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National Drug Early Warning (NDEWS) webinar: A more dangerous heroin: Emerging patterns in the heroin overdose epidemic

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This presentation, to an international web audience, was presented alongside one by Dr Wilson Compton, Deputy Director of the National Institute on Drug Abuse. Sponsored by NDEWS, it explores the structural reasons for the emerging heroin overdose epidemic and ways to address it.

Published in: Health & Medicine
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National Drug Early Warning (NDEWS) webinar: A more dangerous heroin: Emerging patterns in the heroin overdose epidemic

  1. 1. Dan Ciccarone, MD, MPH Professor, Family and Community Medicine University of California, San Francisco A MORE DANGEROUS “HEROIN”: EMERGING PATTERNS IN THE HEROIN OVERDOSE EPIDEMIC
  2. 2. OBJECTIVES EPIDEMIOLOGY • Describe demographic differences in prescription opioid- and heroin-related overdose • Describe regional differences in prescription opioid- and heroin-related overdose • Describe changes in heroin supply • Evidence for contamination/adulteration QUALITATIVE • Relate stories of heroin adulteration: • National • Case study: Baltimore (preliminary)
  3. 3. HEROIN IN TRANSITION (“HIT”) STUDY NIH: National Institute of Drug Abuse • DA037820 • Multi-methodological study: quantitative and qualitative aims • New heroin source-forms and how they are perceived and used • Emerging patterns in consequences of use • Heroin supply flows
  4. 4. HEROIN IN TRANSITION (“HIT”) STUDY DATA ANALYZED: • Nationwide Inpatient Survey (NIS) • Stratified sample of approximately 20% of US community hospitals representing 5 to 8 million hospital admissions annually? • States included in the NIS represent about 95% of the US population • All payer data (Medicaid, Medicare, Private Insurance and uninsured) • Years 1993 to 2013 • ICD-9 codes for opiate (not heroin) and heroin overdoses • Jay Unick, U. of Maryland, lead
  5. 5. HEROIN IN TRANSITION (“HIT”) STUDY QUALITATIVE: • Rapid Assessment Project • “Hot spot” study with ethnographic and qualitative methodologies • 3-4 cities per year • Preliminary findings: Baltimore • Sarah Mars, PhD, lead SUPPLY: • Data sources: DEA: STRIDE (FOIA), Heroin Signature Program, Domestic Monitoring Program, NFLIS
  6. 6. NIS: Opioid OD hospitalizations: 1993-2013 Apogee reached?
  7. 7. Unfortunately: • Heroin use and consequences are up • Rise is concurrent with the later stages of the opioid misuse epidemic TRENDS IN HEROIN USE AND CONSEQUENCES
  8. 8. NIS: Heroin Overdose Admissions, 1993-2012: - Sharp rise, doubling since 2005
  9. 9. ARE THESE THE SAME EPIDEMICS? • Opioid ”push”: • Intertwining of population at risk1 • Stories of initiation: “Every never…”2 • How does the heroin epidemic differ from the earlier opioid misuse epidemic? • Comparisons by age, ethnicity, gender and region 1UNICK, ET AL. INTERTWINED EPIDEMICS: NATIONAL DEMOGRAPHIC TRENDS IN HOSPITALIZATIONS FOR HEROIN- AND OPIOID-RELATED OVERDOSES. PLOS ONE 2012 2MARS, ET AL. “EVERY ‘NEVER’ I EVER SAID CAME TRUE”: TRANSITIONS FROM OPIOID PILLS TO HEROIN INJECTING. IJDP 2013
  10. 10. NIS: OVERDOSE RATES (1993-2012) BY AGE GROUP: HOD: 20-34 y.o. OPOD: 45-59 y.o.
  11. 11. CONVERGENCE IN HOD/OPOD RATES: 20-34 YEAR OLDS
  12. 12. NIS: OVERDOSE RATES (1993-2012) BY ETHNICITY: HOD: White and African American OPOD: White and Native American
  13. 13. AGE AND GENDER DISPARITIES Opioid at- risk Heroin at-risk
  14. 14. NIS: OVERDOSE RATES (1993-2012) BY GEOGRAPHIC REGION: HOD: Northeast and Midwest!! OPOD: Even – South Good News: West
  15. 15. • Timing of opioid and heroin curves: +/- • Key convergences by ethnicity • Symmetrical converging curves in 20-34 yo age groups • Surveys of recent heroin initiates report prior opioid dependency • Demographic differences can be explained by risker sub-population • Exception: Midwest Summary: Opioid “Push”
  16. 16. Heroin patients in treatment: first opiate of abuse • 75% of the 2000 cohort of heroin tx pts started with an prescription opioid Cicero TJ, Ellis MS; Surratt HL; Kurtz SP. The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. Published online May 28, 2014.
