Miami DMP SamplesSouthwest Asian 2.1 % Pure

Southeast Asian 2.3 % Pure

South American 19.2 % Pure

HeroinHeroin



Opiates

• Black tar heroin, few mentions of stronger “white” heroin west of the Mississippi.

• “Cheese” is Tylenol PM and 1% heroin. Kids mix it up themselves. Concentrated in a few Dallas schools.

• Fentanyl is patches in the West, not the rogue powder seen in the Northeast (where heroin is also a white powder).

Heroin Sources and Supply Routes

Sources of Heroin Seized in US Based on Net Weight:1989-2004

0

20

40

60

80

100

1989

1991

1993

1995

1997

1999

2001

2003

SEAsianSWAsianMexicanSo. American

DEA Heroin Signature Program



Average Purity of Heroin Samples in the US:

1992-2004

0%

20%

40%

60%

80%

100%

SoutheastAsian

SouthwestAsian

Mexican SouthAmerican

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003DEA Heroin Signature Program

50%31%

11%

10%

51%48%

34%

16%

14%

24% 16%

41%

14%39% 28%

43%

28%52%

16%

WestAverage Purity: 26%Mexican

EastAverage Purity: 42%So. American

Heroin Purity: 2004

25%

53%

OTHER OPIATESAbuse of different opiates varies by

region.Problem with methadone pain pills (as

compared to diskettes and syrup used in narcotic treatment programs). Codeine cough syrup and rap music.Kids like pills because easy to get from

home, not illegal, cheap, claim it’s prescribed for them if caught, fewer side effects than street drugs, less stigma, parents won’t get as upset as if using illicits, etc. (From Partnership for a Drug Free America’s PATS Survey).



24 or more

6-9

<6

Incomplete data 12-15

Other Opiate Treatment Admissions per 100,000 by State, TEDS: 1993

KEY YEAR: 199310-11 16+

Source: SAMHSA

24 or more

6-9

<6

Incomplete data 12-15


KEY YEAR: 199310-11 16+

Source: SAMHSA

16 or more< 6

6-912-15


KEY YEAR: 1992

10-11

Source: SAMHSA



Other Opiate Items Identified in Toxicology Labs by Region: NFLIS,

2005

24121789684

14270

7140

23471482

3164

986

34163848

826

02000400060008000

10000120001400016000

West South Northeast Midwest

Hydrocodone Oxycodone MethadoneSource: NFLIS

ARCOS Retail Drug Distribution by Drug Code for the U.S: 1997-2004

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

1997 1998 1999 2000 2001 2002 2003 2004

Oxycodone Hydrocodone Methadone

Source: DEA

Treatment Admissions Nationwide by Primary Substance. TEDS: 1992-2004

02468

1012141618

1992

1994

1996

1998

2000

2002

2004

Other OpiatesIllicit MethadoneHeroin

Source: SAMHSA



Characteristics of Heroin and Other Opiate Treatment Admissions Nationwide, TEDS: 2004

0

20

40

60

80

100

% Ma

le

% Whit

e

% Bla

ck

% Hispanic

Av. A

ge

% ID

U

% Or

al

Other Opiates Heroin

Source: SAMHSA

Methadone-Related Unintentional Poisoning Deaths: 1999-2003 from National Center for Health Statistics, National Vital Statistics

System

623778

1158

1911

2452

0

500

1000

1500

2000

2500

3000

1999 2000 2001 2002 2003

ARCOS Methadone Grams Distributed by Type: 2000-2005

0200400600800

10001200140016001800

2000 2001 2002 2003 2004 2005

Tablets Diskettes Liquid

Source: DEA



COCAINEStill Around—

with New Users

Cocaine• Methamphetamine outselling cocaine and crack in some areas in Texas; coke dealers now fronting cocaine to compete—or shifting to selling Ice.

• Purity of cocaine increasing.• Still around with new users.• Proportion of crack treatment admissions who are Anglo or Hispanic continues to increase.

• Injecting crack.

