Indicators of Prescription Drug Nonmedical Misuse and Abuse in South …cdn.trustedpartner.com/docs/library/UWBCCommissionSubstanceAb… · Abuse in South Florida: 2008 James N. Hall1

United Way of Broward County Center for the Study& Prevention of Sub. AbuseCommission on Substance Abuse June 2009 Nova Southeastern University

Indicators of Prescription Drug Nonmedical Misuse andAbuse in South Florida: 2008

James N. Hall1

ABSTRACT

During 2008 an average of 6 persons died everyday (n=2,184) in Florida with at least one pre-scription drug that was, in the opinion of a medical examiner, a lethal dose and the cause ofdeath. In total there were 3,750 lethal dose reports of prescription drugs detected in deceasedpersons or an average of 10 reports per day. These drugs may have been mixed with othermedications, illicit drugs, and/or alcohol. Thus, the number of lethal prescription drug reportsexceeded the number of persons who died. There were an additional 6,286 prescription drugsdetected in deceased persons that were not considered to be at a lethal dose level but may havebeen found in combination with other substances. The total of 10,036 prescription drugs de-tected was related to 4,924 deaths or an average of nearly 13½ deaths per day in Florida during2008. Consequences from the non-medical use of prescription opioids are much higher in PalmBeach and Broward Counties than in Miami-Dade County where heroin is the major opiateproblem. Broward County was the location for two-thirds of the top 50 dispensing practitionersof oxycodone in the United States during the second half of 2008. These 33 Broward “pill mill”pain clinics dispensed 6½ million dose units of oxycodone in the same six months. Oxycodonewas detected in 1,574 deceased persons in Florida during 2008 and was determined to be a le-thal dose level by medical examiners who considered it the cause of death in 942 of those cases.Between 2007 and 2008, reports among deceased persons in all of Florida related to prescrip-tion opioids increased 8-percent, from 5,059 to 5,454. The 342 such occurrences in BrowardCounty represented a 23-percent increase over 2007 while the 361 reports in Palm Beach werea 4-pecent decline from the number in 2007. The 124 prescription opioid reports among Miami-Dade decedents in 2008 represented a 31-perecent decrease from the number in 2007. Reportsof benzodiazepines detected among deceased persons in Florida increased 25-percent between2007 and 2008 from 3,339 to 4,167. The number of those cases in which a benzodiazepine wasfound at a lethal level increased 24-percent from 878 to 1,090 in the same period. The numberof primary addiction treatment admissions for prescription medications accounted for 11.6 per-cent of all primary admissions in Florida during 2008 and has increased 26-percent since 2007and 142-percent since 2004. Release of these data became a key factor in the passage of a Pre-scription Drug Monitoring Bill by the Florida Legislature in the spring of 2009. Muscle relax-ants are known to be abused in combination with “ecstasy” (MDMA) or other drugs and arelinked to increasing reports of these drugs identified among deceased persons in Florida during2008.

1Mr. Hall is the director of the Center for the Study and Prevention of Substance Abuse at Nova Southeastern University and is executive director of UpFront Drug Information Center in Miami, Florida.


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INTRODUCTION

This report reviews data from 2008 about drug-related deaths, medical emergencies, addictiontreatment admissions, law enforcement intelligence, crime lab analysis, and prevalence of drug useamong students. Information is presented by pharmaceutical categories with topics including, pre-scription opioids, benzodiazepines, and muscle relaxants. While the information is classified by asingle drug or category, the reader should note an underlying problem of polysubstance abuse asmentioned throughout this report. Exhibits for the report follow the narrative text.

Area Description

Located in the extreme southern portion of the Florida peninsula, Miami-Dade County has theState’s largest population with 2,398,245 persons according to 2008 census estimates; 62 percent areHispanic, 17 percent are Black non-Hispanic, 18 percent are White non-Hispanic, and 1.5 percentare Asian/Pacific Islanders. Miami is Dade County’s largest city, with 360,000 residents. More than100,000 immigrants arrive in Florida each year; one-half establish residency in Miami-Dade County.More than one-half of the county’s population is foreign born.

Broward County, situated due north of Miami-Dade, is composed of Ft. Lauderdale plus 28 othermunicipalities and an unincorporated area. The County covers 1,197 square miles, including 25miles of coastline. According to 2008 census estimates, the population was 1,751,234. The popula-tion is roughly 48 percent White non-Hispanic, 25 percent Black non-Hispanic, 23 percent Hispanic,and 3 percent Asian/Pacific Islanders. One-fourth of the county’s population is foreign born. Bro-ward County is the second most populated county in Florida after Miami-Dade and accounts for al-most 10 percent of Florida’s population.

Palm Beach County (population 1,265,293) is located due north of Broward County and is the thirdmost populated county in the State. The population is 64 percent White non-Hispanic, 17 percentHispanic, 15 percent Black non-Hispanic, and 2 percent Asian/Pacific Islanders. Seventeen percentof the County’s population is foreign born. Together, the 5.4 million people of these 3 counties con-stitute 30 percent of the State’s 18.3 million population.

Data Sources

This report describes current trends on prescription drug misuse in South Florida, using the datasources summarized below:

Drug-related mortality data were provided by the Florida Department of Law Enforcement(FDLE) Medical Examiners Commission’s 2008 Report of Drugs Identified in DeceasedPersons.