  17. 17. Heroin “Pull” • US heroin seizures are up ~ 100%, 2009-14 Source: EPIC National Seizure System. Reported in the 2015 National Drug Threat Assessment Summary; DOJ, DEA, 2015
  18. 18. 0 5000 10000 15000 20000 25000 Hectares Illicit Poppy Cultivation in Mexico Source: 2013. United Nations Office of Drug Control, World Drug Report 2013 [Online]. Geneva: United Nations. Available: http://www.unodc.org/wdr/
  19. 19. Heroin Seizures, Southwest Border: 2000-2013 • SW heroin seizures up 4-fold Source: National Seizure System. Reported in the 2014 National Drug Threat Assessment Summary; DOJ, DEA, 2014
  20. 20. HEROIN TYPES: SOURCE-FORMS “Black Tar” Heroin: Mexican Brown powder Heroin: Colombian/SWA White powder Heroin: SEA
  21. 21. HEROIN SOURCES OVER TIME Source: Heroin Signature Program. Reported in the 2015 National Drug Threat Assessment Summary; DOJ, DEA, 2015
  22. 22. HEROIN OF UNKNOWN SOURCE Source: Domestic Monitoring Program. Reported in the 2015 National Drug Threat Assessment Summary; DOJ, DEA, 2015
  23. 23. A MORE DANGEROUS “HEROIN” • Fentanyl laced heroin • Novel Mexican heroin? • Other synthetic opioids • Case study: Baltimore
  24. 24. FENTANYL LACED HEROIN • Fentanyl laced heroin and heroin laced fentanyl and just plain fentanyl (and fentanyl analogues): • NFLIS (2015): Fentanyl reports increased by 300% from the late 2013 to early 2014 • Clandestinely-produced fentanyl, not diverted pharmaceutical fentanyl* • 30-40x stronger than heroin by weight • DEA and CDC 2015 warnings • Sources: Mexico and China (fentanyl analogues) • Analogous: Levamistole as adulterant for cocaine *National Heroin Threat Assessment Summary, DEA, 2015
  25. 25. NFLIS: Fentanyl • Testing seized drugs • Highest rise in rates in NE and MW • Recent relative to earlier rises in heroin overdose NATIONAL FORENSIC LABORATORY INFORMATION SYSTEM. Special Report: Opiates and Related Drugs Reported in NFLIS, 2009–2014. Office of Diversion Control, DOJ, DEA. 2015
  26. 26. MEXICAN-SOURCED HEROIN: CHANGES • Mexican opium/heroin production has grown while Colombian production is down 40% • Explanations for rising HOD in Midwest (in addition to fentanyl): • Strong suspicion of more purified product coming from Mexico • Rise in heroin with unknown DEA “signature” • Colombian mimic? • DEA: Mexican white heroin • Explanation for rising HOD in New England: • Distribution innovations: Dispatch* • A market is any place with lower competition (think Vermont) • High purity heroin going to small cities: Gary, Madison, Memphis, Minneapolis, Cleveland * Sam Quinones: Dreamland: The true tale of America’s opiate epidemic (2015)
  27. 27. SYNTHETICS • In addition to fentanyl there are reports of: • Fentanyl analogues: • Acetyl fentanyl • Butyryl fentanyl • Furanyl-fentanyl • Parafluoro-fentanyl • Novel synthetics: • M-15, M-18 • U47700 • Others… Sources: various. National Drug Early Warning System (NDEWS) listserve alerts
  28. 28. BALTIMORE
  29. 29. BALTIMORE: HEROIN • Estimated number of injection drug users: ~19,000 • Doubling of heroin overdose deaths 2010-2014 • Dramatic rise in fentanyl-related deaths late 2013 to 2014 Source: Drug and Alcohol-Related Intoxication Deaths in Maryland, 2014. Maryland Department of Health and Mental Hygiene. May 2015
  30. 30. ETHNOGRAPHIC WORK • Heroin scene: • “Old school:” Open street dealing, branded heroin, free samples(“tastes”!) • Two types: “raw” and “scramble” • Decayed infrastructure: • City on the mend but… • Abandoned buildings, deserted streets and alleyways make convenient venues for drug injection
  31. 31. SHOOTING GALLERY