Race-Ethnicity of US Cocaine Admissions: 1992 v. 2004

0%

20%

40%

60%

80%

100%

Crack-92

Crack-04

IDU-92

IDU-04

Inhale-92

Inhale-04

Black White Hispanic

Source: SAMHSA



30%

35%19%

25%

28% 35%

12%

9%9%

26%

Cocaine Admissions inU.S. and Mexican Border States: 2003

DOWNERS

• Potentiate low-quality heroin (and seen in heroin overdoses)

• Come down from speed or cocaine trips

• Dependence among females• Kids like alprazolam (Four Bars).

Benzodiazepines Identified by Toxicology Labs in the US:

2000-2005

0.0%0.2%0.4%0.6%0.8%1.0%1.2%1.4%1.6%

Alprazolam Diazepam Clonazepam

2000

2001

2002

2003

2004

2005



MARIJUANA• Fairly stable.• Influence of Blunts and Wraps• Use with Fry, PCP, DANK, crack, cough syrup, honey, etc., continues.

• Continuing references to pot and PCP and embalming fluid (ether).

• CJ v. Non-CJ treatment admissions

• Primos--marijuana joint and crack.• Fry, Amp--joint and embalming fluid (PCP?)

• Fry Sticks & Fry Squares--$10 each.• Fry Sweets--blunts in embalming fluid.• Sweet Houses--sell ready-mades.• Candy Blunts--cigarillos in codeine cough syrup.

• Sherms--menthol cigarettes in embalming fluid.

% Texas Secondary Students Who Had Used Any Illicit Drug in the Past

Month, by Ethnicity: 1988-2004

0%

5%

10%

15%

20%

25%

1988

1990

1992

1994

1996

1998

2000

2002

2004

AnglosAfrican AmericansHispanics

Source: DSHS



Addiction Severity Index Problems of Texans Treated with Primary Marijuana

Problem: 2005

0% 20% 40% 60% 80%

Sickness

Employment

Family

Social

Emotional

Sub. Abuse

Non-CJ ReferralCJ Referral

Source: DSHS

Cannabis Treatment Outcomes Among Texas Clients

• Criminal justice admissions to treatment were less impaired, more likely to complete treatment (42% v. 34%), and abstinent from cannabis at follow-up ( 76% v. 66%).

• 55% of all clients met criteria for cannabis dependence.

• CJ clients received less intensive services.• Although DSM-IV underreported, voluntary

more likely to have mood depressive disorder and be prescribed medications for mental health problems.

J. Copeland & J. Maxwell, under review, 2006.

Alcohol



Percentage of Texas Secondary Students Who Reported They Normally Consumed Five or More Drinks at One Time, by

Gender: 2000–2004

22% 22%20%

32%30%

26%

0%

5%

10%

15%20%

25%

30%

35%

2000 2002 2004

GirlsBoys

Liu, L. Texas School Survey of Substance Use Among Students in Grades 7-12, DSHS.

Primary Problem Substance of Texas DUI Admissions to

Treatment

Alcohol

Heroin

Other Opiates

Amphet/ Meth

Powder Cocaine

Cannabis

Crack Cocaine

Other

1996 2005

66%75%

Maxwell, Impaired Drivers at Admission to Substance Abuse Treatment, RSA Poster, 2006.

2% 7%1%

4%



Methamphetamine

Sources of Amphetamine-Type Substances

Sources of ephedrineMajor producers of methamphetamine



Methamphetamine Use in Past Month Among Persons Ages 12 or Older, by Dependence and

Abuse: NSDUH 2002-2005

433

10163

357

158

92

237

216

130

255

154

103

0

100

200

300

400

500

600

700

# P

ast

Mon

th U

sers

(in T

hous

ands

)

2002 2003 2004 2005

StimulantDependence/AbuseOther Illicit DrugDependence/AbuseNo Illicit DrugDependence/Abuse

597 607 583

Source: SAMHSA

512

4 Most Frequently Identified Drugs by NFLIS Toxicology Laboratories

0%

10%

20%

30%

40%

Methamphetamine Cannabis Cocaine Heroin

2000 2001 2002 2003 2004 2005

Source: NFLIS

Normal Course of a Drug Epidemic(Texas Cocaine Admissions: 1983-2004)

0

5

10

15

20

25

30

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

CrackPowder

Outbreak Endemic

Hyperendemic



The Methamphetamine Epidemic:TEDS Admissions/100,000: 1992-2004

0

50

100

150

200

250

300

1992

1994

1996

1998

2000

2002

2004

ArkansasHawaiiIowaCaliforniaGeorgiaConnecticutWashington

It keeps going up

Source: SAMHSA

Stages of Meth Epidemic?• Early Stages—Ice in gay and party scene; powder

meth via overnight express from California; crack in urban areas.