Emergency department (ED) data were derived for Miami-Dade County from the DrugAbuse Warning Network (DAWN), Substance Abuse and Mental Health Services Administra-tion (SAMHSA). The data represent drug reports involved in drug-related visits for illicitdrugs (derived from the category of “major substances of abuse,” excluding alcohol) and thenonmedical use of selected prescription drugs (derived from the case types of “overmedica-


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tion,” “malicious poisoning,” and “other”). Drug reports exceed the number of ED visits be-cause a patient may report use of multiple drugs (up to six drugs plus alcohol). UnweightedMiami-Dade ED data for 2008 are from the DAWN Live! restricted-access online query systemadministered by the Office of Applied Studies (OAS), SAMHSA. Eligible hospitals in only theMiami-Dade County Division totaled 21; hospitals in the DAWN sample numbered 19, withthe number of EDs in the sample also totaling 19. (Some hospitals have more than one emer-gency department.) During 2008, nine EDs reported data each month. The completeness of datareported by participating EDs varied by month (exhibit 1). Exhibits in this paper for 2008 Mi-ami-Dade County data reflect cases that were received by DAWN as of May 5, 2009. Un-weighted Ft. Lauderdale Division (that includes Broward and Palm Beach Counties) ED datafor 2008 are also from the DAWN Live! restricted-access online query system. Eligible hospi-tals in the Ft. Lauderdale Division totaled 27; there were 21 hospitals in the DAWN sample,and the number of emergency departments in the sample also totaled 21. During 2008, eightEDs in Broward County and one in Palm Beach County reported data each month. The com-pleteness of data reported by participating EDs varied by month (exhibit 2). DAWN Live! ex-hibits in this paper for Broward and Palm Beach Counties reflect cases that were received byDAWN as of May 5, 2009. Based on the DAWN Live! reviews, cases may be corrected or de-leted; thus, the unweighted data presented in this paper are subject to change. Data derivedfrom DAWN Live! represent drug reports in drug-related ED visits. Drug reports exceed thenumber of ED visits, since a patient may report use of multiple drugs (up to six drugs and alco-hol). The DAWN Live! data are unweighted and, thus, are not estimates for the reporting area.DAWN Live! data cannot be compared to DAWN data from 2002 and before, nor can prelimi-nary data be used for comparison with future data. Only weighted DAWN data released bySAMHSA can be used for trend analysis. A full description of the DAWN system can befound on the DAWN Web site <http://dawninfo.samhsa.gov>.

Drug primary treatment admissions data for calendar year 2008 are from the Florida De-partment of Children and Families for the State of Florida as submitted to the SAMHSA’sTreatment Episode Data Set (TEDS) as of March 29, 2009, and for Miami-Dade and BrowardCounties as generated on June 3, 2009. The county level data are unduplicated client countsfrom all publicly-funded treatment modalities but do not include reports from detox services.

Crime lab drug analyses data were derived from two sources. The first is from the DrugEnforcement Administration’s (DEA’s) National Forensic Laboratory Information System(NFLIS) for the combined reporting area covering Miami-Dade, Broward, and Palm BeachCounties from January through December 2008. However, the NFLIS data combines some, butnot all, pharmaceutical items into the category of “controlled substance.” This factor makes itdifficult to track the role of illegally diverted medications particularly in Broward Countywhere other indicators of nonmedical prescription drug misuse are among the highest in the na-tion. Thus, Broward County crime lab data for calendar year 2008 are from the Broward Sher-iff’s Office (BSO) Crime Lab which does identify all pharmaceutical items by the appropri-ate generic name. Unfortunately, the Miami-Dade Police Department Crime Lab did not re-sponse to requests for the 2008 data for their County.


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Information on the Zip Code locations of the top 50 Dispensing Practitioners of Oxy-codone in the United States is from the US Drug Enforcement Administration (DEA) Auto-mation of Reports and Consolidated Orders System (ARCOS) July-December 2008.

Data on the prevalence of substance use by high school students in Miami-Dade, Bro-ward, and Palm Beach Counties as well as the State of Florida are from the 2008 FloridaYouth Substance Abuse Survey conducted by the Florida Department of Children and Fami-lies and are illustrated in graphs following the other exhibits in this report.

Data on the prevalence of nonmedical use of pain relievers by people aged 12 and aboveare from the SAMHSA National Survey on Drug Use Health Sub-State Data 2004-2006.

NONMEDICAL PHARMACEUTICAL MISUSE AND ABUSE PATTERNS AND TRENDS

Prescription Opioids (Narcotic Analgesics)

Between 2007 and 2008, reports in all of Florida related to the category of prescription opioidsdetected among deceased persons increased 8-percent, from 5,059 to 5,454 (exhibit 3), followinga 15-percent rise between 2006 (n=4,386) and 2007. Reports of hydrocodone (Vicodin, Lortab),oxycodone (OxyContin, Roxicodone, Percocet), and methadone (Dolophine) identified amongdecedents have been tracked in Florida since 2000. Beginning in 2003, morphine (MS Contin,Roxanol), propoxyphene (Darvon), fentanyl (Fentora), hydromorphone (Dilaudid, Palladone),meperidine (Demerol HCl), tramadol (Ultram), and other opioids were included in the FloridaMedical Examiners Commission’s surveillance monitoring program. Occurrences of 5 prescrip-tion opioids detected among deceased persons during 2008 totaled 342 in Broward County, 124in Miami-Dade County, and 361 in Palm Beach County.