  32. 32. BALTIMORE: “HEROIN” (FIELD WORK 11/15, 3/16) • High quality: “The best stuff I've ever used is the stuff I’m using now“ - 28 yo from Ohio, using heroin x 8 years • Chemical feel/”taste” Q: How does the heroin you are using now feel? A: “Its kinda like [heroin]. It gets me well. But it is also tastes chemically” - 60+ yo using over 30 years • Fentanyl contamination: likely; other synthetics possible • Sometimes sold as is; sometimes desired; however effect short- lasting and users know this • Some fear/concern; some old-timers are doing “tester shots” which is unusual
  33. 33. BALTIMORE: “SCRAMBLE”
  34. 34. BALTIMORE: “SCRAMBLE” • Old term but a new form • White powder heroin – unique • Mixed locally; • contains multiple powders; mixing problem! • in contrast to “raw” heroin: not as powerful but better “rush” • Highly variable: • Wide range in price, volume • Color changes: white to concrete grey, colored speckles or white sparkles • In solution: clear to ice-tea colored • Effect: good rush, duration of effect 0.5 – 12 hours • Unpredictable! • Growing in popularity and market share
  35. 35. CLEAR HEROIN SOLUTION: UNUSUAL
  36. 36. “WE MUST STOP KILLING EACH OTHER”
  37. 37. • The novel entry of Colombian-sourced heroin increased HOD rates; 1993-1999 • New increases: • New forms of Mexican- sourced heroin? • Fentanyl(+) adulteration • Wider distribution models • Intertwined with opioid pill epidemic FINAL THOUGHTS: HEROIN IN EVOLUTION
  38. 38. FINAL THOUGHTS: MULTIPLE PATHWAYS • Opioid to heroin transitions: • High dependency • Opioid restrictions? • Heroin as initial drug of choice: • New England, Mid-Atlantic and Midwest: New market strategies; expanded supply; • New products that we don’t understand • Fentanyl but it cant explain everything as it hits later than the rises seen in heroin OD • Testing bias?
  39. 39. FINAL THOUGHTS: CHALLENGES Rx Opioid hospitalizations RX Opioid deaths
  40. 40. FINAL THOUGHTS: CHALLENGES • Better surveillance: • Public health forensics: “contaminated lettuce” • Heroin and fentanyl products • Synthetics are the new reality eg NPS, cannabinoids • Use patterns and consequences • Harm reduction responses: • Naloxone: 2 decades of community peer use • Technological and policy innovations • Expanding MAT: • Only 3% of DEA registered physicians are buprenorphine prescribers
  41. 41. FINAL THOUGHTS: CHALLENGES • Supervised injection facilities: • Growing intervention worldwide • Best evidence from “Insite” in Vancouver: • Decreased: OD, hospitalizations, infections • Increased: uptake of medical and substance treatment • Stem out of crises – like the one we have now • Challenges: • Wrap-around services • Canada and Europe not like US: • Stigma may bedevil • Persons at risk may not use, communities may not allow; culture at large may not be ready • Legal and political issues
  42. 42. SAFER INJECTION FACILITY: INSITE • Vancouver, Canada
  43. 43. THE BOONDOCKS © 2002 Aaron McGruder. Dist. By UNIVERSAL UCLICK. Reprinted with permission. All rights reserved.
  44. 44. ACKNOWLEDGEMENTS  Heroin in Transition study:  Jay Unick, PhD, University of Maryland  Sarah Mars, PhD, UCSF  Jeff Ondoscin  NIH/NIDA funding: R01DA037820  Jon E. Zibbell, PhD, CDC  Baltimore City Health Dept.  Mishka Terplan  Derrick Hunt, Jeffrey Long and NEP staff  NDEWS: Erin, Kathy and Marwa. - Eric Wish  Maryland Department of Health and Mental Hygiene  Michael Baier  Philippe Bourgois, PhD  Drug Enforcement Administration  Photo credits: Fernando Castillo, Dan Ciccarone
  45. 45. QUESTIONS?

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