• Middle Stages—Mom & Pop cookers and large problem in rural areas; crack still strong in urban areas; Mexican meth starts being trucked in to urban areas.

• Late Stages—primary problem for treatment admissions; spreads across racial/ethnic groups; Ice is dominant form and powder supply decreases; increasing types of traffickers (criminal groups, ethnic gangs, outlaw bikers).

Race-Ethnicity of US Methamphetamine Admissions:

1992 v. 2004

0%

20%

40%

60%

80%

100%

Smoke-92

Smoke-04

IDU-92

IDU-04

Inhale-92

Inhale-04

Black White Hispanic

Source: SAMHSA



Routes of Administration of Methamphetamine of Clients in US

Programs: 1993-2004

010203040506070

1993

1995

1997

1999

2001

2003

OralSmokingInhalationInjection

Source: SAMHSA

% Methamphetamine/Amphetamine and All Other U.S. Admissions by

Urbanization: 2004

05

101520

2530

3540

LargeCentralMetro

LargeFringeMetro

SmallMetro

Non-Metro w/

City

Non-Metro

w/o City

Perc

ent

MethamphetamineAll Others

SAMHSA DASIS Report, 27, 2006 Large is 1 million or more population; Small is MSA with less than 1 million, & Non-Metro is city of 10,000 or more

U.S. Methamphetamine/Amphetamine Admissions by Route of Administration &

Urbanization: 2004

7 11 9 9 916 15 13 16 19

15 14 25 24

62 60 54 50 48

24

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

100%

LargeCentralMetro

Large FringeMetro

Small Metro Non-Metrow/ City

Non-Metrow/o City

Perc

ent

SmokingInjection

InhalationOther

SAMHSA DASIS Report, 27, 2006. Large is 1 million or more population; Small is MSA with less than 1 million, & Non-Metro is city of 10,000 or more



U.S. Methamphetamine/Amphetamine Admissions by Race/Ethnicity &

Urbanization: 2004

5677 78 86 87

5

3 21 1

28

14 6 411 6 9 7 811

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

100%

LargeCentralMetro

Large FringeMetro

Small Metro Non-Metrow/ City

Non-Metrow/o City

Perc

ent

OtherHispanic

BlackWhite

SAMHSA DASIS Report, 27, 2006. Large is 1 million or more population; Small is MSA with less than 1 million, & Non-Metro is city of 10,000 or more

> 5835 - 58

< 1212 - 35

No data

Primary Amphetamine/MethamphetamineTEDS Admission Rates: 1997

(per 100,000 aged 12 and over)

Source: SAMHSA

> 5835 - 58

< 1212 - 35

No data



Source: SAMHSA



> 5835 - 58

< 1212 - 35

No data



Source: SAMHSA

40%

18%3%

14%

13% 7%

31%

10%4%

9%

Methamphetamine Admissions inU.S. and Mexican Border States: 2003

Areas to Watch• Use of meth on the job (Work Force needs)

• Truckers, day laborers, people working long hours and boring jobs.

• Risky sexual behaviors• Heterosexuals & homosexuals.• Party people • Immigrants/migrants away from home and

families.• Increasing criminal distribution

• Traffickers following the migrant trail.• More organized and criminal gangs.



Club Drugs• Problems identified early: MDMA in 1985, GHB

in 1990,Ketamine in 1991, Rohypnol in 1993, but slow responses.

• Research studies underway but are incomplete and can be problematic.

• Use of Internet to obtain information from pro & anti-drug sites (BUT information can be erroneous, untested, outdated, or extreme). And trends move around the world through the Internet.

• Problems testing & identifying various drugs.• Lack of detox & treatment protocols.• Misperception that all club drugs are alike.