Across Florida, the number of tramadol reports detected among deceased persons (n=235) in-creased 50-percent between 2007 and 2008 and those for oxycodone (n=1,574) increased 26-pecent while the number of occurrences for fentanyl (n=235) increased 19-percent, and hydro-morphone reports (n=199) increased 12-percent. Hydrocodone reports (n=870) among decedentsincreased 8-percent; occurrences for morphine (n=660) increased 5-percent and those for otheropioids (n=394) rose 7-percent. Methadone occurrences among deceased persons (n=936) de-creased 14-percent between 2007 and 2008; those for meperidine (n=29) declined 12-percent andpropoxyphene reports (n=322) decreased 6-percent.

During 2008, 4,924 individuals died in Florida with one or more prescription drugs in their sys-tem of which 44 percent (n=2,184) had at least one prescription medication that was considereda cause of death. In total there were 10,036 prescription drugs detected (including 5,454 opioids)and 3,750 of the total medication occurrences were considered at a lethal dose and a cause ofdeath (exhibit 12) including 47 percent (n=2,576) of the opioids. The number of drug occur-rences exceeded the number of deaths because many decedents had more than one substance de-tected including another prescription medication, illicit drug, or alcohol.

The most lethal prescription opioids statewide were methadone which was considered a cause ofdeath for 74 percent (n=693) of the decedents in which it was detected, oxycodone was a cause


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of death for 60 percent (n=941) of the deaths related to it, morphine had a 45 percent lethal rate(n=300), and fentanyl was a cause of death for 44 percent (n=104) of its occurrences. Most ofthe statewide prescription medical examiner opioid cases were polydrug episodes, including 91percent of the oxycodone reports, 89 percent of the methadone cases, 88 percent of the hydro-codone reports, 83 percent of morphine cases, and 83 percent of propoxyphene-related deaths.

The two counties (Pinellas and Pasco) comprising the St. Petersburg Medical Examiner’s Dis-trict (population 1,381,288) had the highest number of prescription opioids reports among de-ceased persons in Florida with a total of 631 occurrences, 60 percent of which were consideredto be lethal doses and a cause of death. Ranking second in the number of prescription opioidsreports among decedents was the Jacksonville Medical Examiner District (population 1,105,524)comprise of three counties (Duval, Clay, and Nassau) that reported 363 occurrences of which 49percent were considered lethal doses. Palm Beach County ranked third, Broward County rankedfourth, and Miami-Dade County ranked fifteenth in the State for the numbers of prescriptionopioids detected among decedents (exhibit 13).

Miami-Dade County recorded 46 oxycodone occurrences among deceased persons in 2008, 40morphine reports, 17 for hydrocodone, 11 for propoxyphene, and 10 for methadone (exhibit 4).These 124 combined mentions represented a 31-percent decrease from the 163 opioid occurrencesin 2007. Among the total opioid reports in 2008, 45 percent were considered lethal doses and 78percent were found in combination with at least one other substance.

Broward County recorded 171 oxycodone occurrences among deceased persons in 2008, 60 mor-phine reports, 47 for methadone, 42 for hydrocodone, and 22 for propoxyphene (exhibit 5). These342 combined mentions represented a 23-percent increase from the 278 opioid occurrences in2007. Among the total opioid reports in 2008, 60 percent were considered lethal doses and 89percent were found in combination with at least one other substance.

Palm Beach County recorded 165 oxycodone occurrences among deceased persons in 2008, 79 formethadone, 53 morphine reports, 51 for hydrocodone, and 13 for propoxyphene. These 361 com-bined mentions represented a 4-percent decrease from the 377 opioid occurrences in 2007. Amongthe total opioid reports in 2008, 65 percent were considered lethal doses and 91 percent werefound in combination with at least one other substance.

As discussed in the Data Sources section above, information on hospital emergency department(ED) cases are from the Federal DAWN Live! system. The data presented are termed “un-weighted” because they are the actual numbers from only a sample of 9 out of 19 hospitals inMiami-Dade County and 9 out of 21 hospitals in Broward and Palm Beach Counties with onlyone Palm Beach hospital included in the 2008 data. Thus, the unweighted data are less than alloccurrences if all hospitals were participating in DAWN Live!.

Unweighted DAWN Live! data for Miami-Dade show 316 prescription opioid reports in 2008(exhibit 6) including the three nonmedical use case types of “overmedication,” “malicious poi-soning,” and “other.” Generally, “other case types” are considered intentional substance abuse.There were also 318 additional opioid reports classified as seeking detox. Among the nonmedi-cal opioid reports, 114 (or 36 percent) were oxycodone ED reports. The total also includes 26


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hydrocodone reports, 20 methadone ED reports, 9 fentanyl reports, and 3 buprenorphine ED re-ports. Most (56 percent) of the 316 Miami-Dade prescription opioid ED reports involved males.Fifty percent were non-Hispanic Whites, 36 percent were Hispanic, and 12 percent were non-Hispanic Blacks; race/ethnicity was either unknown or undocumented for 1 percent. The pa-tients’ ages were as follows: 2 percent were younger than 18, 15 percent were 18–24, 25 percentwere 25–34, 22 percent were 35–44, 20 percent were 45–54, and 17 percent were 55 or older.

Unweighted data accessed from DAWN Live! for Broward County EDs (and one in Palm BeachCounty) during 2008 reveal a total of 1,422 nonmedical use reports for prescription opioids (ex-hibit 7), as compared with 366 reports for heroin. There were also 1,056 additional opioid reportsclassified as seeking detox. Among the narcotic analgesic nonmedical use reports, 697 (or 49percent) were oxycodone ED reports. The total also includes 148 methadone nonmedical ED re-ports, 95 hydrocodone reports, 16 fentanyl reports, and 18 buprenorphine ED reports. Males ac-counted for 54 percent of these reports, and 83 percent were non-Hispanic Whites. Hispanics ac-counted for 7 percent of the narcotic analgesic ED reports, and non-Hispanic Blacks represented 7percent; race/ethnicity was unknown or undocumented for 4 percent. There were 17 (1 percent)patients younger than 18, while 15 percent were age 18–24, 25 percent were age 25–34, 21 percentwere 35–44, 24 percent were 45–54, and 12 percent were 55 or older. Only 1 ED report (less than0.1 percent) did not have an age documented.