Substances Identified by Labs Participating in the National Forensic Laboratory Identification System:

1997-2005

0%

20%

40%

60%

80%

100%

1997

1999

2001

2003

2005

MDMAHeroinMethamphetamineCocaineCannabis

Source: NFLIS

Party Drugs Identified by U.S. Toxicology Labs: 2003-2005

0

2000

4000

6000

8000

10000

12000

14000

LSD MDMA PCP Ketamine GHB, GBL,1-4BD

2003 2004 2005

Source: NFLIS



Admissions to Texas Treatment Programs by Primary, Secondary or Tertiary Problem with a Club Drug:

1988-2005

0

100

200

300

400

500

600

700

800

900

1988

1990

1992

1994

1996

1998

2000

2002

2004

EcstasyGHBHallucinogens

KetamineRohypnolPCP

Source: DSHS

Admissions to Texas Treatment Programs With a 1st, 2nd, or 3rd Problem With a Club

Drug: 2005

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

100%

Ecstasy GHB Halluc PCP Rohypnol

0

5

10

15

20

25

30

35

Ave

rage

Age

White Black Hispanic AgeSource: DSHS

Race/Ethnicity of Texas DSHS Clients Admitted with a Problem with

Ecstasy: 1990-2006

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

100%

1990

1992

1994

1996

1998

2000

2002

2004

2006

WhiteHispanicBlack

Source: DSHS



LSD and Mushrooms

• LSD low dose and more prevalent than we think?

• Mushrooms are more popular than LSD? Need to start watching for them.

GHB, GBL, 1-4BD“Fantasy”

SPECIAL ANNOUNCEMENTS FROM MARK/JLF(updated 12-11-01)

SHOP OUR CATALOGDISCLAIMER AND INFORMATION

"JLF sells poisonous-non-consumable items, consisting of various raw materials and related merchandise used for art, hobby, science, industry, and/or religion. Products include Amanita muscaria ("Fly Agaric") mushrooms, Claviceps purpurea ("Ergot Fungus") sclerotia , Trichocereus pachanoi ("San Pedro") cactus, Psilocybin mushroom spores and kits, Papaver somniferum ("Opium Poppy") pods, Argyreia nervosa ("Hawaiian Baby Woodrose") seeds, Anadenanthera colubrina ("Cohoba") seeds, and many other ethnobotanicals. Also pure compounds such as yohimbine, L-tryptophan, etc."

JLF Poisonous Non-ConsumablesP.O. Box 184Elizabethtown, IN 47232

DISSOCIATIVE DRUGS: PCP, Ketamine, DXMDistort perceptions of sight

and sound and produce feelings of detachment, but not

hallucinations (Zombie effect)



Phencyclidine

• PCP, Angel Dust, Killer Weed• Dissolved in embalming fluid or ether (“Fry,” “Amp,” “Water, Water”).

• Swallowed, sniffed, smoked on joints dipped in “Fry”.

• Menthol cigarettes are dipped into liquid PCP or blunts are laced with powdered PCP.

NDARC Study of Ketamine Users*

• N=100; well-educated; older group of party drug users.

• Some had access because in medical field.• Used with MDMA, MDA & amphetamines.• Many had regular negative side effects such

as inability to speak, blurred vision, lack of coordination.

• Issue for warnings: Usually unpleasant side effects seen by some as “positive” and encouraged experimentation.

*Dillon, Copeland, Jansen, Patterns of Use and Harms Associated with Non-Medical Ketamine Use, Drug and Alcohol Dependence 69 2003) 23-28.

What isWhat is DxMDxM? ? DextromethorphanDextromethorphan is a is a psychoactive drug found in common over the counter psychoactive drug found in common over the counter cough medicines.cough medicines.

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



•• ““RobotripRobotrip”” –– high dosages can produce high dosages can produce hallucinogenic effects hallucinogenic effects

•• Part of family of psychoactive compounds called Part of family of psychoactive compounds called ““dissociative anesthetics.dissociative anesthetics.””

•• Some effects have been described as similar to Some effects have been described as similar to those of ketamine (Special K) and PCP.those of ketamine (Special K) and PCP.