A comparison of 2008 opiate ED reports for heroin and narcotic opioids in Miami-Dade andBroward Counties are contrasted in exhibit 14. Heroin accounted for 73 percent of 1,181 opiateED reports in Miami-Dade County. In Broward County, however, narcotic prescription opioidsaccounted for 80 percent of 1,788 opiate ED reports.

There were 4,699 primary admissions for prescription opioid dependence in Florida during 2008representing 10 percent of the 47,264 total publicly-funded treatment admissions for all substancesincluding alcohol, up from 8 percent in 2007 (exhibit 15). These admissions represent a 150-percent increase in opioid primary admissions since 2004 (exhibit 16). Fifty-two percent of thetotal primary opioid patients were females. Youth under 18-years of age represented 3 percent ofthe clients, and those 18-20 accounted for 7 percent, while young adults 21-25 comprised 25 per-cent of the opioid admissions. Adults aged 26-35 represented 39 of all primary opioid clients andthose aged 36-45 accounted for 16 percent. Opioid clients aged 46-55 accounted for 9 percent andthose 56 and older represented 2 percent. The racial differences (including Hispanics) were 96 per-cent White and 2 percent Black with less than 1 percent in other known racial groups and less than2 percent unknown. Hispanics of all races accounted for 4 percent of all primary opioid admissionsstatewide.

There were 32 primary admissions for opiates other than heroin or 0.9 percent of the 3,371 pub-licly-funded primary treatment admissions in Miami-Dade County as reported by the Florida De-partment of Children and Families in 2008. Females accounted for 53 percent of the other opiateclients and White, non-Hispanics represented 62 percent. Fifty-three percent of these clients wereaged 35 or older.

In Broward County, there were 264 primary admissions for opiates other than heroin accounting6.3 percent of the 4,184 publicly-funded primary treatment admissions as reported by the Florida


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Department of Children and Families in 2008. Males accounted for 59 percent of the other opiateclients and White, non-Hispanics represented 89 percent. Thirty-three percent of these clients wereaged 18-25, 31 percent were 26-34 and 35 percent were 35 or older.

The NFLIS reported 205 oxycodone crime lab cases, 65 hydrocodone items, 23 methadonecases, and 11 propoxyphene items, combined together these 304 reports represented 1 percent ofall drug items analyzed in the three county South Florida MSA (exhibit 9). There were also1,647 “controlled substance” cases in the 2008 NFLIS report many of which were prescriptionopioids during 2008. The Broward Sheriff’s Office Crime Lab reported analyzing 804 oxy-codone cases during 2008 or 8.3 percent of all cases (exhibit 10). There were also 121 hydro-codone cases, 12 hydromorphone cases, and 20 buprenorphine cases in the same year. These 957prescription opioid cases in Broward County represented 10 percent of all cases ranking secondbehind cocaine.

Broward County was the location for two-thirds of the top 50 dispensing practitioners of oxy-codone in the United States during the second half of 2008. These 33 Broward “pill mill” painclinics dispensed 6½ million dose units of oxycodone in the same six months. An additional 12of the top 50 dispensing practitioners were located in Palm Beach and Miami-Dade Counties.

Any lifetime nonmedical use of prescription pain relievers among high school students was re-ported on the 2008 Florida Youth Substance Abuse Survey (FYSAS) by 5.4 percent in Miami-Dade County, 6.2 percent in Broward County, 8.2 percent in Palm Beach County, and 10.4 per-cent in all of Florida. Results from the same survey for any current nonmedical use of prescrip-tion pain relievers among high school students in the past 30 days was 1.9 percent in Miami-Dade, 2.3 percent in Broward, 3.2 percent in Palm Beach County, and 3.9 percent Statewide.Additional results from the 2008 FYSAS regarding the nonmedical use of prescription and over-the-counter pharmaceuticals for middle and high school students in South Florida are in graphson pages 19-21 of this report.

The most recent county-level data on prevalence of nonmedical use of pain relievers across thelifespan (aged 12 and above) are from the 2004-2006 National Survey on Drug Use and Healthin which 5 percent of all Floridians reported such use in the past year. The South Florida coun-ties’ rates were 3.6 percent for Miami-Dade County, 3.8 percent for Broward County, and 4.5percent for Palm Beach County.

Benzodiazepines

Benzodiazepines in general and alprazolam (Xanax) in particular are a substantial problem.There were 4,167 reports of a benzodiazepine present in deceased persons across Florida in2008, representing a 25-percent increase over the 3,339 such cases in the previous year. Of thebenzodiazepine occurrences in 2008, a benzodiazepine was identified as causing 929 deaths (29percent) with a total of 1,090 lethal benzodiazepine occurrences. Among the benzodiazepine medi-cal examiner reports statewide, 1,873 were attributed to alprazolam and 914 were attributed to di-azepam (Valium) with 38 percent of the alprazolam occurrences and 22 percent of the diazepamreports considered to be lethal doses.


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In Miami-Dade County, there were 101 reports of alprazolam detected in deceased persons during2008, of which 36 percent (n= 36) were considered a lethal dose. Eight-five percent of the reportsinvolved at least one other drug (exhibit 4). There were also 44 reports of diazepam detected in de-ceased persons in Miami-Dade County; 18 percent were considered to be the cause of death; 84percent of these deaths involved at least 1 other drug. These 145 combined mentions for alpra-zolam and diazepam represented a 10-percent increase over the 132 such deaths in 2007 and fol-low a 39-percent increase from 2006 to 2007. Miami-Dade County ranked seventh among theState’s 24 medical examiner district in the number of the two benzodiazepines detected amongdeceased person (exhibit 17). Two (or 1 percent) of the combined mentions in 2008 involved aperson younger than 18; 10 percent of the decedents were between 18 and 25, 10 percent wereage 26–34, 37 percent were age 35–50, and 42 percent were older than 50.

In Broward County, there were 203 reports of alprazolam detected in deceased persons during2008, of which 54 percent (n= 110) were considered a lethal dose. Ninety percent of the reportsinvolved at least one other drug (exhibit 5). There were also 136 reports of diazepam detected indeceased persons in Broward County; 43 percent were considered to be the cause of death; 84 per-cent of these deaths involved at least 1 other drug. These 339 combined mentions for alprazolamand diazepam represented a 53-percent increase over the 222 such deaths in 2007 and follows an57-percent increase from 2006 to 2007. Broward County was second only to the St. Petersburgmedical examiner’s district in the number of the two benzodiazepines detected among deceasedperson with 395 such reports (exhibit 17). None of the Broward combined mentions in 2008 in-volved a person younger than 18; 8 percent of the decedents were between 18 and 25, 17 percentwere age 26–34, 42 percent were age 35–50, and 33 percent were older than 50.

In Palm Beach County, there were 176 reports of alprazolam detected in deceased persons during2008, of which 45 percent (n= 80) were considered a lethal dose. Ninety-six percent of the reportsinvolved at least one other drug. There were also 70 reports of diazepam detected in deceased per-sons in Palm Beach County; 14 percent were considered to be the cause of death; 91 percent ofthese deaths involved at least 1 other drug. These 246 combined mentions for alprazolam and di-azepam represented a 29-percent increase over the 191 such deaths in 2007 and follows an 12-percent increase from 2006 to 2007. Palm Beach County ranked third among the State’s 24medical examiner district in the number of the two benzodiazepines detected among deceasedperson (exhibit 17). One of the combined mentions in 2008 involved a person younger than 18;17 percent of the decedents were between 18 and 25, 16 percent were age 26–34, 36 percentwere age 35–50, and 30 percent were older than 50.

Unweighted DAWN Live! data for Miami-Dade show 647 non-medical benzodiazepine reportsin 2008 (exhibit 6). Non-medical reports include those for overmedication, malicious poisoning,and “other case types”. Generally, “other case types” are considered intentional substanceabuse. There were also 233 additional benzodiazepine reports classified as seeking detox.Among the nonmedical benzodiazepine reports, 310 (or 48 percent) were alprazolam ED reports.The total also includes 76 clonazepam (Klonopin) reports, 44 temazepam (Restoril), 36 loraze-pam (Ativan), and 26 diazepam reports. Fifty percent of the 647 Miami-Dade benzodiazepine EDpatients were males. Forty-nine percent were Hispanic, 41 percent were non-Hispanic Whites,and 7 percent were non-Hispanic Blacks; race/ethnicity was either unknown or undocumentedfor 2 percent. The patients’ ages were as follows: 9 percent were younger than 18, 14 percent


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were 18–24, 18 percent were 25–34, 23 percent were 35–44, 19 percent were 45–54, and 16 per-cent were 55 or older. The ages of 1 percent of the benzodiazepine reports were not docu-mented.

Unweighted data accessed from DAWN Live! for Broward County EDs during 2008 reveal a to-tal of 1,345 nonmedical use reports for benzodiazepines (exhibit 7). There were also 536 addi-tional benzodiazepine reports classified as seeking detox. Among the nonmedical benzodi-azepine reports, 694 (or 52 percent) were alprazolam ED reports. The total also includes 90clonazepam reports, 83 diazepam reports, 42 lorazepam, and 32 temazepam reports. Fifty-twopercent of the 1,345 Broward benzodiazepine ED patients were males. Eighty-one percent werenon-Hispanic Whites, 10 percent were Hispanic, and 6 percent were non-Hispanic Blacks;race/ethnicity was either unknown or undocumented for 3 percent. The patients’ ages were asfollows: 6 percent were younger than 18, 17 percent were 18–24, 22 percent were 25–34, 23 per-cent were 35–44, 21 percent were 45–54, and 11 percent were 55 or older.

Data on benzodiazepines treatment admissions are included in single category named “tranquil-izers.” There were 686 primary admissions for tranquilizers dependence in Florida during 2008representing 1.5 percent of the 47,264 total publicly-funded treatment admissions for all substancesincluding alcohol, similar to the 1.3 percent in 2007. Sixty percent of the total primary tranquilizerpatients were females. Youth under 18-years of age represented 14 percent of the clients, and those18-20 accounted for 13 percent, while young adults 21-25 comprised 23 percent of the tranquilizeradmissions. Adults aged 26-35 represented 26 of all primary tranquilizer clients and those aged 36-45 accounted for 12 percent. Tranquilizer clients aged 46-55 accounted for 10 percent and those 56and older represented 2 percent. The racial differences (including Hispanics) were 91 percentWhite and 3 percent Black with less than 3 percent in other known racial groups and 3 percent un-known. Hispanics of all races accounted for 6 percent of all primary tranquilizer admissions state-wide.