• The DxM experience is described as occurring on levels, or plateaus depending on the amount of the dose taken.

• Each plateau is different from another. There are 4 major plateaus + a fifth one that is generally unpleasant and involves a possible trip to the hospital

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

DXM Calculator



Carisoprodol• “Ds”, “Dance,” Las Vegas Cocktail (with

hydrocodone), “Soma Coma” (with codeine).• Reported as problem by CEWG members in

Washington, South Florida, and Texas.• Texas PCC abuse calls from 1998 to 2003—39%

involved only carisoprodol. More likely males, adolescents, happened at other residences, schools, public areas; serious medical outcomes

• 2004 Texas deaths with mention of carisoprodol: 60% male, 93% white, av. age 41. Only 3 of 87 were just carisoprodol; the rest also involved other substances, especially hydrocodone and alprazolam.

Inhalants

% Texas Secondary Students Who Had Used Inhalants Ever or in the

Past Month, by Grade: 2004

0%

5%

10%

15%

20%

25%

Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12

Lifetime Use Past-Month Use



Percentage of Texas Students Who Had Ever Used Inhalants, by Grade and

Number of Different Types Used: 2004

0%

5%

10%

15%

20%

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 1

0

Grade 1

1

Grade 1

2

4+ Types 2-3 Types 1 Type

% Texas Reform & Secondary School Students Who Had Ever Used Specific Inhalants: 2000-2001

61%

41%

17%

14%

13%

11%

7%

6%

8%

6%

2%

2%

4%

4%

5%

8%

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

Spray Paint

Gasoline

Freon

Octane Booster

Lacquer/Toluene

Aerosol Sprays

Glue

Correction Fluid

Secondary SchoolReform School

Age Groups of Inhalant Abusers As Seen in National Data Sets

46% 52%

21%

16%31%

18%

18%

7%

24%

21% 9%37%

0%

20%

40%

60%

80%

100%

TEDS Tmt.-2004 NSDUH Survey-2005 PY DAWN Eds--2005

12--17 18--25 26--34 35+



Occupation by Type of Inhalant Mention, Texas Deaths: 1988-1998

42%49%

16%

37% 5%

4%

10%22%

40%

0%

20%

40%

60%

80%

100%

Freon CHC Toluene

Blue CollarMechanicsStudent

Percent of AIDS Cases Reported by Selected Modes of Exposure: 1987-2005

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

1987

1990

1993

1996

1999

2002

2005

MSM

IDU

M-M & IDU

Hetero

Texas Male and Female AIDS Cases by Race/Ethnicity: 1999-2005

0%

20%

40%

60%

80%

100%

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Hispanic MaleBlack MaleWhite MaleHispanic FemaleBlack FemaleWhite Female



WWW.GCATTC.NET

• Anesthesia doses 2-10 mg/km; recreational doses 50-100 mg.

• Unsafe sexual behavior associated with frequent use of Ketamine. Use at gay circuit parties of concern.

• Taken in cyclical binges similar to cocaine or methamphetamine.

• Available as powder to snort or as liquid to inject; used with “puffers” to get exact dosing.

• Users can become psychologically dependent but no evidence of physiologic withdrawal syndrome.

SPECIAL K (Ketamine)

Conclusions from NSDUH: Nonmedical Use of Rx Pain Relievers

• Increases in lifetime users, but current users relatively stable

• Ages 18-25 had highest rates for all pain relievers reviewed

• Little variation in rates across States, regions, metro/non-metro areas

• Most OxyContin users (lifetime) also used other opiates

Source: SAMHSA



Conclusions from DAWN: Nonmedical Use of Opioid Pain

Relievers• ED visits in 2004 > 150,000 (131k-185k)

– Oxycodone, hydrocodone, methadone > fentanyl, morphine, propoxyphene

– Polydrug use is typical– About half of oxycodone products are

SR type• Patients aged 21-54 had highest visit rates• Rates vary across metro areas examined• Majority of patients treated and released

Source: SAMHSA

Documents

Epidemiology of Drug Addiction · Epidemiology of Drug Addiction Jane C. Maxwell, Ph.D. Center for Excellence in Drug Epidemiology ... J. Copeland & J. Maxwell, under review, 2006