There were 16 primary admissions for benzodiazepines reported in Miami-Dade County treatmentadmissions during 2008, 0.5 percent of the 3,371 primary admissions (including alcohol). In Bro-ward County, there were 66 primary admissions for benzodiazepines during 2008, or 1.6 percent of4,184 primary admissions (including alcohol).

The NFLIS reported 558 alprazolam crime lab cases, 24 diazepam items, and 21 clonazepamcases during 2008 in the three-county South Florida MSA that combined represented 2.1 percentof all drug items analyzed (exhibit 9). The Broward Sheriff’s Office Crime Lab reported 636 al-prazolam cases, 62 diazepam items, 29 clonazepam cases, and 32 other benzodiazepine itemsduring 2008 or 7.8 percent of all cases ranking fourth among all substances (exhibit 10).

Any lifetime nonmedical use of depressants (with “Xanax” use as an example in the question)among high school students was reported on the 2008 Florida Youth Substance Abuse Surveyby 5.5 percent in Miami-Dade County, 5.7 percent in Broward County, 7.8 percent in PalmBeach County, and 8.7 percent in all of Florida. Results from the same survey for any currentnonmedical use of prescription depressants among high school students in the past 30 days was1 percent in Miami-Dade, 2.1 percent in Broward, 2.2 percent in Palm Beach County, and 3 per-cent Statewide.


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Muscle Relaxants

Muscle relaxants may be abused in combination with MDMA and other drugs. There were 415reports of carisoprodol (Soma) or meprobamate (Miltown) among deceased persons in Floridaduring 2008, of which 84 (or 24 percent) were considered to be caused by the drug. The numberof these deaths increased by 23-percent in 2008 as compared to the 337 such deaths in 2006.

Unweighted DAWN Live! data for Miami-Dade County in 2008 show 21 reports on nonmedicaluse of muscle relaxants. Carisoprodol was specifically cited in 8 (or 38 percent) of the reports.

Unweighted DAWN Live! data on nonmedical muscle relaxants use show 154 ED reports in-volving these pharmaceuticals in Broward County in 2008. Carisoprodol was specifically citedin 137 (or 89 percent) of the reports.

The NFLIS reported 15 carisoprodol crime lab cases for the South Florida MSA in 2008, andBroward County reported 67 carisoprodol crime lab items or 0.7 percent of all substances in2008 (exhibit 10).

For inquiries regarding this report, contact James N. Hall,Center for the Study and Prevention of Substance Abuse,

Nova Southeastern UniversityC/o Up Front, Inc., 13287 SW 124 Street, Miami, FL 33186,Phone: (786) 242-8222, E-mail: [email protected].


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Exhibit 1 DAWN ED Miami-Dade County Sampleand Reporting Information: 2008

TotalEligibleHospital

s1

No. ofHospitalsin DAWNSample

TotalEDs inDAWN

Sample2

No. of EDs ReportingMonth: Completeness

of Data (%)No. of EDs

NotReporting

90–100%

50–89%

<50%

21 19 19 7-8 0-2 0–1 10

1 Short-term, general, non-Federal hospitals with 24-hour emergency departmentsbased on the American Hospital Association Annual Survey.

2 Some hospitals have more than one emergency department.SOURCE: DAWN Live!, OAS, SAMHSA, updated May 5, 2009

Exhibit 2 DAWN ED Ft. Lauderdale Division Sampleand Reporting Information: 2008

1 Short-term, general, non-Federal hospitals with 24-hour emergencydepartments based on the American Hospital Association Annual Survey.

2 Some hospitals have more than one emergency department.SOURCE: DAWN Live!, OAS, SAMHSA, updated May 5, 2009

TotalEligibleHospital

s1

No. ofHospitalsin DAWNSample

TotalEDs inDAWN

Sample2

No. of EDs Reporting perMonth: Completeness of

Data (%)No. of EDs

NotReporting90–

100%

50–89%

<50%

27 21 21 6-9 0-2 0-2 12


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Exhibit 3 Numbers of Substances Identified amongDecedents in Florida: 2008

Source: Florida Department of Law Enforcement,Florida Medical Examiners Commission Interim Report 2008

415114132

5,454

4,167

1,791

4,070

0

1,000

2,000

3,000

4,000

5,000

6,000

Alcoho l

Cocaine

Benzos

Rx OpioidHero

in

Methamphet

Musc

leRelaxant

All Rx = 10,0036Alcohol +Illicit Drugs = 6,107

Flagle r

Highla nds

Ha rde e

Polk

Ma rtin

St. Lucie

Okeechobee

Indian River

P utna mAlac hua

Bradfo

rdUnion

Colum

bia

Gilchris t

Levy

Dixie

Suwa nnee

Ha milton

S t.JohnsClay

Duval

Na ssau

Baker

Pinellas

Pa sco

Mana tee

Hillsborough

Bre va rd

Osce ola

Orange

S eminole

Collier

HendryLe e

Glade s

De SotoSara sota

Palm Beach

LakeS umter

He rna ndo

Citrus

Ma rion

Taylor

Madis on

Jeffe

rson

Wa kulla

Le on

Franklin

Liberty

Gadsden

Jackson

Calhoun

Gulf

Ba yW

ashing ton

Escambia

Santa

RosaOkaloosa

Walton

Broward

Dade

Holmes

Monroe

Volusia

Lafay et te

Charlott e

Exhibit 4 Miami-Dade County Drugs Detected AmongDecedents By Single Drug or In-Combination - 2008

020406080

100120140160180200220

Only Drug In Combination

In Combination 116 85 37 37 9 13 30 8 31

Only Drug 85 16 7 9 1 4 10 3 7

CocaineAlprazol

am

Diazepa

m

Oxycod

one

Methado

ne

Hydroco

done

Morphin

e

Propoxy

pheneHeroin

Source: FDLE Florida Medical Examiners Commission Report 2008


13

Exhibit 5 Broward County Drugs Detected AmongDecedents By Single Drug or In-Combination - 2008

020406080

100120140160180200220

Only Drug In Combination

In Combination 105 183 125 159 37 37 51 20 17

Only Drug 41 20 11 12 10 5 9 2 0

CocaineAlprazol

am

Diazepa

m

Oxycod

one

Methado

ne

Hydroco

done

Morphin

e

Propoxy

pheneHeroin


Exhibit 6 Numbers of Selected Drug Reports inMiami-Dade County DAWN ED Data (Unweighted1),

by Drug Category: 2008

1The unweighted data are from 9 Miami-Dade EDs reporting to DAWN in 2008. All DAWN cases are reviewed for quality

control. Based on this review, cases may be corrected or deleted, and, therefore, are subject to change.SOURCE: Miami – Dade County Division EDs DAWN Live!, OAS, SAMHSA, updated May 5, 2009

127

25

865

316

647

1,426

2,371

3,422

0 1,000 2,000 3,000 4,000

Alcohol in Combo

Cocaine

Marijuana

Rx Benzos

Rx Opioids

Heroin

MDMA

Methamp


14

Exhibit 7 Numbers of Selected Drug Reports inBroward County DAWN ED Data (Unweighted1),

by Drug Category: 2008

1 The unweighted data are from 9 Ft. Lauderdale EDs reporting to DAWN 2008. All DAWN cases are reviewed for quality control.

Based on this review, cases may be corrected or deleted, and, therefore, are subject to change.SOURCE: Miami – Ft. Lauderdale Division EDs DAWN Live!, OAS, SAMHSA, updated May 5, 2009

100

19

366

1,422

2,824

2,408

1,356

1,345

0 500 1,000 1,500 2,000 2,500 3,000

Alcohol in Combo

Cocaine

Marijuana

Rx Benzos

Rx Opioids

Heroin

MDMA

Methamp

Exhibit 8 Florida Primary Treatment Admissions 2008

0 2000 4000 6000 8000 10000 12000 14000 16000# Primary Admisssions

All Alcohol

All Cocaine

M arijuana

Heroin

Other Opiates

Amphetamines

Other/Unknown Youth < 18

Adult 18 +

Adult 18 + 12,586 8,759 7,468 1,062 4,563 710 2,143

Youth < 18 659 143 7,203 18 136 22 1,792

All Alcohol All Cocaine Marijuana HeroinOther

Opiates

Amphetami

nes

Other/Unkn

ow n

Source: SAMHSA-OAS: Treatment Episode Data Sets (TEDS) 2008

3,935732

4,6991,080

14,671

8,90213,245


15

Exhibits 9 Top 10 Most Frequently Identified Drugsof Total Analyzed Drug Items, South Florida: CY 20081

100.0 %29,239TOTAL

9.7 %2,833Other2

0.2 %65Hydrocodone

0.3 %951-Benzylpiperazine

0.6 %168Methamphetamine

0.7 %205Oxycodone

0.8 %236Hallucinogen

0.9 %2593,4 Methylenedioxymethamphetamine

1.9 %558Alprazolam

2.5 %736Heroin

16.9 %4,928Cannabis

65.5 %19,156Cocaine

PercentageNumberDrug

1January 2008-December 2008. 2All other analyzed items. NOTES: 1. Data are Miami/Fort Lauderdale/Pompano Beach MSAand include Miami-Dade, Broward, and Palm Beach Counties. 2. “Controlled Substances” represent 1,647 cases and areincluded under “Other.” 3. Percentages may not sum to the total due to rounding.

Source: National Forensic Laboratory Information System (NFLIS) US DEA, April 14, 2009

Exhibits 10 Top 10 Most Frequently Identified Drugsof Total Analyzed Drug Items, Broward County: CY 20081

100.0 %9,686TOTAL

9.0 %872Other2

0.7%67Carisoprodol

1.2 %119Heroin

1.2%121Hydrocodone

1.7 %1653,4 Methylenedioxymethamphetamine

2.0 %201Methamphetamine

2.1 %210Amphetamine

6.6 %636Alprazolam

8.3 %804Oxycodone

8.6 %836Cannabis

58.4 %5,655Cocaine

PercentageNumberDrug

FOOTNOTES: 1January 2008-December 2008. 2All other analyzed items.OTHER NOTES: 1. Data are for Broward County, Florida. 2. TOTAL includes 957 Prescription Opioid Items (9.9 %) and

759 Prescription Benzodiazepine Items (7.8 %). 3. Percentages may not sum to the total due to rounding.

Source: Broward Sheriff’s Office (BSO) Crime Lab 2008


16

Exhibits 11 Opiates Identified among DecedentsExhibits 11 Opiates Identified among Decedentsin Florida 2000in Florida 2000 –– 20082008

0

500

1000

1500

2000

2500

3000

3500

4000

2000 2001 2002 2003 2004 2005 2006 2007 2008

Heroin

3 Rx Opioids

Source: FDLE Florida Medical Examiners Commission Reports 2000-2008

The 3 Rx Opioids areMethadone,Hydrocodone, andOxycodone

Total for all Rx Opioids

was 5,454 in 2008

3 Rx Opioids

Heroin

3,380

132

3,750

6,286

0

2,000

4,000

6,000

8,000

10,000

12,000

Rx Meds

PresentCause


Exhibit 12 Numbers of Rx Drugs Identified amongDeceased Persons in Florida - 2008

10,036

2,184 individuals diedwith at least oneprescription drug in theirsystem that was, in theopinion of the medicalexaminer, the cause ofdeath (Lethal Dose).These drugs may have beenmixed with otherprescription drugs, illicitdrugs, and/or alcohol.


17

8.8. LeesburgLeesburg

7. Melbourne7. Melbourne

6. Orlando6. Orlando

5. Tampa5. Tampa

4. Broward County4. Broward County

3. Palm Beach County3. Palm Beach County

2. Jacksonville2. Jacksonville

1. St. Petersburg1. St. Petersburg

ME DistrictME District

181181

235235

319319

337337

342342

361361

363363

631631

Rx Opioid OccurrencesRx Opioid Occurrences


Exhibit 13 Rx Opioids Identified Among DecedentsExhibit 13 Rx Opioids Identified Among Decedents -- 20082008

Miami-Dade Ranks

15th of 24 Districts

With 124 Occurrences

27%

73%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ED Reports

Rx Opioids

Heroin

N= 1,181

Miami-Dade County 2008

20%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ED Reports

Rx Opioidss

Heroin

N= 1,788

Broward County 2008

Exhibit 14 Heroin and Rx Opioids ED Reportsas Percent of all Opiates

SOURCE: Emergency Department DAWN Live!, OAS, SAMHSA, updated May 5, 2009


18

Exhibit 15 Number of Primary Treatment Admissionsfor Prescription Opioids, Tranquilizers, and Sedatives

State of Florida 2004-2008

0500

1,0001,5002,0002,5003,0003,5004,0004,5005,0005,5006,000

Number of

Prescription Drug

Primary

Treatment

Admissions

Rx Opioids

Tranquilizers

Sedatives

Rx Opioids 1,881 2,279 3,339 3,721 4,699

Tranquilizers 315 395 473 562 686

Sedatives 70 76 83 78 103

2004 2005 2006 2007 2008

Source: SAMHSA: Treatment Episode Data Sets (TEDS) 2004 - 2008

2,2662,750

3,8954,361

5,488

Exhibit 16 Percent of Increase from 2004 to 2008 inFlorida Primary Treatment Admissions for PrescriptionOpioids, TranquilizersTranquilizers, Sedatives & all Other Substances

150%

118%

47%

28%

0%

25%

50%

75%

100%

125%

150%

% of Increase

2004-2008

Opioids Tranquilizers Sedatives All Other *

Source: SAMHSA: Treatment Episode Data Sets (TEDS) 2004 - 2008

•All OtherSubstances

includesAlcohol

Percents of Increase2004-2008


19

Exhibit 17 Benzodiazepines Identified Among Decedentsin Florida - 2008

1451457. Miami7. Miami--DadeDade

1521526. Tampa6. Tampa

1831835. Orlando5. Orlando

1991994. Jacksonville4. Jacksonville

2462463. Palm Beach3. Palm Beach

3393392. Broward2. Broward

3953951. St. Petersburg1. St. Petersburg

BenzodiazepineBenzodiazepineOccurrencesOccurrences

ME DistrictME District

Source: FDLE Florida Medical Examiners Commission Interim Report 2008

Any Lifetime Nonmedical Use ofRx Pain Relievers Among South Florida

and all Florida Middle & High School Students

6.3%5.2%

4.5%

8.0%

0%1%2%3%4%5%6%7%8%9%

10%

Palm

Beach

Broward Miami-

Dade

All Florida

Source: 2008 Florida Youth Substance Abuse Survey


20

Any Past 30 Day Nonmedical Use ofRx Pain Relievers Among South Floridaand all Florida Middle School Students

1.7% 1.7%

1.1%

2.3%

0%

1%

2%

3%

4%

5%

Palm

Beach

Broward Miami-

Dade

All Florida


Any Past 30 Day Nonmedical Use of RxPain Relievers Among South Florida and

all Florida High School Students

3.2%

2.3%1.9%

3.9%

0%

1%

2%

3%

4%

5%

Palm

Beach

Broward Miami-

Dade

All Florida



21

Any Lifetime Nonmedical Use ofRx Depressants Among South Florida


5.2%

3.7% 3.8%

6.0%

0%1%2%3%4%5%6%7%8%9%

10%

Palm

Beach

Broward Miami-

Dade

All Florida


Any Lifetime Nonmedical Use ofRx Amphetamine Among South Florida


2.7% 2.3% 1.9%

3.7%

0%1%2%3%4%5%6%7%8%9%

10%

Palm

Beach

Broward Miami-

Dade

All Florida



22

Any Lifetime Nonmedical Use of

Over the Counter Pharmaceuticals

Among South Florida and all FloridaMiddle School Students

3.6%4.0% 4.2%

4.9%

0%

1%

2%

3%

4%

5%

6%

Palm

Beach

Broward Miami-

Dade

All Florida


Documents

Indicators of Prescription Drug Nonmedical Misuse and Abuse in South …cdn.trustedpartner.com/docs/library/UWBCCommissionSubstanceAb… · Abuse in South Florida: 2008 James N. Hall1